Pronouncement

The following is an excerpt from my (hopefully one day to-be-published) memoir. This is from the very end, as I imagine the death of Dr. Elisabeth Kubler-Ross, author of "On Death and Dying."

In 1997, Oprah Winfrey went to Arizona to interview Elisabeth. “In a bit of poetic irony, the woman known as ‘the Death and Dying lady’ now finds herself at the end of her life,” says Oprah, a sentiment that is fundamentally flawed: it wasn’t ironic that Elisabeth was dying, not at all. That was her whole point, that’s the whole point of everything she worked for, her whole career, her whole life—that we are all going to die. All of us. Even me. Even you. Even fucking Oprah, and even Elisabeth. No, poetic irony would be if she lived forever, if the world’s foremost expert on dying never died, never had the chance to test her theories about the stages and the afterlife out for herself.

But that wasn’t the case. At the time of the interview, Elisabeth was only seventy-one years old and had already had a series of strokes that left her wheelchair-bound and partially paralyzed. To my eye, she looks old, unbelievably old—her skin is wrinkled with dark spots on her face, no doubt from decades of cigarette smoking and many years spent in the California and Arizona sunshine. She is tiny, as she always was, and her big personality is still evident, but physically she seems breakable, snappable. Even her short hair looks thin, waning. It’s hard to find the full video. But in one clip she lies recumbent, and she meets Oprah’s vaguely condescending questions with fullness and openness, almost as she doesn’t get that she’s being condescended to, but of course she does. “When you die, will you send us a sign?” asks Oprah. “I’ll pinch you on the tush,” answers Elisabeth.

But Elisabeth went on living. Strokes, and infections, and she became weaker and weaker. Eventually she went to live in a nursing home in Scottsdale, in Arizona, to be near her son Kenneth. She became angry, famously telling an Arizona newspaper in 2002 that God was a “damned procrastinator” for not taking her yet. It’s a sentiment I hear a lot in hospice, much more than people might think. So many of my patients have been losing themselves for years, maybe even decades—they can’t work, they can’t engage in their favorite active hobbies, they can’t travel like they used to. Then one day they get sick and realize they have to change more things about their life, what they eat, what medicines they take. Little by little their world grows smaller, becomes as big as the bedroom and the living room and the bathroom. Little by little they need help to do just about everything, prepare food and keep the house in order, and then eventually they even need help to walk, to bathe, to dress, to wipe their own ass. I had a woman once dying slowly of cancer who’d been sick for a few years with various other ailments before she came on hospice. It was about Halloween when I first met her. “Do you think I’ll make it to Thanksgiving?” she asked me. “Well, your vital signs are good, your color looks good, your breathing is good…No guarantees, but I think it’s a safe bet,” I answered. “GODDAMNIT!” she yelled and pounded her tiny fist against her thigh. “I want this to be OVER!”

Elisabeth felt that. She knew in her bones that whatever awaited her after death was nothing to be afraid of, and she was ready. And then, on August 24, 2004, Elisabeth finally did die.

I wasn’t there when Elisabeth died, of course. It was 2004. I was still an undergraduate then, worried first and foremost about boys, and what they thought of me, and my body, and how to change it, and my future, and what form it could possibly take. I was twenty. What a thing—to be twenty. What a preposterous, miraculous, beautiful thing.

But I can imagine what Elisabeth’s death was like. I’ve pronounced many patients dead, now. I can imagine what that nurse, whoever they were, must have found when they came to her bedside. I know it well.

When a person dies, their hands and feet become cool first—sometimes they are cold already, before a person dies, or sometimes they have been cool for days or weeks, purple with pooled blood that has ceased to flow. After an hour or so their forehead begins to cool too, and their cheeks, and their forearms. Their skin has a sheen—waxy is a common way to describe it, but it reminds me of the plastic top of a fountain soft drink, the pushed-in tab that is meant to indicate whether it’s diet or regular soda. It’s sort of cloudy, nearly see-through but not quite. Sometimes their mouths are open. Sometimes they are shut. Sometimes their eyes are open and I gently pass my hand over the lids to close them. Sometimes they pop back open, eyelids as jack-in-the-box. A family member asked me recently whether that meant the person had died scared, or died and gone to hell—I wasn’t quite sure what they were wanting to know, frankly. They wanted reassurance, I suppose, which of course I couldn’t give. I’m not god, and thank God for that. Still, I told them no, it didn’t mean that, or at least, I don’t know if it means that. It only means that the muscles around the eyelids had relaxed in such a way as to prop the lids open, or that the anatomy of the face caused them to relax in an open position instead of shut. The family member nodded, unconvinced. Sometimes a weird thing is just nothing. It’s not a sign, or a metaphor, or a judgment. When it comes to dying, that’s hard for people to understand.

The nurse who pronounced Elisabeth would have felt her skin, and seen her open mouth, and stared quietly but purposely at her chest, looking for any subtle rise and fall. Maybe she would have imagined that she saw it—the tiniest elevation of the clavicle, the smallest outward expansion of the delicate ribs. She would have looked harder, closer. Eventually she would have held Elisabeth’s wrist, feeling for a pulse—nothing. She would have taken her stethoscope and placed it over Elisabeth’s heart, listening for a beat, listening for air moving through the lungs. Maybe the nurse twitches ever so slightly and her stethoscope makes a noise, a kind of muffled rub that sounds like maybe, possibly, it could have been a heartbeat. Was it? She would listen harder. Maybe she’d close her eyes. Maybe she’d take her hand off the stethoscope to stop her own pulse from moving it ever so slightly.

Behind her, Elisabeth’s family would be waiting. They know she’s dead, of course. They see, they understand. But also they hope—maybe it isn’t so. Maybe the nurse pauses because the nurse is about to tell them otherwise, about to say No, she’s still with us, there is still time.

The nurse hopes that too.

But there is nothing in Elisabeth’s breast, no swoosh of air through the lungs, no soft drumbeat of pulse. She listens for thirty seconds, then thirty seconds more. Finally she shines a light into Elisabeth’s pupils—they are large, dilated, and fixed, meaning they do not react to the light, do not constrict as they should.

Death is always scary, no matter how many times you’ve been around it, and it always makes an impression. Once I arrived at a home to pronounce someone and their adult daughter was curled beside them in the bed, warming them, and I thought—oh god, what if they aren’t dead? Once, wrapping a body in the ICU in a long plastic bag, the body sighed—AHHHHHHHHHH—as gases released from her body, passed through her vocal cords and came suddenly out of the mouth. Once, I arrived at a house and found a man lying on the floor with a plastic bag over his head attached to a helium tank. He’d killed himself. I’ll never forget his white, bloodless calf, the slip of skin visible between his slacks and his socks.

Elisabeth was no saint. She put her work first in many ways, a reality that must have been hard for her son and daughter to accept and deal with—certainly it was hard for her husband, who asked her for a divorce. Although she loved her mother and father and wrote sweetly about them and their lives and deaths, she has precious little to say about her two sisters and her brother, all three of whom survived her. I imagine her as headstrong, abrasive at times, proud, unbending, being reluctant to admit wrongdoing. All of those traits served her well in some ways—without that audacity, that willingness to piss people off, she would have become a secretary at her father’s business. She never would have pursued medical school, or married a brassy New York Jew, or muscled her way through the hospital looking for dying patients. She wouldn’t have gotten mixed up with scandal, either, of course, and there will always be people who think that her belief in an afterlife is frankly unscientific, and discredits all of the other work she did.

Let them think that. Who cares what they think? They’ll see for themselves.

There’s a poem by James Applewhite that I think of often. The poem goes, “night/ wrenched harder as the body groaned, / then turned beyond her infinite will / to live and make trouble.” I picture Elisabeth like that, in possession of an infinite will to live and make trouble for anyone who would thwart her, anyone who would come between her and what she saw as her life’s purpose, to understand the misunderstood, to help the helpless. Yes, that’s what she did. She aggravated people, alienated people, no doubt. She made trouble.

I imagine that when Elisabeth died, all her dead were there, as all my dead will be there for me one day. They opened their arms to her. They said, “It’s about fucking time!” They laughed and laughed. And in our world, the nurse or doctor who pronounced her stood over her and said, simply, that she was gone, as I say, simply, to families, that their loved one is gone. The family nods, Yes, Yes, we know. Elisabeth’s family, I imagine, nodded Yes, too. We know, they said. But in their hearts they never did. In their hearts they always hoped. Hope that Elisabeth would stay with them, somehow. That she’d never leave. And they hope still. And so do I.