Moving Us Closer To Osler
A Miller Coulson Academy of Clinical Excellence Initiative

Unsent letters from a palliative care doctor to a patient and her dog 


Sometimes we never get the chance to tell a patient what we admire about them. After my patient died, I realized I’d been inspired by the inner strength she showed by caring for her dog despite health and life challenges. 

When I was a palliative care fellow, I had the privilege of caring for a patient with a complex medical history and who’d had challenging encounters with the healthcare system. This unconventional narrative in the form of two letters reflect my wish to honor her and her most beloved companion. 


Dear Puppy,  

I recently learned that your human companion died. I’m so sorry for your loss. You must really miss T. I know that I do. Do you have a new home now? Do you have a new person to love? Who is taking care of you?  

When T first told me that she took you home from the shelter, I was really happy for her but a bit worried for you. There were days when I wondered whether T could take care of herself, let alone be a good human companion for you. What if she left her pain pills scattered about again and you ate them by accident? It turned out that I didn’t need to be worried. She loved you so much. 

I’m sure you remember the time when you ran off in the park and T lost you for five whole days. She was devastated. She was in so much pain that she showed up to the emergency room and had to be hospitalized. We knew how to treat her physical symptoms, but we couldn’t relieve her emotional pain. Miraculously, T’s social worker found you after calling multiple animal shelters. She was discharged from the hospital the next day and you were reunited.  

I like knowing that you were by her side when her cancer progressed. I’m glad that she had you when she enrolled in hospice. I hope that she was able to hug you tight one last time on her birthday, right before going to the hospital.  

Thank you for being so lovable and loving,  

T’s former palliative care doctor  



Dear T, 

On paper, you were “a very difficult patient.” These were the things that I learned about you from reading your medical records:  

Opioid use disorder with difficult-to-treat multifactorial pain. Depression, anxiety, and post-traumatic stress disorder, all untreated. No emergency contact listed and no surrogate decision-maker on file. Frequent angry outbursts toward medical staff and several occasions of leaving the hospital against medical advice. Multiple no-shows to follow-up appointments with the oncologist.  

And these were the things I learned about you after getting to know you in palliative care clinic for six months:  

An animal lover who was fiercely protective of her puppy Z. A brilliant artist with an incredible sense of humor and empathy. An outdoor enthusiast and nature lover who wanted to turn her ashes into a tree after she dies. A person with blue hair who drove a powder blue pick-up truck. Someone with very few friends but followed her intuition when it came to placing trust in others. A mother who held a lot of grief and guilt.  

When we first met, I was a fellow-in-training. You helped me realize the ways in which empathy and intention matter for finding meaningful connections with patients. I still remember the way you used to answer the phone with, “Oh hey, Dr. Li! How’s it going?” Your puppy Z used to make brief, blurry appearances on the screen during our video appointments with unstable connections. I always felt the need to highlight the social history in your notes so that other people who read your charts would look beyond your past medical history, the copy-and-pasted discharge summaries, and long list of “high-risk medications.”  

Recently, a beloved colleague reached out to let me know that she had some difficult news to share about a patient I used to see in palliative care clinic. You immediately came to mind, and I somehow knew that you must have died, even before she told me what happened. I found out that you were admitted to the hospital on your birthday, a date that I won’t forget. I’d put it on my calendar to call you on your special day. I know that I’m not supposed to have “favorite patients,” but I’m only human, and you are quite unforgettable.  

Thank you for showing me that someone’s inner strength sometimes goes unnoticed until you get to know them,  

Dr. Li  








This piece expresses the views solely of the author. It does not necessarily represent the views of any organization, including Johns Hopkins Medicine.