Takeaway
When caring for a patient with terminal illness, shift your orientation from explaining the past to being present and exploring how they want to spend their remaining time in the future.
Lifelong learning in clinical excellence | March 11, 2026 | 4 min read
By Nettie Reynolds, MDiv, interfaith chaplain
Some illnesses cause us people (including ourselves) to ask, How did this happen? The question often begins quietly. A family member may remember something said years earlier about smoking, alcohol, diet, or medications. The patient searches for the moment when things might have gone differently.
As a hospital chaplain, I saw how easily that question could shift. Curiosity about cause can slowly move to assigning responsibility for the illness. Sometimes it shows up in the shorthand way we summarize the patient’s story, or a family member’s passing remark about a habit or lifestyle.
Then patients begin to be identified by the behavior most closely associated with their diagnosis. The patient with lung cancer becomes the smoker. The patient with liver disease becomes the drinker. The patient with poorly controlled diabetes becomes the one who “didn’t take care of themselves.” What began as a clinical observation can gradually narrow into a simplified explanation.
But lung cancer develops in people who have never smoked. Cirrhosis has multiple causes. Illness frequently arises from a combination of biology, environment, genetics, and circumstances that no single behavior fully explains. When a diagnosis becomes tied too tightly to one cause, we risk misunderstanding both the disease and the person living with it.
Moving from causation to presence
Prevention and risk-factor discussions are an important part of medicine. But once someone is facing a serious or life-limiting illness, the meaning of those conversations changes. At that point, the work of care becomes less about prevention and causation and more about presence.
A patient story
I remember a man in his sixties with advanced lung cancer whose chart included decades of smoking. By the time I met him, the disease had spread widely, and the medical team had started shifting toward comfort-focused care. The connection between smoking and lung cancer was not lost on him. In fact, he sometimes mentioned it himself, usually with a small, wry smile.
“I suppose this is what happens,” he said once. “You smoke your whole life and then this is how it ends.” There was no defensiveness in his voice. What he didn’t seem to want was another conversation about causation. He already understood why his illness had occurred.
During one visit he talked about his years of working in construction. He described early mornings before sunrise, winter wind blowing through unfinished buildings, and the crew he worked with for decades. Cigarettes appeared in those stories, but they were woven into a much larger life of work, friendships, and the pride that came from building something that lasts. “Everybody smoked back then,” he said. “That was just the way the day went.”
Listening to him, it became clear how quickly illness can compress a person’s story. Smoking was part of his life, but it wasn’t the whole thing.
Grief’s search for cause
Families often experience a similar pull toward explanation. Serious illness brings grief close to the surface, and grief sometimes searches for somewhere to land. A daughter may replay old arguments about quitting smoking. A spouse may revisit concerns about alcohol use or diet. These comments usually arise from fear and sorrow, but they can change the tone of a room in ways that patients feel immediately. And patients themselves frequently carry their own explanations for what happened. Many have spent long nights thinking about their health histories, wondering whether things might have unfolded differently.
The man with lung cancer said something once that has stuck with me. “Everybody keeps talking about why I got sick. But the truth is, I already know I’m dying. What I’m trying to figure out is how to spend the time I’ve got left.”
That sentence reframed the entire situation. How it happened wasn’t the important question in the room. The question was how to spend the time he had left, and with whom.
Care happens in the present.
We are here now.
Three gentle reframes for clinicians:
1. Widen the story beyond the diagnosis.
When illness dominates a chart, it can unintentionally narrow how a patient is seen. Asking about a person’s relationships, work, hobbies, and what matters most to them can restore a fuller picture of their life.
2. Notice when conversations drift toward blame.
Families often search for explanations when they’re frightened or grieving. A simple redirection such as, “We can’t change what’s happened, but we can focus on how to support your loved one right now,” can help move the conversation toward care.
3. Remember that patients already carry their own stories about illness.
Many people have spent long hours reflecting on their health history. What may help most in the clinical encounter isn’t further explanation of disease processes, but attentive presence and the space to speak about what matters to them now.
This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.