Raya Elfadel Kheirbek is a professor and chief of the division of palliative medicine and geriatrics at the University of Maryland School of Medicine.
For 15 years, my patient had kept a door open for a daughter who would not walk through it. Now he was dying.
His pancreatic cancer had progressed despite treatment. We controlled his pain and eased his breathing. We talked about hospice and how he wanted to spend the time that remained. His daughter was still listed in his medical record under next of kin, a simple entry that made their relationship look intact. It wasn’t. As we discussed the people who would be with him at the end, it became clear that she would not be among them. But her absence carried enormous weight.
In more than two decades of palliative care, I have encountered this kind of absence more often than I once expected: a child who no longer calls, a sibling whose whereabouts are unknown, a name that remains in the medical record long after the relationship itself has dissolved.
My patient had tried over the years to reach his daughter through birthday wishes, brief notes and invitations to come home. Mostly the response was silence. Eventually she asked him to stop contacting her, and he did. But as the end of his life approached, he kept returning to a question he could not answer: How had they arrived at this point?
He did not imagine himself a perfect father. He remembered arguments, anger and words he regretted. He also remembered working hard, paying for her education, worrying when she struggled and celebrating her accomplishments. He had loved her deeply and believed that, despite all the imperfections of his parenting, he had done the best he knew how. Yet somewhere, his daughter had been hurt in ways he could not see or understand.
I hear this bewilderment from many estranged parents. They can name their failures but cannot always identify the moment when hurt became distance and distance hardened into silence. Their children may remember the same years very differently. Love intended is not always love experienced; what one person remembers as sacrifice, another may have interpreted as expectation, and protectiveness may have felt like control. Two people can inhabit the same family and emerge carrying different histories, with no shared account of how they came apart.
Families like this are not unusual. Cornell University’s Family Estrangement & Reconciliation Project found that 27 percent of Americans — roughly 67 million people — are estranged from a close relative. One in 10 reported estrangement from a parent or child. Some relationships eventually mend. Many never do.
Serious illness lends the situation a new urgency. We like to imagine dying with family gathered around the bed, children coming home, hands being held and old grievances softening because time is short. Sometimes death does bring people home. But sometimes the absence of one person can be felt more powerfully than the presence of everyone else.
Medicine is built around the expectation that family will be there. Doctors and nurses ask for next of kin and health care proxies, depend on relatives for caregiving and turn to them when patients can no longer speak for themselves. Yet a name in a chart tells us almost nothing about the relationship behind it. Perhaps along with asking who should make decisions, we should ask who matters, who is missing and whether there is someone a patient would want to reach while there is still time.
This is not a call for physicians to repair fractured families. Some estrangements stem from abuse or profound harm, where distance is necessary. A request for no contact deserves to be honored.
But recognizing estrangement gives patients an opportunity to consider what, if anything, they want to leave behind: an apology that asks for nothing in return, an acknowledgment of harm, a letter that may never be opened, or simply words they need to say aloud even if the intended person never hears them.
My patient’s daughter did not come to see him before he died. He could not rewrite their history, nor could he heal a wound he never fully understood. He had respected the distance she asked for. What remained was his hope that somehow, despite 15 years of silence, she knew that she was loved.
There was no reconciliation, and I am not sure “closure” applies to losses like this. But there can be a measure of peace in acknowledging what cannot be repaired while making room for the love that remains.
I have come to believe that one of the quiet duties of medicine at the end of life is simply to notice the people who are not in the room — and to let the dying person know that their absence has been seen.
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