He said to me, with his eyes still closed, “Thanks for everything, Dr. Hope.” I did not know what it was about that line, those words or how he said it, but as soon as I stepped out of his room I began to cry. I quickly searched for an empty hospital room nearby to collect myself. This sudden, uncontrollable flood of emotions felt overwhelming. I always thought of myself as a person who had her emotions in check, but I was wrong.

About a week before this happened, I was consulted to see a patient for intractable pain. Unfortunately, the pain was because his metastatic cancer was progressing — a situation I see with my patients all too often. I remember my first time meeting him. It was a Monday afternoon. Over the weekend his opioid usage went up dramatically, and it was not helping. As I walked into his hospital room, I observed him trying to lie still because any movement made the pain worse. I was concerned that he may also be experiencing the paradoxical side effect of worsening pain that happens when increasing the dose of pain medicine quickly. His eyes were closed, perhaps to block out the sun. He was in the bed near the window. I could see the furrowing of his brow, almost as if he was concentrating on the pain to try and overpower it himself. I introduced myself to him and that I was there to help better control his pain. He was of course receptive to this.

We spent the next several days together, adjusting his medications, hoping that the next day would be better than the previous. Every morning when I would check on him, I found myself wishing to see a face reflect a feeling of comfort and relief. Unfortunately, “just ok” was as good as it got. Though his pain was somewhat improved, completely satisfying pain control was never achieved. Ultimately, we put together a discharge plan that included home hospice care. I hoped his journey to finding optimal comfort could finally be reached at home. He passed away about two weeks later. I was told it was peaceful. For that I am relieved.

It was at the end of my last visit with him when he thanked me. When I think back on that “emotional flood” moment, I try to understand why that happened. It is not like he said it in some deeply profound, sentimental way. To another listener, it probably sounded like someone saying “thank you” for a simple favor. Of course, it is okay and healthy to feel our emotions. Having them erupt and boil over, however, was a sign that maybe I needed to do some inner reflection.

Alleviating suffering is at the top of my job description list as a palliative care provider. It is what I pride myself on being able to do. That is what my patients, families, and colleagues are looking for me to do. I think what surfaced that day is the reminder of how helpless I can feel, inadequate at times, at doing my job well. I felt that my best was not good enough. I am quick to be hard on myself, always thinking of ways to be and do better. While this has been helpful in life to grow and succeed, I cannot help but wonder what that does to my self-image. It is not my first instinct to honor things I have done well. Though I knew him for only a short time, I gathered that he was not the type of person to say things he did not really mean. There was weight to those five simple words. Receiving gratitude from your dying patient, what is more moving than that?

I think what also contributed to this flood was my actual acknowledgement of grief. Maybe it is because deep down I knew that would be the last thing he would ever say to me. He was a reminder of how fleeting and fragile life can be. He was about the same age as my brother, five days younger to be exact. He had a family who loved him that he was leaving behind. He was not ready to die. A colleague of mine said just the other day, “this work is really hard. We have a 100% mortality rate.” If we do not take the time to acknowledge this grief, it can rear its head in unexpected ways.

Upon further reflection, this reminded me of a similar time when I was a resident. In the span of a weekend, three of my very sick patients died. As a resident, you are always on the-go. The thought of taking a moment to pause and reflect was frankly never a thought. I remember sitting at the computer in our resident room about to place orders on another patient when suddenly out of nowhere, I started to cry. I could feel the uneasy energy of my co-residents who were in the room with me. They were looking at each other, not sure how to respond. I was the person who was always even keeled, so seeing me like this was uncharacteristic and surprising. Little did I know at the time that my typical steady nature, was probably aided by emotional suppression.

People often ask me, “how do you do this every day?” I always assumed it was because of my perspective. Yes, I see sad situations, but I am allowed the opportunity to help make things better. I was convinced that my intrinsic focus on the rewarding aspect of my job is what prevented me from having debilitating feelings of sadness. While this may be partially true, what I did not realize is that I had been suppressing feelings of grief. It was an unconscious adaptation. This automatic default was likely a protective mechanism to do the work that I genuinely love to do.

So where does this leave things now? I would be lying if I said I had it all figured out. What I do know is that I am a work in progress. I am striving to have one small, quiet moment every day to reflect upon what I felt that day. I try to praise something that went well. Maybe by being proactive at doing small lifts in my emotional floodgate will prevent things from crashing down again. But if it does, that is ok too. I think it is time for a little more self-compassion. And to my patient I would like to say, “thanks for everything.”