When contemplating palliative care, our first thought may be to envision pain relievers, symptom assessments, and medical guidelines. However, for individuals facing terminal brain cancer, the situation is significantly more intricate. As communication wanes, physical abilities decline, and the essence of one’s identity comes under threat, the primary requirement is not necessarily increased medication; rather, it is finding meaning, fostering connections, and upholding dignity.

In recent times, I have had the privilege of exploring an ancient art that provides something meaningful during this stage of existence: Japanese calligraphy, known as shodō. Beyond merely being a style of writing, calligraphy in Japan is deeply intertwined with Zen Buddhism and cultural customs that prioritize mindfulness, stillness, and contemplation. Each brushstroke is irreversible, similar to life itself. What captivated me the most is the potential for this practice to serve as a final expression for patients whose verbal communication is fading. A solitary kanji symbol, like 愛 (ai, love), 忍 (nin, perseverance), or 命 (inochi, life), may encapsulate a patient’s last sentiments to loved ones when spoken words are no longer feasible.

The rationale behind this practice is intriguing. Utilizing a brush stimulates intricate motor pathways, visual-spatial focus, and emotional processing areas within the brain. Research conducted in Asia indicates enhancements in mood and cognition among older adults engaged in calligraphy, and in our clinical experiences with brain tumor patients, the impact has been even stronger. At Kyoto University Hospital, those who participated in calligraphy sessions in their final days reported reduced existential anxiety and improved emotional bonds with their families. One caregiver remarked, “It was the first instance in weeks that my father expressed something through his hands that words could not convey.”

I have also observed how this practice crosses cultural boundaries. At St. Christopher’s Hospice in London, patients explored calligraphy via workshops organized in partnership with the Japan Foundation. Despite initial reluctance, several participants (none of whom were Japanese) found the experience deeply affecting. One brain tumor patient, whose hand trembled uncontrollably, traced the character for 風 (kaze, wind). He later shared that it evoked thoughts of transformation and tranquility. Staff noted that he became more socially interactive and visibly composed. Even through cultural differences, meaning extends beyond mere traditions.

In the United States, calligraphy therapy has started to carve its niche within integrative medicine. A calligraphy retreat at Stanford for neuro-oncology patients and their caregivers unveiled something extraordinary: all attendees reported emotional relief, and most characterized the practice as a novel avenue for communication. What unites these programs is not just the brush and ink, but the establishment of an environment where patients can reclaim their voice, identity, and presence at a time when so much has been taken away.

Naturally, incorporating Japanese calligraphy into Western palliative care does present certain obstacles. Healthcare systems facing pressure might question the viability of such approaches. Administrators seek proof, staff often lack available time, and cultural awareness is vital to prevent diminishing calligraphy to a mere aesthetic pursuit. However, when approached with reverence and appropriate context, this journey is not about embracing exoticism. It is about offering patients an additional method of expression.

Next month, I will be heading to Paris to showcase this work at the annual gathering of the Société Française d’Accompagnement et de Soins Palliatifs. While there, I will carry the essence of patients’ brushstrokes from hospices in Tokyo, wards in London, and integrative care facilities in America. My aspiration is that these narratives will motivate my colleagues in Europe to reconsider what it entails to broaden our understanding of evidence. While we may never quantify dignity, tranquility, or significance as easily as we assess pain levels, that doesn’t diminish their reality or the fundamental role they play in the essence of medicine.

At life’s conclusion, when numerous treatments have proven ineffective, it is frequently art that endures. A brush dipped in ink can assist patients in leaving a legacy, communicating without uttering a single word, or simply achieving peace. In those serene moments, medicine and art converge not in conflict, but in unity. From Tokyo to Paris, and hopefully far beyond, brushstrokes continue to remind us that every voice holds value, right up until the very last one.

Vikram Madireddy is a neurologist. Francesco Panto is a psychiatrist. Both reside in Japan.