During ICU rounds I learn that Louis, in his 70s and with a long list of health issues, collapsed at a restaurant two nights earlier and was taken to the hospital.  As complications mounted, Louis requested to move to “comfort measures only”—ending all treatments intended to prolong life—over his wife Esther’s objections.  Esther was expected to return mid-morning, and the ICU staff requested chaplain support in navigating this situation.

When I get to the ICU, I find that Esther has just arrived and has already gone into Louis’s room.  Speaking first with his nurse, I learn Louis completed advanced care documents a few years ago that are consistent with his request.  Given this, and the fact that Louis remains fully coherent, Esther has no legal standing to object to his decision. 

I enter the room and I am greeted warmly by both Louis and Esther.  The nurse enters after me and starts implementing comfort care measures.  Louis’s eyes are mostly closed; he appears calm but laboring. 

Esther begins.  “We have three children and seven grandchildren.  Louis has been calling them and saying goodbye.  There’s only one left to speak to.”

Louis looks toward me.  “I just can’t go on … I don’t want to keep trying.”

“But, Louis, you promised me ten more years!” Esther pleads tearfully.  “You promised me I would be the one to go first.”

“I know I did, but I just can’t do it.”  He closes his eyes to rest.

Esther and I take seats off to the side for a few minutes.  She tells me about Louis and about their life together.  She then turns to his nurse, who has been adjusting equipment on the other side of the bed.  “He seems sleepy.  Are the painkillers making him that way?”

“Oxycodone can cause drowsiness, but we have also stopped the meds that have been keeping up his blood pressure, among other things.  Louis is now entering the phase of active dying; his body systems are shutting down and he will become quieter.  He appears comfortable, and we will keep him that way.  He seems very clear of mind—unusually so for this stage.”

“Oh, you should see him when he is well—he has as sharp a mind as you will ever see.”

Esther and I turn back toward each other.  “What makes this so hard is that our son, who we live with, was recently diagnosed with terminal liver cancer.  He is only 40!  This is all just happening so quickly …”

“I’m sorry.  That is so hard, and you have had so little time to process things since Louis collapsed.”

“Now we are having conversations that we probably should have had years ago.  He’s had health issues for a while, but I didn’t expect this.  I just don’t understand why he seems to have lost the will to live.”

“From everything you have told me, and what I have seen myself, Louis is a very strong-willed man.”

“He certainly is … very much so.”  After a long pause, Esther continues.  “Maybe his body just won’t let him keep going.  Louis always says he doesn’t understand why people make such a big deal out of dying, when we know we are just going to a better place.  That’s what he believes … and I believe that, too, that’s our faith.”

Two nurses come in and prepare to sit Louis more upright in his bed, to make it easier for him to make his final call.  I conclude my visit, and later learn that Louis died 45 minutes after I departed.

◊

I recently read Joan Didion’s memoir The Year of Magical Thinking, which chronicles her grieving process following the sudden death of her husband of 40 years.  There are several parallels with the story of Louis and Esther, including Didion’s grief being complicated by a life-threatening illness that befell her daughter one week prior her husband’s death.  Important differences, too—Didion never had the opportunity for final conversations with her husband.

The most profound parallel, though, is the extent to which both women refused to entertain the imminence of their husbands’ deaths despite abundant foreshadowing.  Didion recounts conversations with her husband that began and ended:

“If something should happen to me …”

“Nothing is going to happen to you.”

Louis’s health concerns were sufficiently severe that he had completed a POLST (Portable Orders for Life Sustaining Treatment), usually used only in cases of advanced illness.  Despite this, Esther persisted in the belief that Louis would live ten more years, and Louis entertained this magical thinking until he could no longer do so.  Esther’s remark, “Now we are having conversations that we probably should have had years ago” was an understatement—during what turned out to be their final hour together, they were just broaching topics such as cremation vs. burial and what kind of memorial service Louis wanted.

Denying the imminence of death is, of course, hardly uncommon.  Even if Esther and Louis had prepared themselves better for Louis’s collapse, Esther’s pain of losing her husband, and the dread she felt for losses yet to come, would be excruciating for anyone in her situation.  It was heartbreaking to sit with her as this new reality began to settle in.  As in my earlier essay Dying is Often the Easy Part, Louis was on the cusp of being released from suffering while Esther’s journey was only going to get harder—and she would have to manage it without Louis, her soulmate for more than 40 years.

One of my primary motivators for this Elder Chaplain project is my belief that normalizing conversations around mortality, especially with our loved ones, can mitigate the distress of a serious health crisis—whether ours or theirs.  In particular, by helping to dispel the magical thinking about immortality that we all can be subject to, engaging in these conversations when we are healthy can help us be more fully present with each other when we arrive at a time of need. 

As the new year dawns, I am grateful for you, my readers, who through your support have joined me in these conversations about mortality.  In the coming year I hope to engage with you more directly, and to bring your voices and experiences into this conversation, so that together we can grow in wisdom.