Before and After


Cecilia Runkle, PhD, MPH1

Perm J 2019;23:18-179 [Full Citation]
E-pub: 03/01/2019

Death is not waiting for us at the end of a long road. Death is always with us ... she is the secret teacher hiding in plain sight. — Frank Ostaseski, The Five Invitations

In 1991, I served on a Kaiser Permanente team to prepare staff for the Patient Self-Determination Act and how to speak with patients and their families about advance directives. Years later, I mentored Permanente Medical Group and Group Health physicians in teaching their colleagues how to have conversations about death and dying.2 In 2016, my partner of 36 years unexpectedly died. During this time I wrote the following haiku about my experience.


Before and During

Doing the right thing
Consequences multiply. Right?
Yes, but still sad

Heart breaks when he says
“I want to come home with you.”
That’s what I want too

“it’s out of your hands”
Striving to do what I can.
Limits are unclear

What to do? I asked
Be present. Speak up. Hold him.
More than good enough

Feel nausea heart quakes
Dead. Gone. Ashes.
Nevermore. Am I in a dream?



Sliding through each day
Without notice: remember.
Images flood mind

Going through motions
Get up, walk, eat, pretending.
Act as if I live

Time drags me under
Too much time not enough time.
I succumb to time

These are early days
Four and one half months so fresh.
Walking the Bardoa

Open or push down
Each moment offers a choice.

My constant mantra
He’s not suffering. He’s safe.
I did my best

Easter services
Happy? No, just not crying.
Solace in a crowd

I am sore angry
“Get on with it,” one voice says.
I will not be pushed

She’s speaking my words
Only someone who’s been there.
Echoing my truth

I am very strong
No proving needed; just ask.
People want to help


At the Library

I told her he died
She remembered his last name.
He’s not forgotten

Glimmers will appear
Accept hard times will remain.
Give it time she says

Each day a new day
To breathe, to feel: remember.
Six hundred plus days

Disclosure Statement

The author(s) have no conflicts of interest to disclose.

How to Cite this Article

Runkle C. Before and after. Perm J 2019;23: 18-179. DOI:

Author Affiliations

1 Department of Practice and Leadership Development, Group Health Physician (now Washington Permanente Medical Group), Seattle, WA

Corresponding Author

Cecilia Runkle, PhD, MPH (

1. Ostaseski, F. The five invitations: Discovering what death can teach us about living fully. New York, NY: Flatiron Books; 2017.
 2. Runkle C, Wu E, Wang EC, Gordon GH, Frankel R. Clinician confidence about conversations at the end of life is strengthened using the four habits approach. J Psychosoc Oncol 2008;26(3):81-95. DOI:
 3. Lions Roar Staff. What’s a bardo? [Internet]. Halifax, Nova Scotia, Canada: Lion’s Roar Foundation; 2017 Apr 19 [cited 2018 Oct 26]. Available from:

Keywords: advanced directive, caregiver, death, family, soul of the healer


Click here to join the eTOC list or text ETOC to 22828. You will receive an email notice with the Table of Contents of The Permanente Journal.


2 million page views of TPJ articles in PubMed from a broad international readership.


Indexed in MEDLINE, PubMed Central, EMBASE, EBSCO Academic Search Complete, and CrossRef.




ISSN 1552-5775 Copyright © 2021

All Rights Reserved