Kindness and the end of life

No act of kindness, no matter how small, is ever wasted.

Aesop (∼550 BC)

The diagnosis of a terminal illness destroys the emotional soul and creates vulnerability, isolation, and fear that inevitably accompany the confrontation of life's end. Innumerable losses occur, including the loss of occupational and familial roles, financial and social status, and oftentimes, a perceived loss of human worth. In such situations, kindness, defined as showing sympathy or understanding and being humane and considerate,¹ can help assuage the turmoil and despair surrounding a terminal life event and assist patients in dealing with the specter of a significantly altered and limited life expectancy. Kindness transcends the physician-patient relationship and generates an elemental human bond that may also exhibit caring, compassion, and empathy; however, such attributes are not cardinal to the concept of kindness, but rather nurture and enhance kindness.

Physicians may find kindness a simple undertaking with nonterminal patients able to perform the mundane activities of daily living, particularly patients with the multitude of reversible maladies that afflict the human body. However, in someone dying of an incurable illness, an uncomfortable sense of failure may surreptitiously preclude an expression of kindness, as may the fear of confronting one's own mortality. The fear of death frequently lies deep within the subliminal recesses of the mind, and when we are confronted with a dying person, the inevitability of our own death comes raging to the surface. But the trepidation surrounding our death must not detract from the care of the patient, for at no other time in our brief existence on earth is the value of the physician-patient relationship so vital. The bewildering and incomprehensible burden of the finality of death and the dramatic changes that accompany the dying process are beyond the ability of many physicians to grasp because we truly do not understand the mysteries of death and dying until we ourselves become patients and experience that life-ending passage.

Nevertheless, kindness can be exhibited by thoughtful listening, by the acknowledgment that often there are no answers to the myriad of questions surrounding death, and in many instances, by merely sitting in silence with the patient. Kindness can also be demonstrated by helping patients explore spiritual frustrations, loss of hope, and questions of value, worth, and meaning, and by encouraging and assisting in life review, a process that allows patients to understand and affirm that past actions were good and justifiable and that they had worth.²

Another avenue to convey kindness is nonabandonment, a longitudinal and continuous caring partnership between physician and patient that promises that we will be there no matter what happens and that we will face illness together.^3,4,5 Nonabandonment is fundamental to the dying process and helps deter further devaluing of the terminally ill patient while limiting exacerbation of incalculable losses. Nonabandonment, while admirable, is expected of the physician, and when present, displays a profound and personal kindness that patients and family members will remember and cherish throughout the dying and bereavement processes.

But we must remember that kindness is not associated with monetary or material gifts or the casual, ambivalent, and often indifferent salutation “How are you doing?” No, the value of kindness indubitably and properly derives from friendship, bonding with another human being, and simply being there and walking side by side for the final journey at life's end.