Dying: a lively subject
While visiting a cemetery in Lancaster, Ohio I came across this saying on a headstone:
“Behold and see as you pass by
As you are now so once I,
Prepare for death and follow me.”
My mother fractured her hip at the age of 99 and despite surgery began to fail physically. She was not very hungry. She was non-ambulatory. One of her comments was quite insightful.
“My life is getting smaller.”
She had previously lived in an independent living apartment and now was in a single room within a subacute nursing facility. She liked where she was and wanted to stay there because it offered security, relationships, and a sense of belonging. The aesthetics of her independent living apartment was now a source of fear of being lonely and neglected. Her living space was becoming smaller. Her wants were becoming smaller. She was physically becoming smaller. It is a statement ripe with meaning. For many of us becoming small and having our life downsized is fearful. However, in dying we cannot ride the camel of possessions through the keyhole of death. You can’t take it with you so you might as well leave it behind. Relationships are portable and require very little space. Perhaps the simplicity of becoming small will lead one to a sense of being in the moment. Putting our toys down, one may find relationships needing only the space that we are.
I wrote a poem about my mother who was at the time healthy and independent. There are 9 of us children and she has let us know in no uncertain terms that there would be “no tubes” and “no compressions”. I would not doubt that she would posthumously put us all in time-out or worse if such events happened. The poem “The Gift: Reminisce” was kindly published in the Journal of Palliative Medicine in 2017 (1).
“The gift is yet given; time reversed.
She breathes with lesser force who gave your beginning.
Resuscitate! Revive!
And so, we started
Energy increased; pulse weakened.
Memories grew, memory fades.
Meaning swelled, life receded.
Sickle unsheathed, as no friend, leaves us parting gifts.
Mother’s rebirth at the evening hour.”
This stanza from a poem by Theodore Roethke entitled “The Dying Man” reminds me of two tools used to help families cope with a dying loved one, rippling and reminiscing (2).
“I heard a dying man
Say to his gathered kin
‘My soul’s hung out to dry,
Like a fresh-salted skin.
I doubt I ‘ll use it again.
What’s done is yet to come:
The flesh deserts the bone:
But a kiss widens the rose.
I know, as the dying know,
Eternity is now.
A man sees as he dies,
Death’s possibilities
Only heart sways with the world.
I am the final thing.
A man learning to sing.’”
Rippling refers to the concentric circles of influence which affect others for years and through generations (3). The term is taken from the visual picture of a rock dropped in a pond or lake with concentric rings of waves that extend out of sight. We may have even influenced others whom we have never known. It is leaving behind a bit of wisdom, guidance, value, or comfort after one has left. It does not refer to a name on a building or a company. Rippling can produce a sense of meaning in the face of transiency and does not require a belief in the afterlife. Gratitude expressed by friends, family, and colleagues will cause rippling for the dying as a good means of reducing the pangs of death and mortality salience.
Reminiscent I have touched upon. Recalling meaningful events in one’s life with the dying adds meaning to the dying. Again, this is without the need for a connection to a belief about the afterlife. Often times I start reminiscing at the bedside. I ask families to give me a sense of understanding of the one who is dying. That often sets off a series of stories, some humorous, some tragic, but all meaningful. I am always surprised about what I learn. Such stories surpass and often color the rather flat social history one finds in most medical charts.
I am afraid that many of us (me included) have this conscious or subconscious sense of mortality. Death is at a distant from the present moment.
“We dream we have a drove of years
Morning bright without a tear
How foolish to think the daylight lasts,
Without the shroud of darkness cast.” (4).
After my cancer surgery over a decade ago, life became intense and now I have entered my seventieth year of life. As I get older, I am less tolerant of wasting a day on my own account. I also want to be in the moment, in the now. Life can be so rich in the end and particularly when it appears short. One of the questions I ask patients is “What do you want to do with the remaining part of your life?”
Then there are losses through the years. I have lost classmates from high school and mentors. Sometimes I feel as if I am in the last generation standing before the next one takes over. The loss of a spouse changes everything and though one may “move on”, life cannot be the same. Fortunately for me, my wife has tolerated me for 46 years which speaks much for her resilience and endurance. This poem by RS Thomas entitled “A Marriage” is about the loss of a spouse (5).
“We met
Under the shower
Of bird notes.
Fifty years passed.
Love’s moment
In a world in
Servitude to time.
She was young:
I kissed with my eyes
Closed and opened
Them on her wrinkles.
‘Come,’ said death,
Choosing her as his
Partner for
The last dance, and she,
Who in life
Had done everything
With a bird’s grace,
Opened her bill now
For the shedding
Of one sigh no
Heavier than a feather.”
A second poem plays upon the ebb and surge of the sea as a coming and going in life.
“The dying need their sacred shore
To cast a receding sigh to silence
then journey to the sun-light sea
and wave to us in ebb tide flow
the worth that earthen life did hold.”
Those who have been in hospice or palliative medicine for a period of time, they will witness an end-of-life dream or vision. These are dreams and visions which become vivid and are usually observed within 48 hours of death. The vision is often of a deceased relative, friend, or saint or it may be a journey, a color, and projects an understanding that death is near. Categories of response may be a comforting presence, preparing to go, engaging with the dead, seeing a loved one waiting, or it may consist of unfinished business or distress. It is not delirium. Those naive to end-of-life visions may mistake it for delirium and attempt to treat it with an antipsychotic. I wrote this poem reflecting on caring for Ed as he was dying:
Ed’s Vision (6)
“He lifts his hands into the air
To reach for someone who’s not visibly there
Was this a transcendent vision’s open stair,
Or a life-dehiscent troubled stare.”
We are given many gifts in accompanying the dying through to their death. Many will die with dignity, and some will be alone or abandoned which is the fear I have, to be honest. I find the greatest meaning in medicine using the art and science accumulated over time to care for the dying. It is intensive care. But it also causes me to reflect on my own end. How shall it all end? (7).
“Shall the end come, slow, vision lost
Or swift in a moment, no time to bid bye?
Shall pain pepper death’s pathway?
Diminishment canker body and soul?
Does mental clarity bring one finally to peace?
Or increase suffering’s hot coals in defeat?
Can thanks be given for the pleasant years be a final address?
Or will I grumble away time as unblessed?”
Acknowledgments
Funding: None.
Footnote
Provenance and Peer Review: This article was commissioned by the Guest Editor (Paul Rousseau) for the series “The Human Experience” published in Annals of Palliative Medicine. The article did not undergo external peer review.
Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://apm.amegroups.com/article/view/10.21037/apm-22-967/coif). The series “The Human Experience” was commissioned by the editorial office without any funding or sponsorship. The author has no other conflicts of interest to declare.
Ethical Statement:
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- Davis MP. The Gift: Reminisce. Journal of Palliative Medicine. March 2018.398-398. Available online:
10.1089/jpm.2017.0487 10.1089/jpm.2017.0487 - Roethke T. The Collected Poems of Theodore Roethke, 1st ed. New York: Random House, Inc., 1975.
- Yalom ID. Staring at the Sun, Overcoming the Terror of Death, San Francisco: Jossey-Bass, 2008.
- Davis MP. Time. Journal of Palliative Medicine. Apr 2018.569-569. Available online:
10.1089/jpm.2017.0540 10.1089/jpm.2017.0540 - Thomas RS. Collected Poems 1945-1990. London: Orion Books Ltd., 1993.
- Davis MP. Three Poems: Dementia, Ed's Vision, Temporal. Journal of Palliative Medicine. Jun 2018.881-881. Available online:
10.1089/jpm.2017.0565 10.1089/jpm.2017.0565 - Davis MP. Five Short Poems. Journal of Palliative Medicine. Jul 2019.868-869. Available online:
10.1089/jpm.2018.0611 10.1089/jpm.2018.0611
