I knew from last night’s house call that my patient Bessie’s time was near. All day long I’d felt the familiar churning inside, the sickly sweet combination of anticipated dread and anticipated relief. So when the phone rang while I was exercising at home, I wasn’t surprised. I quickly dropped the barbell weights to answer the call before it went to voice mail.

It was Bessie’s daughter, Susan.

“Mom is gone,” she said, her tone controlled and calm.

Thus began the final chapter in my decade-long relationship with Bessie and her family. We had initially met when I assumed the care of Bessie’s husband, who’d lived and died in a nursing home where I was medical director. Somewhere along the way, Bessie became my patient as well.

For years, helped by her daughters and daughter-in-law, we’d battled her heart failure. Fragile and chronically breathless, Bessie had a manner that always made me pause and slow down a bit. Perhaps her Southern gentility and courtesy reminded me of my own grandmother, also a transplant from the South.

“Please accept my deepest sympathies,” I told Susan, feeling irritated at how awkward my words of condolence sounded.

After a quick shower, I donned my black suit, worn thin from weddings, baptisms and funerals.

As I drove to Bessie’s home, the wind and snow blew furiously. It seemed ironic that whenever Bessie, who absolutely loathed our cold Northern winters, was in crisis, and I needed to see her urgently, I had to drive through a snow squall.

Yet there was never any question that I would go. Years before, Susan had asked that, when Bessie’s time came, I would make the pronouncement. I knew from Susan’s voice that my carrying out this final act meant so much to the family. The promise, once made, was the kind you keep.

At Bessie’s home the front door was ajar, its thin, glass outer door offering poor protection against the cold and wind. I assumed this was an invitation for me to enter without knocking, but I later learned that it was a tradition–no one knew its origins–whereby after a death a door or window is left open in order to let the soul out.

A single lit candle burned on the dining table. Bessie was lying in her recliner chair, between the kitchen and the dining table. For a split second, I felt a sense–call it hoping against hope–that maybe she was still alive after all.

My senses took in the larger landscape around Bessie, in a delayed, almost mechanical adjustment. Around Bessie sat her two daughters, her son, her daughter-in-law and grandson.

Over the years, I’ve learned that in situations such as these, the words I say aren’t as important as my presence, a tolerance for silence and an open, listening ear. I acknowledged each person there, then turned to Bessie herself.

In the two hours since her passing, her face had already taken on the characteristic high-cheekboned mask of death. Still, I felt compelled to check for a pulse and to auscultate her heart. It seemed such a peculiar but inescapable act, a fusing of necessity, futility and formality–as if Bessie weren’t dead till I said she was. Still, I didn’t see any need to state the obvious.

The family gave me the funeral home’s number, and I called it.

“Hello, my name is Dr. Tyler. I’m at the home of my long-term patient Bessie…”

Strangely, the funeral-home person seemed taken aback that a physician, rather than a hospice nurse, was calling to pronounce a patient. He even asked whether I was “allowed” to do it. Controlling my anger, I assured him that I was and provided the necessary information for the death certificate.

A kitchen-table chair was provided, and I joined the family circle seated around Bessie, waiting for the hearse to arrive.

Over the next hour, I learned things about Bessie that I’d somehow missed during our years together. Her parents were Greek immigrants whose poverty had forced them to give Bessie and her brother up for adoption. She’d been raised by a family on the outskirts of Richmond, Virginia, and had kept in touch with her foster family into late life.

Crackers, cheese and fruit were offered, and I nibbled on them, not out of hunger, but out of politeness. It reminded of my own family’s Eastern Orthodox traditions, how we pray and eat and drink around the graves of our dead. It all felt so unsettling, and yet so familiar.

Oddly enough, the conversation flowed easily as we sat around Bessie. It seemed as if no one was quite ready to let her go. Periodically one daughter would grasp Bessie’s feet and touch her forehead to them. In those moments, I believe she was praying.

After about an hour, the hearse arrived. I felt that my work was finally complete, and I strongly felt that Bessie’s family deserved some final moments alone with her.

Heavy, wet snow covered my car. I backed it slowly out of the driveway, taking care not to hit the hearse parked alongside.

The road home felt slippery and unsafe, and visibility was limited even with the windshield wipers flapping at high speed. Despite a lifetime of driving in Midwestern winters, I didn’t relax until I was inside my home again.

My two teenage daughters and wife were asleep. In years past, I would have taken a few shots of scotch to numb a deep inner disquiet that predictably emerges when someone I know dies, whether a patient or family member or friend or parishioner or acquaintance, whether expected or unexpected, whether it was “their time” or whether it “happened too soon.” In more recent years, I have learned to live life and live through times such as these without the mind- and soul-destroying anesthesia of alcohol–learned to tolerate the grief, the loss, the futility, the ultimate aloneness of being a healer to the dying.

I went into my home office, closed the door, read some Scripture–I can’t recall which verses–and, amid the deep darkness and silence, somehow regained a sense of inner calm and acceptance. I prayed for eternal rest for Bessie and peace and healing for her family. Then I climbed the stairs to bed.

Upstairs, I undressed in darkness and, as I had done countless times before, eased myself into bed gently so as not to disturb my wife. She stirred momentarily anyway, mumbled a few words, but quickly returned to sleep. The following morning, she didn’t even recall the brief awakening.

Now and then Bessie comes into my mind without warning.

Sometimes the trigger is clear: I’m in the midst of examining a diminutive elderly woman with white hair, a Southern accent and gentle courtesy. Sometimes Bessie comes to mind when I’m breathless, panting and sweating from exercise. And sometimes she returns to my consciousness for no apparent reason at all.

Carl V. Tyler Jr. is a physician. This piece was originally published in Pulse — voices from the heart of medicine, and is reprinted with permission.