That Good Night

by Sunita Puri

“You are so adorable,” she said, grinning at me. “You are so green and new that I kind of want to pinch your cheeks! Wait till you’re twenty years in and you’ll have some peace around what you can and can’t change for people.”

  * * *

  My grandmother died three weeks after I saw her, in August 2000. I hadn’t spoken with her since I’d left Mumbai. After I wrapped up work at my internship one afternoon, I’d returned to my aunt’s flat, where I was staying in Delhi. She was nowhere to be found, but had left a note telling me that my grandmother had died, and that I should take the airplane ticket next to the note and fly immediately to Mumbai. My aunt had left an hour earlier. I stared at the note. I read and reread it. I should have called her, I thought. She was much more important than this stupid internship. I could have called her more often for twenty years but I didn’t. There was always something more important, usually something related to school or work, something that I should’ve seen was less important than the woman who had helped to raise me. My hands trembled. I crumpled the note, stuffed a few pairs of clothes in my backpack, and ran outside. August in New Delhi was all heat and dust, and I stood outside my aunt’s flat squinting at the late-afternoon sun, utterly paralyzed, unable to move until a neighbor noticed and put me in a cab to the airport so that I wouldn’t miss my flight.

  Did my mother know? My sobs intensified and the cab driver, an elderly man with kind eyes, glanced at me in the rearview mirror, hesitating slightly before asking me what happened. “Naniji,” I said, the only word I could manage. My grandmother. He shook his head and told me he was sorry. That he reminded me of my grandfather, who also struggled to make a living driving taxis, doubled my sorrow. How is my grandfather? Who told my mother? How can I reach her? I must reach my mother right away. My thoughts raced quickly, becoming as blurry as Delhi’s cityscape, which I caught between tears: the cows whose tails swatted at endless hordes of flies, the red-yellow-green-blue storefronts with painted advertisements for Lay’s potato chips and Thums Up cola, the clouds of exhaust emitted by the trucks and rickshaws and motorcycles and taxis that battled one another for road space. My grandmother was my mother for half of my first year in this world and I saw her only five times after that and now she’s gone. I thought of the last time I saw her, the way her cold hands startled me when she hugged me close, how I’d pressed my face against hers, feeling the outline of her cheekbone and jaw. As always, she’d smelled of coconut oil and mustard seed and Tiger Balm. The flight from Delhi to Mumbai seemed endless; I thought only of her face, the one I’d seen three weeks ago and the one I’d seen in photographs when she’d held me close in my infancy.

  After the flight landed and I gathered the few belongings I’d managed to bring, I hailed another taxi. I winced as the taxi driver drove up to the apartment complex where my grandmother had lived with Uncle Raju. Everything familiar felt completely different. I couldn’t bring myself to step into the elevator that you could access only by pulling back a creaky metal door and stepping into the narrow space inside. I headed for the stairwell, dank and dark, smelling faintly like a pile of wet towels. Paint peeled off the light green walls, which were covered with red splotches that, when I was younger, I fearfully assumed were blood. My mother explained that the red streaks were there because people chewed and spit out betel nut (paan) over the many years my grandmother had lived here with Uncle Raju. I looked at the walls now, wishing it was 1988, when I’d climbed the stairs for the first time, unable to tell the difference between blood and paan, frightened by the darkness of the stairwell but thrilled to be bounding up to meet my grandmother at the door, her thin arms wide, her cotton sari soft, her embrace indistinguishable from my mother’s.

  Soon, she would be dust. Her cremation, Uncle Raju told me, would be the very next day.

  “Mama won’t be able to get here in time!” I objected, incensed at the thought that the cremation had been planned without taking into consideration my mother’s need to travel.

  “She said that if you are here, it’s like she is here.”

  We called my mother together. I could tell she was trying very hard to hold back her tears. “They shouldn’t wait for me,” she said. I couldn’t believe that my mother wasn’t bothering to drop everything to try to be at her own mother’s cremation.

  “It’s just her body, Sunita, it’s not her,” she reminded me gently. “She’s with God now.” She began to cry softly then. She told me that Uncle Raju had called her in the middle of the night. Calls from India in the middle of the night were always emergencies, and she had awoken, startled but immediately bracing herself for terrible news.

  Uncle Raju told my mother that my grandmother was breathing so rapidly that she could barely take in one breath before gasping for the next. She was sweating and her lips were turning blue. Should we take her to the hospital? my uncle asked my mother. The last time she’d been hospitalized, my grandmother had required the support of a ventilator to treat a terrible flare-up of her emphysema. She was on the breathing machine for six days, after which she told Uncle Raju and my mother, “Never do that to me again.”

  “It is the hardest thing to be a daughter but also a doctor,” my mother would tell me months later. My mother knew what another intubation would mean: a breathing machine in the ICU, possibly a tracheostomy if my grandmother even survived, with a slim chance of her ever coming off a ventilator because ultimately her emphysema would never heal.

  My mother knew everything about these situations. She knew about the frenzied, tearful eyes of daughters like her, having to make a decision like this. She knew how to push medications that would relax the patient she hovered over; from the head of the bed, she watched their breathing slow, their face go slack, their body relax after the tremendous work of breathing forty times per minute, trying to sustain life. She would go on autopilot, she told me, having opened thousands of patients’ mouths, searched for their vocal cords with a laryngoscope, and slid a breathing tube down their trachea until their chests would rise and fall to the rhythm of the ventilator. Then they were peaceful, appearing as though they were simply sleeping. The daughter might be outside the room, watching, wondering if she had made the decision her mother would make, fearing that she wouldn’t be able to live with the sadness of her mother’s death and her own guilt if she had refused to have her mother intubated. My mother would pull out her stethoscope, the same one she used to help me listen to my own heart and then hers, and listen for tides of air moving through both lungs. Her job was done. Crisis averted. But perhaps another crisis loomed—that of the patient being unable to survive without the ventilator if her lungs simply couldn’t recover.

  My mother told me she didn’t cry when Raju first called. She listened. Doctorly. She imagined her mother on a ventilator, knowing all of the risks intimately. No, my mother told Raju. She wouldn’t want this. She’s told us once before. Give her sacred ash. Give her inhalers and make sure the oxygen tank is on. Pray.

  My mother still cannot describe this phone call in detail to me without asking me angrily why I feel the need to know this information, to force her to remember that painful night. I have pieced together what I am writing here from the moments over the past fifteen years when she described a glimpse or two of that night. She hung up with Uncle Raju and went to the room in our home that she and my father had made into a prayer room. Pictures of deities surrounded her in the midnight stillness and silence. She lit a candle and bowed deeply, feeling the carpet beneath her knees and hands and sobbing into it, praying and begging for God either to take her mother quickly and painlessly or to heal her spontaneously. I had to remember that she didn’t want the machine. She told us that. And even if she had, and we had put her on it, she would have never made it home, where she wanted to be.

  Her cheeks brushed against damp carpet and the flame flickered, moving the shadows of Lord Ganesha’s and Lord Krishna’s figurines ever so slightly across the wall. She imagined she was
with her mother, and that her mother looked just as she had one year before, when she had last seen her. She imagined pressing her cheek against her mother’s, holding her through her breathlessness, saying the prayers that she said now, at a distance of nearly nine thousand miles, over and over again through her tears and trembling. I implore you, Lord Shiva, please ease all suffering, and free us from the cycle of birth and death, leading us to immortality.

  म्बकं यजामहे सुगन्धिं पुिटवर्धनम्

  उर्वारुकमिव बन्धनान्मृत्योर्मु क्षीय माऽमृतात्

  tryambakaṃ yajāmahe sugandhiṃ puṣṭivardhanam

  urvārukamiva bandhanānmṛtyormukṣīya mā’mṛtāt

  Over and over and over again, as the candle flickered and the shadows moved and the carpet dampened and the phone finally rang again, and she knew.

  Loving my grandmother meant letting her go.

  * * *

  In Dave, I saw a second chance to care for my grandmother. He resembled her more every time he visited the clinic. I still cry at the image of my grandmother struggling for air, and struggle myself to make peace with the idea that all I know now came thirteen years too late to benefit her. She didn’t have the option of a home palliative care or home hospice team to visit her. And in India, morphine, which could have eased her difficulty breathing, was difficult to obtain because of the stigma associated with the use of opiates, the fear of misuse and addiction. But she did have Uncle Raju and Anu, and for that I am grateful.

  I’d been shocked to learn that although Dave lived in a rich country, he still couldn’t access home-based palliative care simply because of where he lived. And though he did have access to morphine, he remained hesitant to use it. As I watched his oxygen requirement increase, more frequent gasps punctuate his sentences, and his face grow puffier from the increasing doses of steroids he needed to use, I pushed him harder. He’d told the social worker exactly what he’d told me. No home for me. I need to set things up for my son. Not ready to die yet.

  “Hi, Doc, sorry I’m late,” Dave said as he ambled into the clinic room and shook my hand. The new coolness of his hand startled me. I noticed his paler palms and bluer fingertips. He sat down and sucked in air, hands on his knees, smiling, eyes ringed by darker circles. I glanced at his vital signs. When he was resting, his oxygen saturation hovered around 88 percent despite a recent increase in the amount of oxygen he needed.

  “How’s it going, Dave?” I asked, my concern apparently quite visible. Over the course of my education, I’d come to sense when patients’ bodies were starting to decline more rapidly. Something would nag at me. By the time I was nearly finished with residency, I’d learned to listen to my intuition, though I never understood what triggered this inner alarm. Perhaps it was something about the way the patients looked, apart from how their lab tests and CT scans looked. Now, in fellowship, I’d discovered the same inner guidance alerting me to patients whose bodies were failing faster than expected. Was it the shadows behind his eyes? I wondered. Was it the way his gasps appeared sharper?

  “No need to look at me like that, Doc, I’m doing just fine.” Sharp gasp.

  “It looks like you might be a little bit more out of breath than before,” I offered, looking at his oxygen tank.

  “I think it’s because I was rushing here,” he said. “I had to drive back from my brother’s house.” Cough. “So, how’s things with you? Your job search going okay?”

  At our last clinic appointment, I’d shared with Dave that I’d started to look for jobs in the Bay Area. Since palliative care fellowship was only one year long, it felt like my job search started just as I’d finally settled into a routine. “Thanks for asking. It’s going okay, but I’m still not sure where I’ll end up.”

  “You know, this really strange thing happened the other day, Doc,” he said after I asked him how he’d been. “I got up, and I was breathing hard, but then I looked outside my window and I swear to you, I thought I saw a horse pulling a buggy. It was the strangest thing.”

  When the brain is deprived of enough oxygen, patients can start to hallucinate. “Wow, that must have really startled you,” I said, choosing my words carefully to modulate my concern.

  “It really did! At first, it was kind of a pleasant sight, but then it wouldn’t go away. I mean, a horse and buggy outside a warehouse? Doesn’t make sense.”

  “Were you dizzy or out of breath at the time?” I asked.

  “No. In fact, I’d just taken my inhalers and all my medications. I was just getting ready to leave my place. It was like a scene out of an old movie, and then it was just gone. Do you think it means something?”

  Dave might have hallucinated for several different reasons, but because he struggled to breathe at the time, I worried that his oxygen levels might have been dangerously low.

  “I do think it means something,” I replied slowly. “When the amount of oxygen in the blood gets pretty low, sometimes people see things or hear things that aren’t really there. That would mean that maybe you saw a horse and buggy because your lungs are having a harder time getting enough oxygen to your brain.”

  “Oh,” Dave replied. “So I’m really getting worse.”

  “I’m worried about you, Dave,” I said. “Have you given any more thought to what we talked about last time? I think we’re seeing signs that you really do need more help.”

  Dave sighed, exasperated. “I talked to the social worker. She told me that nobody can come help me at home because I live in a warehouse and that’s not the type of place those teams go.”

  My anger over this injustice persisted, but sharing my indignation with Dave wouldn’t change the situation. “I don’t understand why, but apparently that’s the case, and I’m really sorry,” I began. “Dave, I know you told me that you’re not open to staying in a facility, but I’m worried that you might need more help just to take care of yourself in the coming months. To finish the things you’re working on, you might need some help taking care of yourself.”

  Dave smiled, a flash of his yellowing teeth against his cracked lips. “I knew you’d bring this up again,” he said wearily, hands again on his knees, his sentence chased with a deep breath. “I’m just not ready yet. I still have work to do on the house.”

  As I’d gotten to know Dave, I’d come to understand how fiercely he raced against a ticking clock to ensure that he left his son in the best possible situation. He persisted despite his son’s behavior, despite the fact that continuing to drive limited the medications I could give him to relieve his worsening gasping. Because I admired him and possibly because I was secretly hoping he’d outlast his prognosis, I hadn’t actually had a forthright conversation about how his disease was progressing. The thought of doing so made me feel as though I would lay waste to the meaning he still hoped was possible to make of his remaining time. I hesitated before I spoke, understanding firsthand why it was so difficult for oncologists and other specialists who had built relationships with patients over time to tell them the difficult truth of how sick they were, and how they were likely to get sicker quickly.

  “Dave, I know you’ve mentioned to me that you still have things to do. And I want you to be well enough to do those things. But it’s clear to me that your emphysema is getting worse. And I wouldn’t be a good doctor to you if I didn’t talk with you about what you might want as you get sicker.”

  “You mean if I get sicker?” Dave responded.

  Doing everything for you means having this conversation. I told myself that if I wasn’t honest with Dave, he might not have a say in what happened to him if he took a turn for the worse. He might get treatments he’d never want, suffering in ways that could be avoided just by having an honest conversation with him. To be his doctor, you must tell him the truth. It might be hard for you. But thi
s isn’t about you, it’s about Dave and his life.

  “Dave, unfortunately your emphysema is going to continue to get worse until it takes your life at some point. I know that is difficult to hear. It’s difficult for me to say, but I have to tell you this because it’s important that we talk about what you want for yourself as you get sicker.” I held my breath, hoping that he wouldn’t shut me out.

  He nodded. “Yeah, Doc, I know, I know you’re right, but it just doesn’t seem like it’s my time yet, you know?” Before residency and fellowship, when I pictured a dying patient, I’d imagine someone comatose, lying in a bed, fully dependent on others for care. But dying can be a slow unfolding, rather than a sudden catastrophe. A dying person might still be able to walk, talk, and go about their lives, even when living with a terminal illness. This was why it had been hard for me to accept that my grandmother was dying: she was still in her right mind, still moving around my uncle’s flat, still able to eat and interact with us. Dave probably—and understandably—saw himself the same way: managing to live, not incrementally dying.

  “I know. You have so much life in you, Dave, and I can hear how hard it is to reconcile your sharp mind with how much your body is struggling.” Right now, Dave was clear-minded and relatively stable, rather than critically ill and hospitalized. We could actually have a conversation about topics that would only be harder to discuss when he couldn’t breathe, or became confused and disoriented, or suffered from too much pain to talk. It wasn’t an easy discussion, but it lacked the occasional awkwardness of similar conversations I’d had with hospitalized patients I’d never met before.

  “Dave, do you remember when you were on a breathing machine about two years ago when you had a flare-up of your emphysema?”

  “Yeah, how could I forget it? That was a tough time. But I pulled through.”

  “How do you think you’re doing now compared to back then?”