Frank Brennan is a palliative care physician based in Sydney. He has written up some of his experiences in taking care of the dying as short stories. Here is one, called "Silence".

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For years the hostilities had continued. Sometimes there were small successes. Hope rose and fell with his energy. Once he yearned for victory or at least a negotiated truce. Repeatedly now they sat and told him the news. It worsened by the week. They spoke of perseverance; he dreamt of peace.

He was due to have chemotherapy the next day. He had been deteriorating gradually but was, over the last days, much worse. He was weaker, eating less, sleeping more. It was time to discuss the future. When I arrived at his room I was pleased to see his wife, her presence would make communication easier -- we could all talk through things together.

I began by saying that, as they could both see he was becoming too weak to continue with the chemotherapy. I said that I thought that his time was coming, that death was approaching. Sometime over the next week or two he would begin to sleep longer until eventually he would go into a deep sleep. I said that from now on, the most important things were to keep him comfortable and for him to share his time with his family. He looked up at me with large blue eyes.

His wife stood at the end of the bed rubbing his feet through the bedclothes. She lifted her hands and opened them, palms facing down the bed toward his face. Expansive hands, open hands. She said, "We've had a great life together you and I. My darling we have".

I was moved by her expressive hands and her phrasing, "My darling, we have". He said, "Well if that's it, that's it. Everyone has to go through it I suppose and now" he said, looking up toward her, "it's my time". She walked around the bed and lightly placed her left hand on his cheek.

I talked a little more, answered their questions and left the room. A few minutes later she walked out and said, "He wants you to say all that you've just said to the rest of the family. Could you wait here awhile?" I agreed. Shortly I was called back, the family had gathered. The patient and his wife had a daughter who was deaf. She had married a deaf man. They had three daughters who had normal hearing, one held a baby. A cousin had just arrived from New Zealand -- we all entered the room.

I walked over to where I had stood earlier that hour. One of his granddaughters, Anne, stood opposite me. Her parents stood diametrically across from her at the foot of the bed. As I began to speak I realised that their position was not accidental -- Anne stood there to face her parents and sign my words.

I repeated what I told the patient and his wife. I said that I thought he would not suffer any more than he had and that we would do our very best to ensure his comfort. I said that more than any medication we could give, the most important thing now was love -- reflecting on their time together as a family and their love for him as a man. That this was a precious time, however long, and it would be best spent preparing.

As I spoke, something unexpected happened. Deliberately I'd slowed the delivery of my speech so that Anne could comfortably sign. With the slowing the individual words abruptly came into focus. These were words I say each day; the slowing revealed their depth. They were no longer grouped or bunched together, rushing past phrases too delicate or sensitive. They were now words in isolation, stark for all to hear and see. Somehow the unison of my speech and the signing seemed to allow me to speak the same words at a pace and a depth that began to resonate like stones dropped in a well.

I was reminded of the deep significance of those words, the words and our roles as health professionals, words such as death and dying, hope and reflection, love and dignity. I had begun by speaking to this family in the territory of facts, now I was in a different territory altogether. A patient recently said to me, "Never underestimate the power of your concern". That concern may manifest in all possible ways. There is a season for silence and a season for language and at its pinnacle all manner and form of concern is indivisible.

I noticed the effect on Anne, committed to signing; she was doing three things simultaneously. She was hearing my words, fateful, sad and reflective; she was signing the words to her parents, knowing what those words meant to them; and she was looking into their eyes, all without preparation. I looked up to watch the long arc of her hands, the sweep of her fingers, the crisp slide of one cupped palm on another. I looked beyond her hands to her face; her cheeks were wet; she signed, she cried, her hands and her tears in unison.

The rhythm and grace of her hands signed the words, shaped the words and became the words until eventually my voice, her signing, and their faces had become one. As a doctor I may have spoken with more eloquence but never with more resonance.

I stopped speaking. I looked back into the eyes of the patient. "Go on doctor," he seemed to say, "you're doing all right". I started again, not daring to look up. I could not face the fluency of her hands and the sight of her face. It seemed almost too intimate to witness. I stepped away and stood in a corner of the room. Each member of the family took turns to come up to him. They leant over to look directly into his eyes. Each spoke quietly, some in a whisper, one to gently tease him, and others in low tones of fondness. And each kissed him, some on his forehead and some to his lips. It was a ceremony of immeasurable grace.

As unobtrusively as I could, I began to leave the room. The deaf mute man, Anne's father, now carrying the baby, turned from the huddle surrounding his father-in-law. He stepped toward me, reached out and shook my hand. He mouthed the words "thank you". I wept, I wept for the singular beauty of what I had seen that afternoon, for the courage Anne had shown, I wept for their love, I wept for all the patients, on all the days and for the sadness of leaving. And finally for this small act of decency that a grieving man would interrupt such an intimate moment with his family to turn and thank me. I rarely weep. Long ago I abandoned the question of whether it is professionally appropriate or otherwise. Now, I do not worry either way.

We are humans working in the most human of enterprises. Our tears whether they are shared often, rarely, or never are part of us as much as our skills, our knowledge, and our presence. Anne's father looked at my tears, reached over and rubbed my elbow. He made a sound like the cooing of a dove. At that moment in this room the sound was more eloquent than a dozen speeches. Without a single word he had uttered the striking last line of a poem.

The baby, mirroring his action, reached out. I lifted the baby into my arms. I thought of a colleague who described seeing an elderly terminally ill woman in an obstetrics and gynaecology ward. The patient had heard the sound from beyond her curtain of a galloping patter. She was told it was the sound of a foetal heartbeat magnified. She looked up and said, as one life is coming into the world, one is going out. I did not want to leave. On a late afternoon in May, this room had become the world. The baby reached back to Anne's father. I gently handed him over, walked out and quietly closed the door behind me.


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