Lo, How a Rose E’er Blooming: Fragility and the Conversations We Struggle to Begin

“Lo, how a rose e’er blooming from tender stem hath sprung.”

The hymn begins with an image of fragile life emerging in winter. A rose appears where it should not be possible, thin stem rising through hard ground. In serious illness, especially during the holiday season, this image has always felt true to me. The clinical world carries its own winter. Treatments accumulate, appointments crowd the calendar, decisions loom larger, and families gather around what has been unspoken. And, at the center of much of it is fragility. Not only of the body, but of honesty. Patients often cannot bring themselves to say what they truly want. Clinicians hesitate to ask. The result is a silence that grows heavier as the season grows colder.

I have learned that when people avoid medications, skip appointments, or begin to withdraw from treatment, the reason is often not confusion per se (though there is uncertainty). Often, it is something much quieter. People are tired. They are reevaluating what they can carry. They do not want to burden their families or disappoint those who equate more treatment with more hope. They hold back their truth to protect others. And the system, fragmented and fast moving, rarely creates the continuity required for these truths to surface early.

Research confirms this pattern. Patients with serious illness often keep their deeper preferences private because they fear upsetting or burdening their loved ones (Bélanger et al., 2020). Many continue disease directed therapy that no longer aligns with their goals because they feel obligated to preserve hope for others (Song et al., 2021). These realities shape the emotional landscape of serious illness care. Silence is not lack of need. Silence is protection.

The hymn becomes a guide. Fragility, like a tender stem, reveals what lies beneath the frost. It is not only a symptom. It is a signal.

From Tender Stem Hath Sprung

Fragility in illness often acts like a quiet form of prophecy. A patient’s hesitation, a missed refill, a soft admission of fatigue, all of these moments carry meaning. They point toward something deeper that has not yet been voiced. Research on communication shows that patients routinely offer subtle emotional cues during visits, and most of these cues signal unspoken fear, uncertainty, or the need for relational reassurance (Finset & Zandbelt, 2022). Yet a significant proportion of these cues are not acknowledged. Even in oncology, where decisions are high stakes, clinicians respond to fewer than half of emotional openings (Gössi et al., 2025).

When these cues go unrecognized, the burden stays on the patient to initiate the real conversation. Many will not. In one study of individuals with advanced cancer, patients reported wanting to discuss prognosis or preferences, yet waited for the clinician to ask because they feared being perceived as pessimistic or disappointing (Mack et al., 2012). What emerges is a pattern where fragility is speaking, but no one has yet created the warmth where truth can bloom.

Amid the Cold of Winter

The clinical environment itself compounds the challenge. Discontinuity is now the norm. Patients see multiple specialists across different settings, often with no shared narrative. Research shows that continuity of care is one of the strongest predictors of whether meaningful end of life discussions occur early rather than in crisis (Levy et al., 2022). When continuity is absent, everyone waits for someone else to take the lead. Clinicians may worry the timing is wrong. Families may feel the subject is too heavy to introduce. And patients, trying to spare others, often decide to wait as well.

Bernacki and Block (2014) note that clinicians frequently avoid initiating goals of care conversations when they do not feel they know the patient well enough or when the visit is pressured. That hesitation is understandable. At the same time, without someone responsible for holding the arc of the story, the deeper truths often go unspoken until options have narrowed. Sudore and Fried (2010) emphasize that meaningful conversations must begin long before decline becomes unmistakable because health changes unpredictably. Without continuity, the system becomes cold ground. Insight has difficulty taking root.

This is the winter the hymn describes. A world not ready for something tender. A landscape too hardened for quiet truth.

True Man Yet Very God

Incarnation is the turning point of the carol: divinity taking on flesh. In healthcare, incarnation is not just theological. Healthcare offers the opportunity for an embodied practice of presence. Through choosing to sit instead of stand. Through attending to tone, eye contact, posture, and warmth. Through bringing the full self, rather than hiding behind a distant clinical stance.

Research consistently affirms the therapeutic power of embodiment. Patients perceive their clinicians as more caring and more trustworthy when those clinicians sit at the bedside rather than stand (Swayden et al., 2012). Eye contact has been shown to be the strongest predictor of perceived empathy in clinical encounters (Montague et al., 2013). Even small gestures of warmth, such as a supportive touch or a calm nod, increase patient openness, decrease anxiety, and strengthen the relational alliance (Kukora et al., 2021). These behaviors help patients feel safe enough to share what they have been carrying alone.

Empathy is not only relational. It shapes outcomes. In a study of diabetic patients, physician empathy was associated with significantly better glycemic and cholesterol control (Hojat et al., 2011). Compassionate communication also reduces anxiety and improves adherence across multiple conditions (Trzeciak & Mazzarelli, 2019). Attentive presence in practice has measurable effects.

To Show God’s Love Aright

When fragility is met with presence, truth can finally surface. Research on serious illness communication shows that conversations that begin with curiosity and partnership lead to greater alignment between a patient’s goals and the care they receive (Back et al., 2019). Instead of assuming the goal is more treatment or assuming the opposite, clinicians create space for questions like “What are you hoping for now” or “What matters most today.”

Patients describe immense relief when they are finally able to articulate what they truly want without fear of judgment (Schulman Green et al., 2021). Families often recalibrate once they understand the emotional burden the patient has been carrying. Care plans shift from assumption to alignment.

Here the hymn’s central image returns. The rose blooms not because the conditions are ideal, but because the presence of warmth makes growth possible. Fragility is not a failure. Fragility is the doorway to what is real. Christmas is a story of presence in the midst of vulnerability. A rose blooming in winter. A child born in a place of scarcity. In healthcare, we see versions of this story every day. Patients offering hints of truth. Families carrying heavy expectations. Clinicians wanting to help, but unsure when to begin. When continuity and presence come together, even briefly, people find the courage to say what they need.

The task is simple and difficult. Notice the cues. Listen more than speak. Make space where fragility can bloom into honesty. In doing so, we help shape care that feels coherent and human. We help create a story where the tender stem has room to rise.

References

Back, A. L., Fromme, E. K., & Meier, D. E. (2019). Training clinicians with communication skills needed to talk about serious illness. JAMA Internal Medicine, 179(1), 1 to 2. https://doi.org/10.1001/jamainternmed.2018.5148

Bélanger, L., Rodríguez, C., Groleau, D., Macdonald, M. E., & Marchand, R. (2020). Why older adults' treatment preferences change over time. The Gerontologist, 60(7), 1211 to 1220. https://doi.org/10.1093/geront/gnz157

Bernacki, R. E., & Block, S. D. (2014). Communication about serious illness care goals: A review and synthesis of best practices. JAMA Internal Medicine, 174(12), 1994 to 2003. https://doi.org/10.1001/jamainternmed.2014.5271

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Gössi, F., Arpagaus, A., Gross, S., Zumbrunn, S. K., Bissmann, B., Hunziker, S., & Becker, C. (2025). Physician responses to emotional cues and concerns and their associations with patient outcomes. Patient Education and Counseling, 142, 109386. https://doi.org/10.1016/j.pec.2024.109386

Hojat, M., Louis, D. Z., Markham, F. W., Wender, R., Rabinowitz, C., & Gonnella, J. S. (2011). Physician empathy and clinical outcomes for diabetic patients. Academic Medicine, 86(3), 359 to 364. https://doi.org/10.1097/ACM.0b013e3182086fe1

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Mack, J. W., Cronin, A., Keating, N. L., Taback, N., Huskamp, H. A., Malin, J. L., ... & Weeks, J. C. (2012). Associations between end of life discussion characteristics and care received near death. Journal of Clinical Oncology, 30(35), 4387 to 4395. https://doi.org/10.1200/JCO.2012.43.6055

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Trzeciak, S., & Mazzarelli, A. (2019). Compassionomics: The revolutionary scientific evidence that caring makes a difference. Hatherleigh Press.