My next inbox message read, “The patient wants the doctor to go on the internet and find him a cure. Patient declines scheduling appointment at this time.”

That was the note from the nurse coordinator, who had dutifully called Stan after his recent hospital stay for abdominal pain and a laparoscopic biopsy of an abdominal wall mass. The news wasn’t good—he had recurrent colon cancer, and it was metastatic. Stan understood the implications: palliative options, no cure, a terminal diagnosis. His typically dry sense of humor had turned a bit dark in his phone message.

I scanned the nurse’s notes once more, then clicked complete. It was an FYI, after all. Our office routinely called patients after a hospitalization, documented any needs, encouraged a one-week follow-up. Stan had declined the visit; he wasn’t in pain, he had no medication or testing needs, and he had no questions for me, his PCP, that wouldn’t be answered by an oncology visit in a few weeks. Stan didn’t need me right now, and I didn’t feel I had much to offer him. We had given our support—well, the nurse had anyway. Stan’s chart disappeared from my inbox.

Two weeks passed, including a spring break vacation. I came back to a full inbox. Stan’s name wasn’t there, but somehow his situation lingered in my mind. We had known each other for at least a decade now—consistent office visits, occasional sightings around town at the grocery store or a civic meeting (the joys and dangers of a small town). He had the typical platter of geriatric illnesses: a previous cancer and cure, diabetes in average control, mood disorder with modest control. At age 80, a visit with Stan was mostly a social encounter, some jokes, a philosophic question here and there. “How does one define depression, anyway? Are any of us happy? How would I know?” He had frequent attempts to turn the conversation to me, and at times he was entertaining, at times too personal, at times disarming. On retrospect, he was masterful at building up an emotional armor, and it was hard to penetrate.

Of late I was feeling disconnected from my patient panel, providing solid care in the office but perhaps not going the extra step. I had vowed this year to stay a little more in touch with my patients—read with more attention that stack of consults and nursing home reports and PT notes; make a few more phone calls myself rather than leaving them for the CMA; make a home visit here and there; randomly check in with a tenuous patient.

I should call Stan. Cancer patient, terminal. He needs support. I picked up the phone.

The phone call didn’t amount to much, a few minutes. He wasn’t quite sure why I had called. I explored what he knew about his cancer, what his options were, did he have any appointments, how was he handling things (“my wife’s having a hard time”). I offered support, though I am not sure I suggested an office visit. He vaguely mentioned the Death with Dignity Act, and wanting to find a doctor to help him pursue the Act. It wasn’t a brilliant conversation.

Two days later Stan was on my schedule; he had requested an appointment. The CMA and I huddled; it would probably be a short visit with Stan. I wasn’t sure if I would have anything to offer, and I wondered in fact why he was coming in.

Stan came. His demeanor was matter of fact, straightforward, the armor was in place. No pain, eating well. He had seen the oncologist, and he had deferred palliative chemo. He was doing okay. I probed, he parried. I finally asked how his family was doing; they couldn’t possibly be as stoic as he was.

And then there was a catch in his voice, and a slow tear. “The wife’s having a hard time… a hard time.” I let it linger. And then, “You know, the phone call… WOW, the phone call.” He stared at me, expectantly, looking for an answer. I stumbled. I considered feigning ignorance, but I knew. He had come because of that phone call. “Well, Stan, we’ve known each other a long time. You know, I care about your health….” I couldn’t quite say it—I care about you.

Stan said “Wow, the phone call” at least twice more before he left that morning. He gave me a sideways hug and shed a few more tears. We ventured onto hospice conversations and Death with Dignity (yes, Stan, I have participated in the process before). We vowed to talk again soon.

Over the next few months, Stan came frequently. He enrolled in hospice; his visits with various oncologists quietly ended; and he actively pursued Oregon’s Death with Dignity Act with my assistance. Together we followed the directions—consults, signatures, attestations, lock out periods, and finally the prescription for the lethal dose of medication. We had longer talks, a few jokes, a few tears, some awkward moments, and always a hug.

On one visit to the office, Stan brought in the medication, the actual concoction of prep pills and lethal pills that could take his life. He wasn’t sure he understood the sequence. The pill bottles were numbered, the instructions explicit; we read through the bottles and lined them up in order. We reviewed the requirement that he had to give himself the medicine—a loved one could not administer the pills to him—and the caveat that he couldn’t reach the point of being so sick that he couldn’t take the pills himself. We wondered aloud who should be present if and when he reached for the bottles.

My paper inbox is typically empty at the end of the day, signaling work done, conclusion, a permission to put away my stethoscope, grab my coat and transition to home. But for the last few months a stack of documents hugs the tray, face down, a paper clip holding together a loose collection of Oregon Death with Dignity Act paperwork. The documents remain unfinished, only to be completed when Stan’s life ends—with or without the pills. It’s the only paperwork I can’t yet scan into his chart, or find another file for. It sits in the tray and reminds me—of Stan, of unfinished care, of death perhaps—ultimately of a relationship that is professional and personal and complex, and doesn’t fit into any other spot.

That single phone call altered the course of Stan’s care; more profoundly, the call had altered our relationship. I realized that I also needed to work on vulnerability, and connection. Stan may have been hiding behind his wife’s emotions. What was my emotional armor? Making lists and completing them? Emptying my inbox of phone messages? Lining up bottles of lethal doses of morphine and valium in numerical order?

Stan and I continue to meet. He’s trying to organize his family assets for his wife’s sake. Meanwhile, I’ve kept a better list of hospice patients, jotted down their addresses, plotted out how to make some random home visits. I’m trying to make a few more phone calls after patient’s major surgeries or traumatic events. I am touched by certain patients, drawn to certain conversations, and still avoid other connections. It’s random, and human.

I have certainly found over the decades that the ancient wisdom is true: more friends will become patients, and more patients will become friends. The lines blur, and in that haziness lies all the joy, pain, and beauty.