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December 07, 2016 at 04:48 PM EST

With a midseason finale title like “Last Christmas,” you have to expect the episode will wrangle with issues of life and death (especially given that one character in the present timeline has terminal cancer and one character from the past timeline now lives in an urn on Kate’s mantel), but in typical This Is Us fashion, even I was left slack-jawed by the specific mortality in question.

We open on Christmas Eve 1989. Kate’s complaining of a stomachache. Rebecca’s sure the empty box of cookies in the kitchen has something to do with it, but when Jack feels Kate’s forehead, she’s burning up. Turns out she has appendicitis and needs surgery. Kate is obviously nervous about the operation, so Rebecca breaks off a small sprig of garland from the hospital’s decorations, telling Kate it’s a magical Christmas branch and that “nothing bad happens on Christmas Eve.” (We’ll ignore the multiple studies highlighting just how deadly a time of year Christmas is…)

While at the hospital, the Pearsons run into a familiar face: Dr. K, the man who delivered the twins and inspired them to adopt Randall. But this time, sadly, he’s a patient. Rushing out of town for the holidays, he hit a patch of ice and wrapped his LeSabre around a tree, and his family won’t make it in from Montana in time to say goodbye. Which seems a touch overdramatic, until Dr. K explains he has slow hemorrhaging between his lung and heart and doesn’t think he’ll survive a surgery.

“Don’t let this flattering hospital lighting fool you, Rebecca,” he says. “I’m old.”

Rebecca and Jack decide they will stay by Dr. K’s side (at least until their daughter is out of surgery). Randall, meanwhile, wanders down to the hospital gift shop and uses his savings to buy a snow globe for Dr. K, a get-well/thanks-for-helping-me-get-adopted present.

Dr. K demurs at all the praise: “All I did that day was nudge a man in a direction he already wanted to go.” Nonetheless, he accepts the thoughtful gift from the boy and suggests that when Randall has a chance to do good, he pay it forward.

In the current timeline, nobody’s Christmas seems to be going as planned. Kevin finds out on Christmas Eve his play — sans its leading lady, as Olivia vanished a month ago — has been canceled. As a small make-good for alienating his costar and getting her play axed, Kevin joins playwright Sloane and her family for Hanukkah dinner. (Sloane may or may not have told her family she was dating The Manny.) “I can’t show up with no play and no Manny,” she pleads. At the table, Sloane delivers a moving retelling of the Hanukkah story that inspires Kevin: “We have to have faith in each other,” he says. “Screw these producers, we can put this play on ourselves!” Kevin will front his own money to pay for the production, and Sloane will step into the lead role.

Meanwhile, Kate and Rebecca are at a consultation for Kate’s upcoming gastric-bypass surgery, and the realities are bleak. Post-surgery, Kate’s stomach will be the size of an egg; she’ll be able to eat only two ounces of food at a time; she’ll have to take vitamins for the rest of her life to avoid malnutrition. During the car ride home, distraught over hearing about her daughter’s struggle with depression and binging for the first time, Rebecca asks if it’s all her fault.

“Did I do this?” she wants — needs — to know. “I did, didn’t I? With the food.”

“I don’t know,” Kate answers honestly.

NEXT: Blue Christmas

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