I received a call one morning from Jacob, a nurse on the oncology unit. He said Sue, a patient I’d built a warm rapport with during an earlier stay (Telling Our Life Stories), had just arrived back on the unit and was not doing well; Sue’s wife Andrea recalled my name and asked Jacob if I could visit.

I arrive and find Sue in distressing pain, with Jacob doing all he can to make her comfortable. Andrea, whom I’d never met, rushes over to greet me.

“I knew this day would come, but I can’t believe it’s happening so quickly.” She collapses into my arms, sobbing. All I can do is quietly acknowledge the truth: dying is hard, for patient and family, no matter how ready you think you are.

After a moment Andrea straightens up and announces brightly, “Sue, Chaplain Greg is here to see you. You remember how much you enjoyed your visits with him?”

I move bedside opposite Jacob, take Sue’s hand, and greet her warmly. But Sue is past the point where comforting words and touch can ease her distress.

“I feel like I’m burning up inside. I need pain meds NOW!” Sue struggles to get out of bed, and Andrea and I restrain her while Jacob administers pain and anxiety meds. Soon Sue’s struggling diminishes, and she lays back in bed.

Jacob begins to start IV lines and prepare Sue for her stay. Andrea reaches for another hug and repeats, “This is all just happening so quickly.” As Andrea’s sobs subside, I agree to return later in the day, once their children arrive.

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Death sometimes arrives with no forewarning: a massive heart attack, a brain aneurysm, an accident. Past a certain age, though, we are more likely to die from conditions that progress relatively slowly: cancer, congestive heart failure, or simply old age. This is largely a blessing, I think, as it gives both the dying person and their loved ones time to prepare, and to share conversations that can be among the most intimate and meaningful of their lives.

But this blessing brings with it a challenge: navigating many difficult decisions around whether to pursue treatment(s) for the condition(s) or to cease curative care and let nature run its course, with treatments focused solely on comfort and quality of life. In my experience, there is no “right” way to do this—so many considerations are specific to each situation and individual.

Many factors influence patients in the direction of curative care, even when the odds seem small. First, of course, is our own desire to enjoy more time and postpone death, as well as our loved ones’ desire for us to continue living, postponing the loss they will suffer when we die. Our healthcare system is also incented toward curative care: doctors and other providers are trained to treat illnesses, after all, and they make their livings—and derive professional and personal fulfillment—from providing curative care, not discontinuing it. Our prevailing cultural narrative is one of “fighting” and “battling” illness, not “giving up hope” until the bitter end.

For some, this is the course they choose, and I can understand why. A family friend was diagnosed at age 87 with lymphoma and fought it tooth and nail, undergoing excruciating treatments against medical advice—and was rewarded with 6 more years of life, replete with weddings of grandchildren and births of great-grandchildren, dying suddenly while still pursuing an active life. This outcome was far from foreordained, however, and others facing the same circumstances might wish to choose differently.

Sue’s story is more representative of my experience as a chaplain, and in life. When first diagnosed with cancer, Sue pursued curative treatments that gave her several joyous years. When I first met her, she’d exhausted most options, but told me “there’s an immune therapy treatment I could try; it might make a difference, but even if it doesn’t, it could give me more time with my wife, children, and grandchildren.” A solid choice for her, I thought then. Unfortunately, it didn’t buy her the time she’d hoped for.

There’s a term we use on my chaplaincy team: transforming hope. Not giving up hope—life is meaningless without hope—but refocusing the goals one hopes for as circumstances evolve. Sue’s hope for more time didn’t seem unrealistic when we spoke, though I don’t know what prognoses her oncologist gave her regarding pursuing immune therapy vs. discontinuing curative care—or even whether a candid discussion of these alternatives took place. It can be so hard for patients, families, and providers to refocus goals of care even when the evidence suggests they might want to.

The result of failing to do so, though, can be a crisis like what Sue and her family experienced. Andrea shared with me that it had quickly become clear Sue’s immune therapy treatments weren’t working, but their hope did not evolve to align with this reality—until Sue’s crisis made such hope untenable. Instead of gradually transforming their hope, it all had to happen so quickly …

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By afternoon Sue is resting comfortably. I gather with Andrea, their sons, and an adult grandchild—a lovely family wanting only the best for Sue. Andrea says she and Sue planned for her to die at home—in the not-so-near future. Now she wants to know my thoughts. I offer that, while dying at home is an ideal we often hope for, it can be stressful if the patient has high care needs, as Sue does. I watch Andrea flash back in her mind to the scene in Sue’s room earlier that day, then shudder at the thought of trying to manage this at home.

I continue, noting that the hospital setting frees family members from most caregiving activities, so they can focus on simply being present. Andrea quickly agrees, and the other family members breathe a sigh of relief—they will approve Sue’s transition to comfort care. They share a few warm reminiscences of Sue with me, then head off toward her room. Hope is transforming before my eyes …

Sue died peacefully just before dawn the following day, surrounded by her family.