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JJ had made peace with her end-stage renal disease. Her family had not.

“I've lived a great life,” she often said to her hospital care team. “Besides, I've been waiting 29 years since my divorce for Robert Redford to come knocking, and if he hasn't come by now, I might as well meet him in Heaven when I look a little better than my current state.” And she did seem to have lived a great life. She was frequently visited in the hospital by children and grandchildren, friends, and even a few extended family members. Over and over again, we saw her deeply engaged with these well-wishers in ways that suggested nothing less than a caring, close community around a vibrant woman.

She appeared to go to great lengths to perk up on behalf of her visitors, even when she was clearly overtaxed from her day and her disease. With her family in particular, she forced a kind of energy and positivity that left her afterwards exhausted and depressed.

“JJ,” I said to her one evening when I stopped by for a visit. I was a medical student doing clinical rotations. She lay with her eyes closed and her face drawn as I took her pulse. “You're absolutely wearing yourself out. You know it. What's going on?”

She winced. “They don't need to know,” she said without opening her eyes. “My son in particular…he's—well, he's sensitive. And I don't want this all to turn into a boohoo fest. I'm okay with my time being up. But none of them will be and I don't want a pity party and sympathy cards.”

I looked up at her. “They don't know?”

She winced again. “Nope.”

JJ's family did, in fact, know that she was dying. The members of her care team knew that the family knew because fights erupted frequently in the sitting area down the hall from her room, around the corner from the nursing station, and we couldn't avoid overhearing. The fights, as it happened, were primarily about whether or not to tell JJ that her disease was terminal.

“You think they don't know?” I said again, more incredulously than I intended.

“They don't.”

That same afternoon, her middle daughter caught up with me in the cafeteria.

“Henry, how are you?”

“Good, Jane. Yourself?”

“Shattered, from watching Mom wear herself out trying to convince us and herself that she's alright,” she said, grimacing wanly.

“Oh?”

“She thinks she's going to recover. She thinks we think she's going to recover. She's putting on an incredibly brave face, and pardon the expression, it's killing her. And it's a horrific waste of her energy.”

I looked down at my tray. It wasn't my place to tell her that her mother was well aware of her condition. But I felt that my patient and her family were shouldering an unnecessarily heavy burden at a time already difficult enough.

“We've talked about it, as a family, you know? If we should tell her, tell her that it's okay for her to stop pretending. That we know. She's trying to protect us as much as she's trying to protect herself. That's just like her, too, to use her last ounce of energy to protect our feelings.” She shook her head. “It's causing a lot of friction. Sam, Seth, and I want to tell her. Georgia and Craig are adamant that we don't.”

She met my eyes and smiled ruefully. “Sorry about the screaming matches in your hallway.”

“Oh, no, not at all. This is a difficult time.”

“I wish we could all stop pretending. There are conversations I want—I need to have with my mom before she's gone, and I can't have them if we're playing like she's going to be okay.” She shook her head and took a couple of steps towards the double doors.

“I'll see you later, Doc.”

I saw her again the next morning as she visited her mother. They were working hard to outdo each other on being positive, even as their opportunities to do so dwindled rapidly with JJ's deteriorating health.

“Mom, maybe next month we'll be able to go down to the Savoy and see the Gauguin exhibit? It's supposed to be one of the biggest in history in the US.”

“Oh honey, we should! That would be fantastic. I wish your brothers would go but I know they won't.”

“Well, there's no helping the uncivilized, Mom!” She laughed too loudly. “We'll just have to do a ladies-only outing for the sophisticated among us!”

“Yes, honey, we certainly will. And you know that when I get out of here, I'm going to be positively mad for a tarragon chicken salad from Kent's.”

“God yes, Mom. Immediately, first thing.”

It was painful. I couldn't believe how much work they were putting into lying to each other when both of them knew the truth, and when so much was at stake and time was fleeing fast.

On my evening rounds, JJ was awake and studying the fleet of greeting cards on her side table and the windowsill.

“Hallmark killed letter writing, you know that? It's a lost art,” she said, waving a hand at the bright array. “No one says anything meaningful anymore in writing because Hallmark does it for you, so you just sign your name at the bottom after you find the perfect one.”

I chuckled. “Don't let Hallmark know you know, JJ. They'll be after you.”

She laughed. “Not my top priority.”

“What is your top priority?”

She tilted her head and gazed over my shoulder, and I saw the glistening in her eyes. “Enjoying the time I have with these people.”

“JJ, you didn't ask for my opinion, but I think if that's what matters to you, then you have to tell them what's going on. If you don't, it seems to me you are going to continue being exhausted and unsatisfied with your time with them, and I have to wonder if there are things they'd want to do differently as well if—” I swallowed hard, “—they knew.”

She considered this. “I don't disagree with you. It's just too hard when they're in here and I'm looking at them. I can't bring myself to do it.” She chuckled. “And there's no Hallmark card for that, surprisingly.”

I looked at her collection. “Agreed. Whatever did we do before Hallmark?”

“We wrote letters. Real ones from the heart. With no fancy doodads.”

I looked back at her. “Well, there you go. How about you write them a letter?”

She lit up. “That's a really good idea. Then I wouldn't have to worry about them interrupting me or them losing it and then me losing it and not getting through it.” She considered it further. “Would you write it with me?”

“Absolutely,” I said. “I'll come back after I finish up my rounds here in the next thirty minutes and we'll get right on it.”

So we did. I returned to her room with a legal pad and pen after my visits. I pulled a chair up next to her bed, and she dictated a beautiful letter straight from the heart. She told her family that she knew she was dying, and that she wanted them to know she considered herself deeply blessed and ready. She spoke of how she didn't want them to feel pressured to act cheerful because she really was okay, and that she wanted to enjoy her time with them, having conversations that mattered and soaking up each other's company. She said she hadn't wanted to tell them sooner because she feared it would put a damper on the time she had left, but that she'd realized “pretending” was also putting a damper on the time she had left.

When she was finished, I tore the pages off the pad and asked her if she wanted me to give them to her daughter.

“No, thank you,” she said. “I would please like an envelope and I will give it to my children myself.” She looked at me. “And thank you. Thank you for the suggestion and for helping me. I needed to do this.”

I wasn't there when she gave the letter to her family, but we all noticed the change in their dynamic. It was quieter in her room, but in a way more peaceful than somber. We all noticed that there seemed to be more intense, intimate conversations taking place, and less superficial, forced cheerfulness. We saw quiet tears.

We saw no more fights in the hallway.