Open Spaces and The Valley Between

“Everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances.”

—Viktor E. Frankl ¹

The room was quiet that evening. Charlie Chaplin reruns played in the background, the silent expressions filling the spaces between us. We watched Westerns, too—John Wayne’s slow swagger was familiar and comforting.

Music floated gently through the air—Neil Diamond’s voice, Jose Feliciano’s ballads, “Quando, Quando, Quando,” and finally “Sweet Caroline.” These weren’t just songs. They were echoes of a life well lived.

He had come so far—from a curious nine-year-old to the dignified man now lying in bed with metastatic pancreatic cancer and a malignant bowel obstruction. The decline was unmistakable: intravenous fluids, total parenteral infusions, liquid diets for comfort, and piperacillin-tazobactam for aspiration pneumonia. Medications crossed borders with him—from the United Arab Emirates to Bani Gala, Pakistan—as he faced what could no longer be postponed. Here, in a home tucked among mountains and valleys, he slept and woke with nature’s quiet companionship.

As his disease progressed quietly, his personality began to shift, and his frustration surfaced. A whirlwind of emotions flooded over me and swung between extremes—from moments of despair to unexpected joy. Was this anticipatory grief? The ache of letting go while still holding on? I cycled through anguish and sorrow, grasping for moments of happiness in the familiar routines and shared memories. Yet, the pain remained as I watched my father—who was always fiercely independent, even at 89—become weaker. Stoic and steady, he still carried his wit with his quiet jokes, lightening even the heaviest moments. His humor was a balm, a shield, and a final gift. However, underneath, there were moments of frustration—he had expected to live until “99,” and the betrayal of his own body was something no humor could undo.

He visited my mother one afternoon, gaunt and hollow-eyed. In a frail whisper, he said, “I’ll starve to death.” I sat beside him, gently explaining that the loss of appetite was part of his advanced illness—that the malignant bowel obstruction had made eating impossible. But he wasn’t asking for a clinical explanation. He was grieving something deeper. He hadn’t eaten in seven weeks. He missed the act of cooking, and the joy of nourishing others. That night, he turned to my mother and quietly said, “I hope I die in my sleep.”

He often stared out the large window—eyes fixed on trees and mountains. When I asked if he had any final words of wisdom, he said simply, “Never stop learning.”

We were a team: four daughters, a frail ex-wife, and grandchildren. No social worker. No formal hospice. Only love, makeshift care, and experience. My sister, a neonatologist, coped by intervening—adjusting fluids, and correcting his hypokalemia and hypomagnesemia. My eldest sister buried herself in paperwork—power of attorney, banking, and practicalities of letting go. My youngest sister withdrew.

And I—trained in palliative medicine—recognized what others didn’t. The signs. The turning points. The needs. I also knew the ethical dilemma: physicians should not treat family. But what happens when you are the only one qualified, and the system offers no alternatives?

In that moment, blurred by necessity and love, I became both daughter and physician. Dosing opioids is what I did best, to ease his pain, not from ego, but to prevent suffering—in a region where such care was otherwise unavailable.

Two days later, a regional conflict erupted. Airports were closed throughout the country. India launched strikes in Islamabad, Pakistan, less than half a mile from where I was staying, including the military base—missiles, drones, and blasts and explosions echoed through the night. My stomach clenched as I thought of my children. We were now in a warzone—geographically and emotionally stranded. I kept thinking, would there be another night of bombardment? A ceasefire quickly followed, bringing tremendous relief and prompting thoughts of “What if?”

As a palliative care physician, I had the privilege of knowledge—and access. I had brought fentanyl patches, hydromorphone, scopolamine, atropine drops, midazolam, and olanzapine after obtaining a prescription from my father’s oncologist in Abu Dhabi. These were staples of palliative medicine—yet unavailable in the region. Locally, only codeine, tramadol, and tapentadol were accessible. I was advised to seek morphine on the black market. The idea that families, already overwhelmed by grief and uncertainty, might be forced to seek relief in the black market was heartbreaking. Through my father’s journey, I saw the disparities in global palliative care.

In his final weeks, he surprised us with a request to visit his son-in-law’s new home. My father had always loved to socialize, to connect. He walked slowly, each step measured, his breath labored. His dazed eyes and the nasogastric tube taped to his cheek reminded us of his fragility. Still, he paused before the mountains and said, with quiet appreciation, “It looks like a house in Dubai,” he said, admiring how the sleek design stood against the backdrop of mountains nestled in a quiet valley.

Throughout his illness, my father never once complained of symptoms—though I knew he had them. His silence was not denial; it was strength. In the face of decline, he preserved his poise, never asking for more than what was already given—love, presence, and the simple beauty of shared moments.

He reminded us to hold space. To lead with love. To notice beauty, even when it hurts. And to move forward, even when everything tells us to stop.

Bani Gala, serene and cradled by trees, became more than a home.

It was the valley between life and death. Between letting go and holding on. Between knowing and not knowing.

This is where we lived his final days—in open spaces, with sorrow, silence, and fleeting moments of grace.

“Never stop learning,” was his final teaching.

And yet, nothing prepares you for the lesson of loss.