For 15 years, a patient with advancing pancreatic cancer held onto hope for a reconciliation with a daughter who ultimately never returned. As his illness progressed and his time grew short, the silence between them lingered heavily, underscoring a complex dynamic often overlooked in end-of-life care.
Raya Elfadel Kheirbek, a professor and chief of the division of palliative medicine and geriatrics at the University of Maryland School of Medicine, reflects on such cases as emblematic of a broader reality faced by many families. Despite appearing as a simple entry on medical records, the designation of a “next of kin” often masks fractured or nonexistent relationships. In more than two decades of palliative care, Kheirbek has observed frequent instances of estrangement—children who no longer communicate with their parents, siblings out of contact, or names persisting in charts long after familial bonds have broken.
Estrangement can be difficult to pinpoint within a family’s history. Many parents acknowledge their imperfections and mistakes yet are confounded by how those shortcomings transformed into enduring silence. From their perspective, efforts of love and sacrifice may be interpreted very differently by their children, who might remember control or expectation instead. These divergent personal narratives contribute to the widening distance, which may never fully close.
Research supports the prevalence of such estrangement. A study by Cornell University’s Family Estrangement & Reconciliation Project found that approximately 27 percent of Americans—around 67 million people—are estranged from a close family member, with about 10 percent reporting estrangement specifically from a parent or child. While some families eventually reconcile, many do not mend their divides.
The presence or absence of family members at the end of life carries significant emotional weight. Common cultural narratives emphasize dying surrounded by loved ones, envisioning reunions and the easing of old conflicts. Yet reality often diverges, and missing relatives can sometimes dominate the experience more than those who are present. Medical professionals typically rely on families for decision-making and caregiving, assuming their availability and willingness to participate. However, the name listed as next of kin may not reflect the true extent or quality of those relationships.
Kheirbek suggests that healthcare providers could benefit from asking patients not only about their designated decision-makers but also about who matters most to them, who is absent, and whether there is someone they would like to reach before it is too late. Such conversations can offer patients the chance to express unresolved feelings—whether through apologies, acknowledgments of harm, or simply voicing love—even if reconciliation is impossible or unwanted.
She notes this is not an appeal to force reconciliation, especially where estrangement results from abuse or other profound harm; honoring patients’ wishes for no contact remains paramount. Instead, recognizing absence allows space for patients to find some peace in acknowledging irreparable fractures while embracing remaining bonds.
In the case of her patient, the daughter never came to his bedside before his death. Though a history of silence and distance could not be undone, the patient hoped that she understood he loved her despite their estrangement. Kheirbek concludes that part of the role of medicine at the end of life is to observe and acknowledge the people missing from the room—and to ensure that those losses are seen and gently honored.