Conversations With Patients Who Have Died

Imagining conversations with patients who have died helps to remember and honor them

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This has happened before: A young patient I’ve worked with for a long time in psychotherapy dies of a medical illness. Sam had been diagnosed with lung cancer several years ago. In recent visits, he looked increasingly frail, hovering between dreams of a long-deferred move back to a small town and an awareness of how little time he had left. He began missing appointments, and then I received a message from a friend saying that Sam was dying, asking how he could comfort him. Following this, the friend called to say that Sam had died.

In decades of practice, I’ve never figured out what to do with feelings of sadness and incompletion when treatment ends this way, including the question of what is so deeply unsettling: Is it the fact of the patient’s death, uncertainty about if I had helped the patient enough to find solace in the final weeks of life, or the evocation of my mortality? Add to the list my guilt for being the lucky one in the consultation room who didn’t get sick.

In the early years of my practice, when an unbearable number of young men I treated died of AIDS, I went to funerals and sat quietly in the back of chapels, sometimes expressing condolences to loved ones who I had gotten to know as care partners, but more often remaining anonymous. For understandable reasons, I was not asked to join spoken remembrances of the deceased.

Some have applied the concept of disenfranchised grief to the bereavement experience of psychotherapists losing patients (Kouriatis and Brown, 2011). We do not share our feelings with other survivors of a patient’s death and may question the legitimacy of our grief. We wonder if we should have been more present near the time of death, even if some patients do not seek us out for final conversations at a time of vulnerability and intimacy perhaps best reserved for loved ones.

And how do we honor patients' commitment to psychotherapy when we haven’t had a chance to express our appreciation for the opportunity to have worked together?

These questions often linger, so I sometimes find myself having conversations with patients after they’ve died: I conduct post-mortem interviews.

I ask Sam if he made peace with his death and that of his former partner, who died of cancer several years ago. I want to know if Sam was able to come to terms with running out of time before he could move to the country home he longed for. I want to tell him that it was a privilege to be entrusted with stories of his youthful aspirations and transgressions, midlife reckonings, and adjustment to cancer diagnosis and treatment. And I want to tell him how much I appreciate his perseverance in the face of a metastasizing illness when he had difficulty seeing me, literally, because of brain lesions.

My conversation with Sam will remain one-sided and unfinished but likely be transformed by the memorialization I’ve done for patients who died of AIDS decades ago: remembering not the endings but their embrace of life that included signing up for psychotherapy with the hope that their aspirations would be recognized even if they could not be realized. I say these patients’ names to myself, remembering how they lived, not how they died.

Yet conversations with deceased patients continue, and I suspect there may be an additional motive. I miss the opportunity to witness these patients age as I age, sharing with them the whimsy and poignancy of a more expectable course of growing older that has been denied them. This sometimes tacit, sometimes spoken, mutual acknowledgment of aging as it occurs with living patients would have imparted an added richness to our working relationship and satisfied a wish to know how lives turn out.

Death precludes follow-up sessions and the welcome experience of seeing patients resuming contact after a hiatus of many years. But conversations with patients who are no longer alive diminish death by remembering how lives once were and imagining how they might have been. It’s a different type of follow-up that honors the deceased and ensures that their stories remain part of the long-term memory that practitioners of a certain age treasure.