A Better Death

by Ranjana Srivastava

  As an oncologist, I’m used to caring for patients who slowly decline and die. There’s time to grieve, adjust and anticipate. Sudden death provides none of these consolations. Unfortunately, over the years, I have witnessed many such deaths too, a few from catastrophic illness but more commonly due to accidents and suicide. The high rates of burnout, substance abuse and mental illness in the medical profession mean that many doctors know someone who has succumbed to a drug overdose or committed suicide. I have lost colleagues without having an inkling that there was something wrong with them – interns who didn’t show up to work; specialists at the peak of their career; nurses who ran a ward just a week earlier.

  I’ve also lost patients who were not expected to die just yet. We reassured them that they were on the mend and told their families to go home for the night. Then something unpredictable happened. The patient suffered a heart attack, stopped breathing, or simply failed to wake up for lunch.

  Once, mid-conversation on a ward round, I drew back the curtains to find a deceased elderly patient. His nurse had just set down his cup of tea and had gone to ready the shower. We all needed a few minutes to process our shock.

  And like so many others, I have mourned family members with whom I shared a meal one night and whose funeral I attended later that week. Relatives I assumed I would grow old with but who died without notice. It seems hardly fair that death could be so brisk and remorseless and yet, as many of us will experience, it is exactly so.

  In the grip of grief, people often wonder which is better, an expected death or a sudden one, as if we could ever settle our views on this perennial question.

  However, having witnessed many deaths and discussed the aftermath with others, I can share my observations.

  An expected death, predicted to the extent that it can be, provides an opportunity for conversations, with ourselves and those near and dear to us. These conversations can be practical – how we wish to divide our property, who should receive our jewellery, and how we want to wrap up our business – to the philosophical: who we should thank, who we must ask for forgiveness, and which of our beliefs and gestures will console us in the end. For loved ones, an anticipated death allows a final chance to understand people and honour their final wishes.

  While this presents a rich opportunity to tie the loose ends of our mortal life and set the conditions for dying well, it would be a stretch to say this is indeed how most people die. From what I see, many of us die clinging to hope, reluctant to reconcile to our mortality, our affairs unsorted not unlike our wardrobe, unable to affirm what really matters. The heaviest consequence is that we let other people, including doctors, make significant decisions on our behalf without knowing us. Therefore, an opportunity to die well doesn’t mean we actually die well – something that deserves thinking about.

  As I have seen for myself, sudden death is instantaneously shattering and very traumatic. The grief may not be greater but there has been no time to gather our coping skills.

  One day, I was crossing a busy road and thinking about my next meeting when a friend called me about our colleague’s suicide – I’d recently waved to him in the corridor. Another time, my plane had just touched the tarmac when a text message flashed on my screen: a young woman I’d had dinner with the previous night had died.

  It’s hard to not be blown away by the sheer relentlessness of an event that gives no warning that a meal, a hug, a walk, or an argument might be our last. The kind of death that makes no room for prior realisation or reconciliation. That may come later, but first we will have to contend with our unexpected loss and the churning thoughts about what we could have done differently.

  The person who loses a loved one slowly wishes to avoid a lingering death. The loved one mourning a sudden death pleads for more time. No matter how people die, death stings.

  According to a fable, a king once asked some wise men to come up with a saying that would hold true in good times and bad. After deliberating, they handed him a ring that had etched on its inside, This too shall pass. My most admirable patients live by this dictum, knowing that to live wisely is to meet both joy and sorrow with equanimity. This realisation gives meaning to their lives and forges a legacy in their wake. It doesn’t hasten their death; instead, it renders their remaining life more pleasurable.

  But how should we prepare ourselves and our loved ones for our own death, sudden or otherwise? I can’t help thinking that Ramesh led the kind of life that made it easier for people to move forward.

  In the days after he died, there was a roaring silence on the wards and people went out of their way to avoid each other so as not to be reminded of their lost colleague. The wound felt deep and penetrating and insufferable. And to be honest, unfair. How could an octogenarian golfer survive a heart attack but not someone much younger? What could we do to protect our loved ones from such a fate?

  In the years since his death, it’s been instructive to watch the healing process and relate much of it to how Ramesh conducted himself in life.

  His kindness and concern for others meant there was a groundswell of support to commemorate him. His colleagues continued an annual conference in his name and young doctors were moved to give back to others as he had done for them. This created a community of mourners instead of helpless individuals.

  His wife, blessed with an innate calm, was left in an unimaginably difficult situation to care for their two children. She made a conscious decision to not lament her fate but be grateful for the years they had together and remember the good he brought to the lives of others. I can’t help thinking that she was greatly helped by the genuine respect and grief for Ramesh that reached her from far-flung corners of the world. Having been largely insulated from his professional life, she was consoled that her sacrifices had been for a greater cause.

  On the subject of what we can do to help loved ones grieving a sudden death, there’s actually a great deal that doesn’t need undue effort. One is overcoming our own sense of shock or betrayal and reaching out to someone, a profoundly therapeutic act.

  The weeks after my colleague’s suicide were very challenging for all those who knew him. He was funny, talented, and enormously popular – it made no sense that he didn’t appreciate this. Some doctors attended a memorial, others sought counselling, some were desperate for details, while others wrestled with conflicting emotions. Some of his closest friends were angry and confused. We had to accept our different reactions and it took time to recover, although he is still missed.

  I attended every function held in Ramesh’s honour and also gave the eulogy. It was one of the hardest things I’ve done. Sometime later, I visited his wife, unsure of what to say and never having imagined such an occasion. She showed me a mountain of cards she’d received, so we sat in companionable silence, reading the recollections and condolences of all the people he had touched. I remember thinking how deeply consoling it felt that Ramesh’s loss was also felt by others. Indeed, a sorrow shared was a sorrow divided. I have never since underestimated the power of a thoughtful card or a short visit as a mark of care and respect for the deceased and those who survive.

  In the course of my work I meet many relatives who dread the death of a loved one and say they couldn’t possibly go on. But in truth, they find out that we humans have a tremendous capacity for resilience and recovery. We may not have thought of an alternative plan for life when things are working but, when circumstances demand it, we find a way because we are profoundly adaptable. We should take heart from this.

  Which brings us back to living well even when the choice of dying well is taken away from us. Whether we die an anticipated death, as most of us will, or die suddenly, our lifelong qualities are what we will be remembered by.

  We should practise being content within ourselves and showing generosity in our dealings with others. We should mind our health and strive to live long and productive lives but behave as if our last days were upon us. To think and behave now as we intend to do at the end of
our lives could help us craft a way to ease our own death and make it alright for others.

  Facing the aftermath

  To weep is to make less of the depth of grief.

  William Shakespeare

  I LOST ALL FOUR GRANDPARENTS at an age when I was too young to appreciate their qualities or have a chance to talk to them to better understand my heritage and history. One of my grandmothers died at home in India after a long period of frailty from which she never recovered. She didn’t have a terminal illness but a fall in old age followed by a badly fractured hip was enough to push her towards terminal decline. She developed a pressure ulcer and became confused and delirious, and in those days of very basic medicine, especially where we lived in India, her family could do little more except sit by her and soothe her through our presence. When she died, the rambling house fell literally quiet in the absence of her tortured screaming. But in its place descended a deep sadness and much soul-searching about how we could possibly have made her death better. Did we reveal our frustrations too often at her nocturnal whims? How many times did we hush her even when she didn’t know what she was shouting? Did we accidentally ignore her pain, hunger or thirst?

  Custom expected us to love and respect all our elders. My adolescent cousin devoted herself to our grandmother’s skincare and hygiene with the skill and deft touch of a trained nurse, able to distinguish a cry of pain from a sob of gratitude. My grandmother’s two sons did everything in their power to keep her well and sought out whatever medical care was available. But it was evident that she suffered at the end of life and it was a relief to us all when that suffering ended. As the last rites were fulfilled according to Hindu tradition and she lay on the funeral pyre, we hoped that she would join her husband in whatever lay beyond.

  After the funeral, the house echoed with silence. We missed her so much that we had someone attend the house to summon her spirit from the afterlife, so we could communicate with her. It sounds slightly ridiculous now, but I remember how comforting it was to hear that she was okay. Humans will cling to any hope, however feeble.

  My other grandmother succumbed to cancer. She died in a prominent Indian hospital, suspecting, but unaware to the end, that she had a terminal illness. She experienced none of the feared symptoms like pain, breathlessness or confusion, but she grew weaker by the day. In line with the times, her diagnosis was not disclosed to her and no one asked what she wanted at the end of life. To this day, in many cultures, it’s unheard of to mention such things.

  My grandmother was a devout woman who had begun each day by walking barefoot in a fasting state to pray at an ancient Hindu temple for god to keep her family safe. It is here she went to pray when one of her children got married, when a grandchild was born, and when someone fell ill. But before she went, she had to be satisfied that her large family was fed, which meant fanning a homemade fire, and later a rickety stove, since dawn. Sometimes, it would be nearly lunchtime by the time she set off to pray. A basket of flowers and beads in hand, she’d dash to the temple before it closed and hurry back, often ravenous but always fulfilled. One didn’t have to agree with her philosophy, but it was impossible not to be moved by her discipline. For a long time after she died, people blamed her prolonged fasting habit for the cancer, but no one could say.

  I can’t help thinking that perhaps, if we had asked, she might have expressed a wish to go back home and spend her last days in the shadow of the same temple that had anchored her life. She would almost certainly have wanted to spend more time with her husband, children and grandchildren, and go home to sort out her few but carefully stored belongings. Instead, thinking we were helping, we urged her to stay in the best hospital in town for all her remaining days, so that doctors and nurses would fuss over her, giving her medicines that achieved nothing, while we waited for her to die.

  One late night, we stole her away from under the eyes of the nurses to bless the vows of her youngest son, whose wedding had been hastily brought forward. The nurses were rightly mad when they found her missing from her bed and the oncologist didn’t mince his words either. We were a little taken aback by their reaction and profusely apologetic but many years later, when I became an oncologist, it struck me that we only behaved like that because we knew that no doctor would dream of letting her out, leaving us feeling desperate. We regarded the professionals as omnipotent and omniscient but since we didn’t know how to articulate our questions and they didn’t think to broach difficult conversations, we fumbled in the dark, literally and metaphorically. All this sounds terrible in hindsight, but I know that this was the norm at the time and my grandmother received much better care than most.

  As her liver failed, she slipped into a coma and died. In contrast to my other grandmother, who’d fractured her hip, her end from cancer was much more peaceful and controlled. She received good personal care and died with dignity but, astonishingly, the ripple impact of that death continues to affect our family to this day. No one could have predicted that the tensions accumulated during that difficult period would create a rift among the siblings, their children and grandchildren that would lead to enduring pain and difficult questions decades later.

  The family would be tasked with questions, not about whether her symptoms were managed (she didn’t have many) or whether her death was preventable (it was not), but whether some frank conversations might have elicited her wishes about how she wanted to be remembered and who she wanted to leave her possessions to. Might her own expressed wishes have made a difference to those left behind? We will never know.

  I offer these two personal memories to illustrate that no matter how ideal or imperfect a death, all survivors contend with some form of grief. In dealing with the gradual deterioration before death typical of the modern era, our mourning begins when people lose the qualities we best knew them for. Anticipating their death and letting go of our dreams for their future feels right and wrong in the same breath.

  One of the privileges of my work is being allowed a window into how people cope with the aftermath of death.

  Caring for the dying is all-consuming. Many family members throw themselves into this task with a kind of focus, abandon and passion that they may never have shown for anything else, even surprising themselves. This work is physically exhausting and emotionally challenging, so it’s only natural that the finality of death creates a large hole and fuels many regrets. Relief from some of the physical aspects of caring is accompanied by many questions. Did we do enough? Did we say the right things? Could we have been better?

  But the aftermath ought to be a time to console ourselves that we did what we could at the time. There are many ideas in human relationships that are not spelt out as well as we’d like, but we were there, we tried our best, and now we can rest easily. To be human is to be fallible.

  One of the most painful things about the aftermath of death can be the doubts that surface in our head from time to time. It feels right to mourn the dead and only speak well of them since they are not there to defend themselves, but a corner of our mind can’t help remembering how strained our relationship was and how angry, defensive or uncharitable they could be, even though we gave up some of the best years of our life being their friend, their carer, or both. I knew how conflicted I felt when a colleague said something unnecessarily harsh about a deceased friend we had both liked. To recollect his faults behind his back felt disloyal but to deny they ever existed was untrue. I understood then that even someone we loved and missed could be imperfect and acknowledging this didn’t amount to denigrating the whole person.

  I lost a late-term twin pregnancy days before I was to begin my first job as a specialist. The loss was as sudden as it was inexplicable and for months afterwards, eyeing the bump under my clothes, my patients would innocently ask when the baby was due. Of course, there was no baby and at the time, I feared if there would ever be one. The innocent anticipation of my patients would leave me outraged at the injustice of life and the unfairness of death – until I
looked around me and realised that I was part of some grand scheme of life, magnificent and muddled at the same time. Some days, I wanted to lean into my grief, other days I wanted to run away as far as I could. One of the most poignant things to happen to me was an elderly patient telling me to take my time with grief. He had lost his wife of fifty years and everyone was impatient for him to move on, but he was quite happy to live beside her memory. My patient told me that the acute, raw, all-encompassing grief was too exhausting to sustain and would eventually dissipate, leaving in its place a dull ache that would flare without notice from time to time as a reminder that death never completely lost its hold. Time proved him correct. Since then, countless patients have taught me that all grief is legitimate and there is no hurry to vanquish it according to a timeline imposed by ourselves or another.

  Society gives us greater permission to mourn a dead pet or a lost job than a loved one. We feel reluctant mentioning the dead, fearing that our words might visit bad luck or pour grief on the bereaved. We know how to celebrate an impending birth and mark the milestones of life, but we struggle to handle that other major event that must surely follow birth: death.

  We mustn’t hurry our sorrow merely to accommodate a world that’s uncomfortable with the idea of mourning. Grief has no arc and bereavement doesn’t follow a protocol. In an increasingly secular world, we may no longer adhere to the religion or customs of our ancestors, but we can still seek to be illuminated and consoled by how other people mourn.

  Hindus cremate their dead as soon as possible and hold no rituals or prayers in their home for the next thirteen days as they await the departure of the soul, which they hold immortal, from the body. The one-month anniversary and the annual anniversary of the death are marked by special rites thought to bring peace to the dead and the living. Having taken part in these events, I have experienced the inner peace and closure they bring.