This article is about a husband and wife; a patient and caregiver. The article begins with this question: "As a loved one arrives at the end of life, how do we know when it’s really over?"

The husband was a kidney dialysis patient for nine years. One day the husband refused to go to dialysis. His wife, the caregiver, after much tough talk, persuaded him to go. He died several months later.

As the wife tells us, "... for years now I have wondered what I had failed to understand that day."

What had I missed? Looking back, I didn’t grasp that not only was Bill sick of dialysis, but he was protesting the quality of life it maintained. He never said he did not want to live anymore, but paradoxically he also was suggesting that he no longer had the courage to be a dialysis patient. Although Bill was not talking about giving up and dying, somewhere the spirit in this brave, brilliant man was fading.

She also tells us:

I do not call myself to task for my lack of understanding. It is probably useful that I didn’t understand, or I would have gotten myself and my family into a dreadful existential tangle. But at least, looking back, it has helped me call a spade a spade and give Bill credit for what he, at least, knew. http://www.nytimes.com/2011/09/06/he...%2Findex.jsonp

This couple's experience immediately resonated with me. My Dad passed away just over ten years ago. One day about six months before his death, my Dad told me he no longer was going to take his medication. "It did not work anyway," he said. I talked him into taking it.

Years after his death, I realized in his way he was asking for help. My failure to truly listen sometimes haunts me. I did not even suggest he talk to his treatment team about the medications not helping. My Dad had endured many health problems without complaining. Perhaps his protest about the medications was an indication he too had lost the spirit to fight, especially when he was not getting the help he needed?