End-of-Life Option, Ray’s Story

Choosing end-of-life option, Ray Perman’s Story

In 6 states, those facing terminal illness can decide when to die

Five years ago, 64-yearold Ray Perman was diagnosed with terminal cancer.

Perman, a designer and consultant who lived in the San Francisco Bay area, had sarcoma carcinoma, a rare and terminal cancer that affects only about 200 people a year in the United States. He also had a common, low-grade, progressive prostate cancer, not unusual for men his age.

The sarcoma caused a large, rapidly growing tumor to form in his prostate and nest against his colon. At the suggestion of his oncology team, he immediately underwent surgery to have his prostate, bladder, numerous lymph nodes and other flesh removed.

At the time of surgery, biopsies showed that both forms of cancer had metastasized, spreading the cancer to other lymph nodes. For a year, he and his doctor decided to wait instead of pursuing further cancer treatments.

A year later, the sarcoma reappeared in the form of a 5-inch, football-shaped, rapidly growing tumor in his lower abdomen, and later 12 quarter-inch and 1-inch tumors appeared in his lungs.

He was told he had two to six months to live.

Perman, at the suggestion of his oncologist, decided to try an unusual combination of two of the most powerful chemotherapy drugs available: Taxotere and Gemzar. The treatment was predicted to have about a zero to 30 percent chance of “doing something.”

The combination was so toxic, Perman said, that it caused his legs to swell, his fingernails to fall off, excessive bleeding, loss of body fluid and neuropathy, a nerve disorder that causes weakness, numbness, tingling, pain and balance problems in the arms, legs, hands and feet.

Miraculously, the treatment worked.

The large, aggressive abdominal tumor in his lower abdomen and the 12 in his lungs shrank, extending his life.

A second round of chemotherapy began about a year and a half later, when more sarcoma tumors appeared in his pelvis, tailbone and rib cage, but this time it had little effect.

“When it became obvious that treatment wasn’t working, that the side effects of the treatment were worse than the disease and that I had only a few months to live, I knew I had some decisions to make,” said Perman. “And I decided to seek only palliative care through hospice at my home and began to investigate the use of the California End of Life Option that went into effect on June 9, 2016, and authorizes medical aid in dying.”

Barbara Coombs Lee, president of Compassion and Choices, a nonprofit organization dedicated to expanding and protecting the rights of the terminally ill, says that where end-oflife options are legal (Oregon, Washington state, Montana, Vermont, California, Colorado and Washington, D.C.), the fear of liability has been lifted and patients are able to talk frankly with their doctors about their fears and hopes and how to end life peacefully.

“When you’ve watched someone suffer, you will quickly become a convert for peaceful end-of-life options,” said Coombs Lee, adding that when people don’t have options, they revert to denial.

According to a recent Gallup poll, 69 percent of Americans said they agree that “when a person has a disease that cannot be cured … doctors should be allowed by law to end the patient’s life by some painless means if the patient and his or her family request it.”

And doctors mostly agree, according to a Medscape survey of more than 7,500 doctors from more than 25 specialties. In the 2016 survey, 57 percent agreed that “physicianassisted dying should be allowed for terminally ill patients,” while 29 percent were opposed. In Medscape’s 2010 survey, 46 percent were in favor and 41 percent were opposed.

Dr. David Grube, national medical director of Compassion and Choices, said he’s found that in states where end-of-life options are legal, patients most often bring up the topic with their doctors. Those doctors, he said, are then ethically bound to be sure their patients understand the parameters of end-of-life laws.

To participate in end-oflife options, a patient has to have a terminal disease with less than six months to live as corroborated by two doctors and has to be psychologically capable and physically able to selfadminister oral medication.

“One third of those (in Oregon) who do get a prescription don’t use it, but it makes a huge difference for a person to know that he or she is in control and has the right to self-determination,” said Grube.

For Ray Perman, once it was clear that there was no further viable treatment for the cancer, the key issue became quality of life.

He spoke with his exwife and adult children, who had been supportive, and began the end-of-life options process required in California. He got confirmation from two oncologists that he was terminally ill with no chance of recovery; told his doctors of his wishes; and was competent and able to self-administer the life-ending medication.

His prescription was filled.

“I know I am going to die, and this end-of-life option has given me the freedom to enjoy the rest of my life without the fear of losing control over my own existence,” Perman said. “I don’t want to be described as struggling or battling cancer. I am living and breathing and singing and playing music with cancer, and most of all, I’m enjoying the profound beauty of life.”

On Feb. 4, Ray Perman took his end-of-life medication, and surrounded by his family, he died peacefully.

Good Things to Do With Your Body

Donating body for research

People’s reasons and science’s uses are many

Students from Texas State University’s Forensic Anthropology Center search for the remains of a missing person. ( Texas State University)
Image 1 of 4

By Kay Manning  Chicago Tribune 10.26.16

Patricia Kelly had to watch her husband, William, descend into dementia, but he never wavered from a desire to give his body to science, and what followed his donation inspired her — and now their daughter — to not only pledge to do the same but to become fierce advocates of the idea.

When William Kelly died in 2011 and Patricia Kelly in 2015, they became part of an unusual program at the Indiana University Northwest in Gary, which teaches anatomy while encouraging communication with donor families through letters, visits and a memorial service.

Her mom cherished the letters she received from International Human Cadaver Prosection Program students, said daughter Susan Ellingsen, of Munster, Ind., “taking a big magnifying glass (she was legally blind) and reading them over and over. They were very personal and told us all they discovered about my dad.”

“My mother made a video to let students know why she donated her body and what hope she had for them to be the best they could be and to always take their patients’ lives and families seriously,” she said.

Ernest Talarico, who runs the prosection program, said he was troubled in medical school when all he knew about a cadaver was a number and maybe a cause of death. Fellow students disrespectfully named bodies, he said.

“The tradition in anatomy lab is to focus on the science, not to get too attached,” Talarico said. “What we do is a new paradigm. And research shows it makes better doctors.”

Many bodies donated for research have poignant back stories. William Kelly had a number of ailments and wanted science to more fully explore them.

Judy Clemens, of Hebron, Ind., had a progressive form of multiple sclerosis that so frustrated her that she took her life, but not before asking that her body be studied to better understand the disease.

Other donors are educators, scientists and members of law enforcement who know the importance of hands-on learning to solve crimes, find missing people or bodies, and bring closure to aggrieved families. They even designate that their corpses be used for such studies as how fast vultures decimate a body, or how cold or hot weather affects decomposition. Still others specify that their remains be used to train cadaver dogs.

Some bodies are donated by families seeking to save money since many programs pay for transportation and stage a memorial service for the deceased or return the cremated remains.

A future purpose for donated bodies involves recomposition, the turning of human bodies into nutrient-rich compost. A prototype for what the project director sees as an environmentally friendly alternative to burial and cremation is expected to be built in Seattle in the spring and will accept bodies for a pilot program to fully test the process.

“There’s scientific value to donating your body, but there’s a huge educational value,” said Cheryl Johnston, director of an outdoor facility at Western Carolina University, where eight bodies are in various stages of decomposition. The training they afford “is benefiting people by applying things in the real world.”

Daniel Wescott runs the largest so-called body farm in the country at Texas State University, where researchers and cameras document the rate of decay of 70 bodies above and below ground, bodies clothed, unclothed and wrapped in tarps, bodies protected by wire cages and bodies left vulnerable to scavengers. When reduced to skeletons, the bones become part of a permanent research collection.

The Forensic Anthropology Center simulates conditions under which bodies or people may be found if they are victims of crime, or are missing after wandering off or a natural disaster, such as a flood. A decomposed body produces soil that’s darker in color and vegetation that reflects light differently, allowing a drone to pinpoint a location to be searched. That saves time and money, Wescott said, and then experts can determine how long a body might have been there, leading to quicker identification and finding or eliminating suspects in criminal cases.

“It’s all for justice, not just for law enforcement, but to keep somebody from going to jail if innocent,” he said.

Decomposition research and technology have better prepared Texas to handle the border-crossing deaths of immigrants, Wescott said. Bodies are buried without names, leaving loved ones uncertain as to the refugees’ fate. The facility is trying to identify some 80 corpses, but “the very, very slow process” has led to only 10 names so far, he said.

Donated bodies also help train dogs that can detect human remains. Lisa Briggs, a professor of criminology at Western Carolina University, started training her golden retriever Laila at 7 1/2 weeks, and the 2-year-old has found three bodies and several people alive.

Briggs said she feels fortunate to have whole bodies with which to teach Laila because using synthetic versions of decomposed remains or even a single body part such as teeth or a placenta, as some trainers have to do, is inadequate.

“Drug dogs are trained on one scent — maybe marijuana — but with humans, there are so many variables, such as what they had on, whether it was cold or hot, medicines they were taking, if they drowned,” Briggs said. “No one can understand how important it is” for dogs to be exposed to all those factors.

She said she remembers an instance in which Laila was looking for two people presumed by police to be dead. The dog found the bodies in water by smelling the gases bubbling to the surface, Briggs said, adding she can be asked to help on up to 20 cases a year.

She’s seen the pain families go through when a loved one is missing. “I can only imagine what it’s like not knowing,” she said.

Brittany Winn said she knew her adopted “nana,” Clemens, was donating her body to Indiana University Northwest in hopes that something could be learned about multiple sclerosis. But Winn was unprepared for Clemens’ suicide in 2011 and the quick disappearance of her body.

“We didn’t know where her remains were. It was heart-wrenching for us,” Winn said.

Months later, a Manila envelope arrived from Talarico’s program, and his students’ first contacts with the family “had us in tears,” said Winn, who has gone on to participate in the program for four years as a student and team leader and is working as a medical scribe for a Fort Wayne, Ind., endocrinologist. She wants prosectors to understand the donor and those closest to him or her.

“It’s not just a cadaver but a person who meant the world to my family,” Winn said. “Words from the prosectors are the beginning of closure. And seeing that they get everything they can from the program makes me feel better. What they learned will be with them for life.”

She has registered as a donor, she said, but donations also can be arranged after death. Requirements vary, but programs generally will not take the bodies of severe accident victims, those with infectious diseases or bodies that have been autopsied, embalmed or had organs removed. Some have weight limitations; some will take cremated remains and body parts, such as amputated limbs.

Katrina Spade, founder and executive director of the Seattle-based Urban Death Project, started searching as an architecture student for a new way to look at death, out of concern that the existing options of burial and cremation are expensive, harmful to the environment and often shortchange traditional rituals surrounding a death. She realized the method used to compost dead livestock could be adapted for humans.

“All of nature is based on dead material being turned into new life,” Spade said. “It’s a renewal, but we’ve destroyed it through cremation or by pumping bodies full of chemicals and burying them in concrete boxes. It couldn’t be farther from what nature wants to do.”

She envisions nonprofit recomposition facilities being built in urban areas where land is scarce and there are unused structures such as churches or warehouses. Bodies could be carried by family members in a quiet candlelit ceremony or to the accompaniment of a brass band, she said, and then covered in wood chips to begin the transformation into soil.

“It’s a really beautiful way to treat bodies after death,” Spade said.

Kay Manning is a freelancer.

A Surgeon


As I work with the doctors I have now, people I like and trust, I remember a surgeon who was good to me a long time ago.

When I was maybe 35 years old, a neglected skin cancer, basal cell, had grown to the size of a half dollar on my left temple. My internist referred me to a surgeon who removed the tumor and grafted skin from behind my right hear to cover the wound.  Later I wrote this poem.                         {Ever see a half dollar? 1.2 inches across.}


Levin, you bound my head too tight about

a knot of gauze that gnawed my scalp as I

emerged from anesthetic murk. When I

complained you blamed it on the fight I gave you

coming through to conscious wrath.  When you,

who’d snipped, and patched and finely stitched,

finally spun off the swath, you called in all

the floor staff, other cutters, cops and cleaners

to my bed to look and wonder, shake your hand, allowed

in friends and neighbors, local merchants and a TV crew

to praise your nifty work. You were proud,

but at the first, when a friend had come to speak

of dread and anger, you could hear,

and in the legal instance you could bend.

Levin, I bitched, I didn’t pay you,

but I loved you and I didn’t want you dead.


Levin died a year later of a brain tumor.





Drug Co. Drops States’ Death Business

 The death chamber of the lethal-injection center at San Quentin State Prison in California.CreditEric Risberg/Associated Press

May 13, 2016

The New York Times

NYTimes.com »

Pfizer has blocked its drugs from being used in lethal injections, cutting off the last open-market source of such drugs

Friday, May 13, 2016 4:02 PM EDT  source

The pharmaceutical giant Pfizer announced on Friday that it has imposed sweeping controls on the distribution of its products to ensure that none are used in lethal injections, a step that closes off the last remaining open-market source of drugs used in executions.
More than 20 American and European drug companies have already adopted such restrictions, citing either moral or business reasons. Nonetheless, the decision from one of the world’s leading pharmaceutical manufacturers is seen as a milestone.
Read more »

How to Deal with Digitals after Death (or Before)

Help Squad: Even in death, a person’s digital footprint lives on

This column grew from a request for help I received from a reader named Angie. Angie’s husband died in October, and she has struggled with the various government agencies and financial institutions she has had to contact since his death. I am still working with Angie on an issue involving the retrieval of survivor benefits from her husband’s health reimbursement account, which will be featured in an upcoming Help Squad.

Angie’s situation made me realize that, in general, people are not prepared for all the logistics that follow a family member’s death. So for guidance on what can be done to make this process easier, I spoke with Harrison, Va.-based elder law attorney, Sally Balch Hurme, author of the best-selling “Checklist for My Family: A Guide to My History, Financial Plans, and Final Wishes.” Hurme had a wealth of information to share. Below are some of her recommendations.

Do now

Everyone should make a secure list of their digital assets, e.g., smartphone, computer, email, social media accounts, then record the associated user IDs and passwords someplace retrievable by a family member. Hurme warned: “It’s a nightmare if you don’t have these passwords. Without them, you will most likely not be given access (to the deceased’s accounts).” She then added this interesting side note: “iTunes will be a problem if it is not your account. You could potentially lose all your music if it was purchased using the deceased’s account.”

If anyone is a veteran, he/she should acquire his/her DD-214 (certificate of discharge) and keep it with his/her important papers.

“This is your key to the kingdom,” Hurme said. “You’ll get nothing from the VA without the DD-214. And there are both burial and survivor benefits to be had.”

Be sure all pension plans, annuities and retirement plans have named beneficiaries. Without this they become a part of the deceased’s estate.

Do post-death

The following items should be attended to as soon as possible following an individual’s death. And Hurme counsels: “It’s advisable to have a good dozen copies of the death certificate as you will need them for (everything below).

Contact Social Security (800-772-1213) if the individual received social security payments. The last check will have to be returned as it is paid in advance.

Cancel health insurance. If it is Medicare, this will also be done through Social Security.

If the deceased was a veteran, contact the Veteran’s Administration.

“Most funeral home directors know what specific VA benefits are and what you have to do to get them,” Hurme adds.

Cancel the deceased’s driver’s license, and be sure the DMV knows the individual has died.

“This is identity theft protection because you don’t want a fake driver’s license being created,” Hurme said.

Notify the three credit bureaus – Experian, TransUnion and Equifax – to flag the individual’s file as deceased. “Thieves read obituaries and you don’t want anyone using the deceased’s credit history or personal information to get credit using their record,” Hurme warned.

Notify the banks where the individual had checking and/or savings accounts. Be aware if any are joint accounts; they will be temporarily frozen. As necessary, change the names on bank accounts, utility bills, homeowners insurance, auto loans and auto insurance.

If there is life insurance, contact the provider.

Says Hurme: “Many companies require a physical copy of the life insurance policy before they will pay it out, so survivors will need to know where this is and who to contact to claim the proceeds.”

Contact pension plan, annuity and retirement savings plan companies.

“IRAs will need to be rolled over to the named beneficiary’s IRA,” Hurme explains. “This can get complicated, so working with a financial adviser is essential. Do not attempt this on your own. There are very significant tax penalties if you do it incorrectly.”

Need help?

Send your questions, complaints, injustices and column ideas toHelpSquad@pioneerlocal.com.

Cathy Cunningham is a freelance columnist for Pioneer Press.

Copyright © 2016, Chicago Tribune

Easter Morning


Easter morning,

Bright and cool.

The church is warm, filled

To receive the good news.

Pastor ascends her pulpit,

Over looks the congregation,

Raises her arms and calls

He is risen !

I am thrilled and

wish just then I could believe.


I think of those followers,

Before the Rising,

Cowering together,

Despairing in their loss

Of leader, the defeated

message, meaning

Of their lives.

Descended then the Ghost.

Said the noted bishop:

We cannot know what happened.

We do know something wonderful,

Some incredible,

Wonderful thing had happened.

To us.


Memorial Day

The uniforms                                                                                                                  who rang the bell
didn’t say your kid is dead.
Said soldier fought with valor,
fell in battle, earned this medal.
Norm said shove your medal,
go to hell, my kid is dead.



Dulce Et Decorum Est *

Bent double, like old beggars under sacks,
Knock-kneed, coughing like hags, we cursed through sludge,
Till on the haunting flares we turned our backs
And towards our distant rest began to trudge.
Men marched asleep. Many had lost their boots
But limped on, blood-shod. All went lame; all blind;
Drunk with fatigue; deaf even to the hoots
Of disappointed shells that dropped behind.

GAS! Gas! Quick, boys!– An ecstasy of fumbling,
Fitting the clumsy helmets just in time;
But someone still was yelling out and stumbling
And floundering like a man in fire or lime.–
Dim, through the misty panes and thick green light
As under a green sea, I saw him drowning.

In all my dreams, before my helpless sight,
He plunges at me, guttering, choking, drowning.

If in some smothering dreams you too could pace
Behind the wagon that we flung him in,
And watch the white eyes writhing in his face,
His hanging face, like a devil’s sick of sin;
If you could hear, at every jolt, the blood
Come gargling from the froth-corrupted lungs,
Obscene as cancer, bitter as the cud
Of vile, incurable sores on innocent tongues,–
My friend, you would not tell with such high zest
To children ardent for some desperate glory,
The old Lie: Dulce et decorum est
Pro patria mori.

Wilfred Owen

DULCE ET DECORUM EST – the first words of a Latin saying (taken from an ode by ancient Roman Horace). The words were widely understood and often quoted at the start of the First World War. They mean “It is sweet and right.” The full saying ends the poem: Dulce et decorum est pro patria mori – it is sweet and right to die for your country.

Hazel in Hospice

by George Lynch

Hazel was a Hospice patient I had been with for two years – a record for my agency. She was bed-bound,  and the first thing I noticed entering her room were all the burn marks on the floor around the bed and on the asbestos blanket that they had over her. She smoked like a chimney but she was dying so…  She was really a nice person and very, very modest. She always kept the bed clothes up around her neck. I was going over there on a Thursday night to take care of her while her husband went to his bible study. I mostly lit her cigarettes for her and we watched Jeopardy together. She liked listening to my guitar and had one song that she wanted to hear over and over again – Children go where I send thee: how shall I send thee? Well, I’m gonna send thee one by one… One for the little bitty baby etc.  I got sick of it. I would try to skip it but she always called me back.

One night I was over there and heard, “Oops”. I looked up and she had dropped her cigarette among the blankets. We couldn’t find it. I started gently pulling the covers off her chest looking for it and was becoming increasingly uncomfortable. Obviously I couldn’t just leave the thing there smoldering. Suddenly she said, “Ouch”. She had found it.

I asked her how she happened to become a Christian. She had gone to a home bible study group and gradually received the Holy Spirit. To my knowledge she never stepped foot into a church but she was very religious. I asked how her husband had come to Christ and she said she sat him down on the couch following her conversion and told him to get with the program. He did.

With all the cigarettes going, she always had full ashtrays. Her husband came home one night and is told me a story. While he was talking to me, he picked up a roll of toilet paper and tore off a length of it. I wondered what he was going to do and was starting to retreat to the front door. He took the paper, folded it over into maybe 4-5 ply, picked up the full ashtray and emptied the contents on to the paper. He then folded it over on itself and dropped it in the wastebasket. And this guy was a PhD, his wife bedbound! I wondered who carried his insurance.

After Hazel died, the agency sent me in on a bereavement visit. I was talking with her husband and there is no apparent sadness at all– it sometimes takes a while for the grief process to kick in). He said to me, “You ever see Hazel’s bed sores?” I replied in the negative, whereupon he jumped up and returned with some 8 x 10 glossies of the open sores on her buttocks and thighs. This was before she went on hospice.


Easter Poem



Easter morning,

Bright and cool

The church is warm, filled

To receive the good news.

Pastor ascends her pulpit,

Over looks the congregation,

Raises her arms and calls

He is risen !

I am thrilled and

wish just then I could believe.


I think of those followers,

Before the Rising,

Cowering together,

Despairing in their loss

Of leader, the defeated

message, meaning

Of their lives.


Descended then the Ghost.


Said the noted bishop,

We cannot know what happened.

We do know something wonderful,

Some incredible,

wonderful thing had happened

to us.





New Testament, Acts of the Apostles, 2:3

. . . suddenly from heaven there came a sound like the rush of a violent wind, and it filled the entire house where they were sitting. Divided tongues as of fire, appeared among them, and a tongue rested on each of them. All of them were filled with the Holy Spirit . . .  The New Oxford Annotated Bible, 1991.

Hospice Encounters

A few years back, I was asked to stand in for a hospice volunteer who was going on a four-week vacation.  She had been covering five patients in a nursing home.  I set out to meet them the first time, explaining to each that I was taking Melody’s place for a while.  I found the first one in the sitting room reading a newspaper.  I went up, introduced myself and explained why I was there.  She turned, looked at me, and went back to her paper.  I waited a bit and then asked her if she was reading anything interesting.  This time she put paper down and sort of scowled.  As it worked out eventually she came to believe that I was her son-in-law and I let her (I don’t mean I started calling her “mom” or anything.  It just made things easier).  I took her for walks outdoors in her wheelchair and we spent a lot of time in front of an aquarium.   She couldn’t get enough of the fish.  Patient #1 worked out fine.

Patient #2 and #3 I just could not connect with (dementia).  They just wanted to be left alone.  So I left them alone.

Patient #4 was a Polish lady in a private room with her underwear draped over the back of the chair I would normally sit in.  I remained standing.  She was suspicious of who I was and exactly what I was asking of her.   We talked a little but she did not want to leave the room for walks or anything.  I saw her a few times and then, a week or two later I happened to be walking down the hall and saw her sitting alone in her room in a big overstuffed chair, staring out into space.  I stopped at the open door and said, “Hi Mary, how is it going today?” and went in.  She started complaining of how she was constantly being disturbed.  The aides came in all the time, the nurses came in to take her blood pressure and temperature, the maintenance people came in to vacuum and someone else came in to make the bed, and someone else came in to tell her about some event taking place and would she like to go.  Nobody ever left her alone.  She said, “Then there is always somebody stopping at my door saying, “Hi Mary, how is it going today?”  She wasn’t really trying to be rude – it was just the last time she remembered being bothered by someone.  I thought it was hilarious.

Patient #5, a little woman, was all curled up in a chair in her room, crippled from MS or Muscular Dystrophy.  Arms and legs turned in unnatural positions.  I went in and introduced myself and explained that I was taking Melody’s place for a few weeks.   She just stared at me – no emotion, no smile, no movement, nothing.  I happened to have my guitar with me and asked her if she would like me to play a song.   Again, no response at all; a blank poker face looking me right in the eye, sort of like Dirty Harry.  I got the guitar out anyway and played a song with no response.  No movement to the rhythm of the song, no recognition, nothing but this blank Dirty Harry stare.  So I packed up my guitar and left.

A day or two later, I reappeared to try again.  She was in the same chair, arms and legs curled up.  I said, “Hi Deborah, I was here a day or two ago.  How are you?”  Nothing.  No glimmer of recognition, eyes just as blank as pools of black water.  Then she moved her mouth.  She was trying to tell me something, but I could not make it out.  Her voice was very weak, her words unintelligible.  She was having a tough time physically trying to talk, but she definitely was trying to tell me something.  I went to the nursing station and asked if there was anyone around tuned in to Deborah in room 215. I said that she was trying to tell me something but I couldn’t make it out – and there actually was someone who could communicate with her.

I returned to the room and Deborah continued to glare at me.  I got the feeling she was actually sort of hostile.  A few minutes later, an aide came in and said, “Deborah, what are you trying to say to your friend?”  The aide put her ear right next to Deborah’s mouth, listened, and then without straightening up, she turned sideways to me and said “SHE WANTS YOU TO GO AWAY!”

I left the room and was walking down the hall laughing.  I met my coordinator and it was all I could do to get the story out, so funny!


I am in a hospice meeting with 40-50 other volunteers  (five guys) and we are  encouraged to talk about our patients.  So this fellow next to me starts telling how he bought some roses for his patient when he discovered she liked flowers, and how the family came in and they all loved him and said how wonderful he was . He said he thought he had developed a good  relationship with the  patient and caregiver.

I couldn’t help myself.  I raised my hand and said I too had developed a relationship with my patient.  I told the group about “SHE WANTS YOU TO GO AWAY!” and the whole class fell apart laughing.

George Lynch