This holiday season, I want to share a deeply personal story about a patient I've had the privilege to look after for over 25 years. I'll tell you about her hot pink shoes and a crumpled piece of paper that changed her life. I'll call her Mrs. L.
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A few winters ago, just before the holidays, she came to see me. She was in her late 70s and had advanced heart failure. She limped into the office wrapped in her usual oversized, full-length parka, wearing crocs because her feet were too swollen to fit into any other shoes.
Just the walk from the waiting area into the exam room made her short of breath
Image credits: Erik Mclean (not the actual photo)
She sat down, and before she could even fully catch her breath, she said, “I thought about those four questions you'd asked, and I'm ready.” My heart sank just a bit. I tried not to show that my eyes were tearing up still. I was glad she remembered our conversation. It wasn't her mind that was going, it was her lungs and her heart.
She was talking about the bestselling book I'd advised, called "Being Mortal: Medicine and What Matters in the End." It's by Harvard surgeon and writer, Dr. Atul Gawande. The questions he writes about are used to guide people through serious illness, questions that have become a roadmap to help me make sure that the medicine I provide aligns with the goals that a patient wants for themselves.
These four questions cannot be asked too early, but they can be brought up too late
Image credits: Jessica Fadel (not the actual photo)
The first is, “What's your understanding of your situation?” The second, “What are your fears and worries?” Number three, “What are your goals if time becomes short?” And finally, “What trade-offs are you willing to make?” These four big questions were devised to make the most of a person's final months, weeks or days, but the sooner they're considered, discussed, and shared, the better we do as a patient–doctor team.
So Mrs. L reached into her bright red oversized purse and pulled out a somewhat crumpled-looking paper. She peered down through her bifocals and began with, “What is my understanding of the situation?”
She looked up for just a moment. We met eyes, and she paused. “I know my heart doesn't pump quite like it should, and the years of smoking have damaged my lungs. My body may be decrepit, but my mind is strong enough to realize that this will probably be the last Christmas I'll be at the dinner table.”
Doctors aren't supposed to feel this sad. I thought, this cannot be healthy. Think, what about the wall we physicians are supposed to build to become better doctors?
“What are your fears and worries?” I asked. “Not hearing my grandkids laugh,” she said
Image credits: Hillary Peralta (not the actual photo)
Because of all the time I spend in hospitals, I waited to see if she might say that she was afraid of dying. “Anything else?” I asked.
“My brother being left behind,” she said.
I moved to the third question, “And what are your goals?”
“If time becomes short, one last holiday season at home, making it to my brother's 90th birthday, and recording a personal video for each of my grandkids.”
Not surprising, medical machinery and procedures didn't make the list, so we came to trade-offs. Quality time was far more important to her than quantity. In fact, she was keen to go over her medications and limit them to only those that kept her comfortable and out of hospital and, quote, “Not one extra pill more.” Did she want to be intubated or tube-fed? No. What about an ICU admission? An emphatic no. And just like that, she gave me, or rather, us the roadmap. I could become a better guide.
Even still, there were fewer frantic trips to the emergency room, more evenings spent with her brother, and the time she needed to start making video recordings. She ordered a hospital bed.
Grab bars were installed in her bathroom, and she brought extra-wide hot pink slip-on running shoes
Image credits: Barbora Polednová (not the actual photo)
She wore them at every visit. She was wearing them at every house call, and ultimately, she died the way she wanted—at home, with her brother at her side, knowing that each of her grandchildren would, in fact, receive that personalized video she had so thoughtfully made.
She was buried on a Sunday in an open-casket funeral, and I cried when I saw the crumpled paper on her chest. She'd written the words “Made it!” with an exclamation point.
Her brother hugged me. “The videos,” he said, “the videos were a hit.” And yes, she'd made it to his 90th birthday party.
He swallowed hard, he smiled, not wanting me to see the tears in his eyes, and winked. “She's got those hot pink running shoes on,” he said, and then turned away. His timing couldn't have been better. I turned away and cried. I miss her still.
Four questions don’t shape the way we die. They define the way we live
Image credits: CARP
This holiday season, my wish for you is the courage to face those questions and the gift, the gift of health, peace, and time with the people you love in 2026.