The Book of Two Ways

by Jodi Picoult

  “Yes,” I say. “Of course.”

  * * *

  —

  AT THE HOSPICE, we used to have a cat that predicted death. It was a tabby that never had a name other than Cat, as far as I know, but she lived in the building and there was a line item in the budget for her food. We had two therapy dogs that came in to see patients, but the cat was quintessentially standoffish and wouldn’t suffer being petted. Her only use, as far as I could see, was to let us know when someone had less than twenty-four hours to live.

  Without fail, if I went into a room and found the cat curled up at the bottom of someone’s bed, they died shortly after. I don’t know if it was a sixth sense, or some kind of olfactory cue—I know dogs have been trained to sniff out some cancers—but that damn cat had a hundred percent success rate.

  After I became a hospice social worker, it was nearly a full year before someone died in front of me. (Even now, many of my clients die when everyone leaves the room, as if they have been hanging on by sheer force of will to the people who will miss them.) One morning, I walked into Judith’s room at the hospice facility and Cat was staring at me, flicking her tail.

  Without alarming her daughter, Alanna, who was the primary caregiver, I did a quick survey of Judith. She was unresponsive, her breathing thick. I looked at the cat, nodded, and she jumped off the bed and slunk from the room.

  “Alanna,” I said, “if there’s anything else you need to say to your mother, I’d say it soon.”

  Immediately tears sprang to the woman’s eyes. “It’s already her time?”

  If there is one thing I’ve learned while doing the business of death, it’s that it comes as a surprise, even in hospice.

  I pulled up a chair beside her. Alanna leaned forward, unconsciously holding her breath every time her mother inhaled. Cheyne-Stokes breathing—which sometimes happens when a person is dying—is a cycle, slowed inhalations followed by faster pants, and then no respiration at all, before it starts up all over again. The pattern repeats every few minutes. Even though it is a normal occurrence as the respiratory system shuts down, it sounds agonizing, and it is hard to listen to, especially for family members who know that this is the beginning of the end.

  My job is to support not just my patients but also their caregivers. So I tried to distract Alanna, asking how the night had been, and when her mother had last opened her eyes. Finally, when I realized that Alanna was coiling tighter and tighter, I asked her how her parents got engaged.

  I once read that every story is a love story. Love of a person, a country, a way of life. Which means, of course, that all tragedies are about losing what you love.

  When someone with a terminal disease can’t stop fearing the future, it’s comforting to look to the past. We tend to forget that we were all young, once. And that there was a time when we had beginnings, instead of endings.

  Alanna looked up at me. “My mom and dad came from really different backgrounds. Dad had family money, but my mom had next to nothing. They decided to take a trip to the national parks, and my mom showed up with a cooler full of sandwiches, because every time she’d gone somewhere as a girl her mom packed all their meals. It was like she never even considered restaurants as a possibility.”

  I imagined Judith, wherever she was at that moment, listening to her own history and smiling on the inside. We know that of all the senses, hearing is the last to go.

  “They went to Old Faithful,” Alanna said. “My dad had been planning to propose. But there was some random guy who kept asking questions, and my mom—who had read everything she could about the geyser before the trip—kept answering him. How often does it erupt? About twenty-two times a day. How high does it reach? Around 130 feet. How hot is the water? Over 200 degrees Fahrenheit.” She smiled faintly. “My dad was losing it. So finally he tapped my mom on the arm and said, ‘I have a question.’ He got down on one knee, and asked, ‘Where does all the water go?’ ”

  I laughed. “What’s the answer?”

  “I have no idea. She never gave it to him. She just said yes.”

  We looked down at Judith, who let out a puddled sigh, and stopped breathing altogether.

  Alanna went still. “Is that…is she…?”

  I didn’t respond, because I needed to make sure it was a cessation of breathing, not just a moment of apnea. But after five minutes had passed without another breath sound, I told Alanna that Judith was gone.

  She pressed her forehead to her mother’s hand, still clutched in her own. She was sobbing hard, and I did what I always did—rubbed her back, soothed, gave her a moment for her grief. I slipped out of the room to the front desk. “We need a nurse to come in and declare a death,” I said, and then went back to comfort Alanna.

  After a little while, she sat up, wiping her eyes. “I have to call Peter.” Her husband. And probably a dozen other relatives. Her eyes were swollen and slightly wild.

  “It can wait a minute,” I said. I wanted to give Alanna something to take away with her. “Judith told me many times how much it meant to her to have you here.”

  Alanna touched her mother’s wrist. “Where do you think she is now?”

  There are all kinds of answers to that question, and no one is more right or wrong than another. So I told her what I knew for certain. “I don’t know,” I said, and I gestured toward the body. “But she’s not in there.”

  Just then, Judith’s jaw moved, and she drew in a deep, viscous breath.

  Alanna’s gaze flew to mine. “I thought she was…”

  “So did I.”

  The nurse appeared, looked at the breathing patient, and raised a brow. “False alarm?”

  I tell this story a lot at conferences and workshops: that the first person who died in front of me did it twice. It always gets a laugh, but it’s not funny, not at all. Imagine Alanna having to grieve her mother a second time. Imagine if the worst thing in the world happened to you, and then you had to experience it all over again.

  * * *

  —

  MY POTENTIAL NEW client has the same birthday as me. Not just the month and date, but the year, too. I have been the death doula to clients who are younger than I am, and in a few terribly sad cases, to children. In the past I have been philosophical about it: it’s not my time, it is theirs. But today, I look down at my intake form and it feels like a metaphor.

  Winifred Morse lives in Newtonville, in a small duplex that backs up to the green run of the Boston College Law School campus. She is dying of Stage 4 ovarian cancer, and unlike most of my clients, she called me herself. Usually I get inquiries from concerned family members, who want me to come in to support a loved one without telling the client what I do, as if naming a death doula is what will trigger mortality itself. I don’t take those jobs, because it feels dishonest to me, which means that I often have to tell a caregiver to wait until the client herself is facing down the barrel of death and accepts that she needs support.

  I drive to her home and stand outside for a moment, closing my eyes and taking a few deep breaths to release the tension in my shoulders and spine, pushing Brian to the far corners of my mind. Right now, the only problems I will let myself have are Winifred Morse’s problems. I can worry about myself on my own time.

  Her husband, Felix, answers the door. He is at least six foot five, all hooks and angles, like a praying mantis. When I introduce myself, he smiles, but the joy stops short of the fill line. “Come in, come in,” he says, and I find myself in a foyer whose walls are covered with modern art. There are canvases where soft pink blots look like the curves of a woman, from a certain angle. There are some with angry black slash marks, like the claws of a beast trying to rip its way free from the frame behind. There is one that has the most painstaking gradients of blue from top to bottom, like all the moods of the sea. It makes me think of my mother.

  I do not know much about m
odern art, except that it is supposed to evoke feeling, and I can’t drag my eyes away from that painted ocean. “I like that one, too,” Felix says, coming to stand beside me, his hands in his pockets and his elbows sharp. “Win painted it when she was pregnant with Arlo.”

  I file that information away, wondering where her son is, and how he is processing her illness. “She’s an artist, then,” I say.

  Felix’s mouth twists. “She was. She hasn’t painted, really, since she got sick.”

  I touch his arm. “And how about you?”

  “I’m no artist. I can’t even draw a stick figure. I teach driver’s ed.” He looks at me, sheepish. “I wanted to be a doctor, but my grades weren’t good enough. So I figured out another way I could save lives.”

  I try to imagine Felix cramming his frame into the passenger seat of a car, patiently instructing someone to turn on their signal before pulling away from the curb. “I wasn’t talking about work,” I say. “I meant…how are you feeling? Are you eating? Sleeping?”

  He looks at me curiously. “Shouldn’t you be asking Win that?”

  I always pull the caregiver aside for a private conversation when I see a client. Sometimes, they notice things about a loved one that I would not—like a shaking hand when reaching for water, or restlessness at night. They’ll tell me if a client isn’t sleeping, if she’s moody, if she’s seeing people who aren’t there. Sometimes a client will put on a brave face and not admit to pain or fear when they’re with me, but a caregiver always tells the truth, because they think it will help me give them the answer to the question they can’t ask their loved one: when and how will it happen?

  Anticipatory grief is real and devastating. It can run the gamut from How will I survive alone in the world? to What do I do when the Internet cuts out, because she’s always been in charge of calling the cable company?

  “I will ask her those questions,” I tell Felix, “but part of my job is making sure you’re okay, too.” I glance around the entryway, where—scattered among the artwork—are the trappings of illness: a walker, a pair of compression socks, a prescription packet on a side table. “Your whole life has been taken over by cancer, too.”

  He is quiet for a beat. “My whole life,” Felix murmurs, “is her whole life.” He glances up at me. “You’ll see. I’ve never met anyone like her. When I think about her not being…here anymore, I can’t picture it. I can’t imagine anyone taking her place. There’s going to be this Win-shaped space when she’s gone, and I’m scared it’s going to be bottomless.” When he stops speaking, his eyes are damp, and he seems startled to find me there. “I’ll show you,” he says.

  He leads me into the rabbit warren of the house, which has more twists and turns than I would have expected for a tiny duplex. Win is in the study, where floor-to-ceiling bookshelves spread behind her like the wings of a great eagle. She is moving slowly postsurgery, but still moving, shuffling her feet as she puts a book back in its place. She turns to me, and I instantly mark the effects of chemo and radiation and drug therapies: the paper-thin skin, the slightly jaundiced whites of her eyes. Her collarbones jut out from above the neckline of her shirt. Her hair is soft and downy new growth, like the fuzz of a duckling. Her abdomen is distended with fluids.

  “You must be Dawn,” she says, reaching out a hand.

  Even in her diminished state, there is a crackling, an energy that pulls focus, so that you cannot help but have your attention drawn right to her. Her eyes are an unholy gold, set against her dark skin. I imagine how magnetic she was before she got sick. Felix never stood a chance.

  “It’s really nice to meet you, Winifred,” I say, and I mean it. One of the reasons I love my job is because of the people I meet. True, I lose every single one of them, but in a way that’s why it’s even more important that I am able to get to know them before they’re gone.

  “Call me Win,” she says, and she grins. “It’s quite the misnomer, since I apparently won the Death Lottery.”

  “Dying is a misnomer. You’re alive, until you’re not.” I slide a glance toward Felix. “Besides, if we’re talking about unlikely labels, his name takes the prize. Felix Morse basically means Happy Death in Latin.”

  Win laughs. “I think I like you.”

  That is basically the point of this initial meeting—not only to see if my potential client feels comfortable with me, but to see if I feel comfortable with her. In Win’s case, her age is a factor, too. I can’t project myself onto my work, consciously or unconsciously. I can’t serve as a death doula if I’m thinking, What would I want in this situation? Or This could be me.

  When I was in Chicago as an undergrad, I volunteered at a domestic abuse shelter. There was a woman there about my age, who had lost her father when she was young, and who had a two-year-old she had to take care of, and she just got under my skin—to the point where I couldn’t sleep unless I knew she had eaten that night, that her son had eaten, and that she was not at home with her violent husband. The volunteer coordinator called me in and told me I wasn’t going to last long if that was how I approached every case. She’s not you, the coordinator said. Since then, I’ve learned to maintain my distance, but sometimes, it’s too hard to do that, and those are exactly the jobs I shouldn’t take. There are boundaries I cannot cross, even in a field that routinely collapses the space between people.

  “Why don’t we sit down?” I suggest.

  Win and Felix settle on a leather couch, I pull up a side chair. “So,” I start, “what would you like me to know?”

  “Well, to begin with, the doctors told me I have less than a month,” Win replies.

  I watch Felix’s fingers tangle with her own. “That’s why they call it ‘practicing’ medicine,” I say. “They may give you a certain amount of time to live, but they really don’t know. It might be longer, and it might be shorter. My job would be to make sure you’re prepared no matter what happens.”

  “We probably should talk about cost,” Felix says.

  “We will,” I reply. “But not at this visit. This is really just a first date. Let’s see if we’re compatible—and then we can start planning our future.” I won’t decide whether to take on a client (or let a client hire me) until the second visit. That first encounter needs to settle.

  I turn to Win. “How are you feeling today?” I always start with the physical, and then move on to emotional well-being.

  “I’m up,” Win states. “I showered.”

  I understand what she is telling me: today is a good day. There are some where a client isn’t up to leaving bed, or putting on clothes.

  “Is there any swelling around the surgical site?” Win shakes her head. “How about your hands and feet?”

  The questions follow a pattern: Do you have any pain? Are you warm enough? Have you eaten today? How have you been sleeping? I ask Felix if hospice has provided them with a morphine kit—a comfort measure that stays in the refrigerator, along with other meds, in case they are needed immediately, before a hospice nurse can arrive.

  “Do you feel like you have the support you need?” I ask.

  Win looks at Felix, a whole conversation caught between them. “I do. But I wish he didn’t have to. It’s not fair to him.”

  “It’s not fair, period,” Felix mutters.

  “Let me tell you what my role is, as a death doula,” I say, leaning forward. “I’m here to assist you and make sure your needs are met right now. I can help you with anything that’s left undone—I can work with you to plan a funeral; I can help you organize your will or your finances; I can clean your garage if the clutter is driving you crazy. I can comb through a storage facility if there’s a picture in there of your grandmother you really want to see. I can take you to see an opera one more time, or read Fifty Shades of Grey out loud to you. I can organize your social media accounts so that your friends know you’ve died, when the time comes. I
can help move you outside, so you can watch the birds.”

  I deliver this the way I always do: matter of fact, no sugarcoating or pretending that death is not inevitable. “Is there anything you don’t do?” Felix asks, joking.

  “Windows,” I reply, and grin. “For real, though—medication. I can’t prescribe it and I won’t administer it. That’s up to you. So are diaper changes, if and when necessary. I will help with a bedding change or a wheelchair transfer, but that’s really the job of a caregiver and it’s a liability for me if I’m alone with Win.” I turn to her. “All you have to do is tell me what will create greater peace for you, at any given moment, and I will do my best to make it happen.”

  She stares at me, unblinking. “Will you be here when I die?”

  “If that’s what you want,” I say, “then yes.”

  The room settles around us, a cocoon, and inside it we have already begun to change. “How will you know when that will be?” Win asks softly.

  “I’ll be in contact with your medical team. And there are signs and symptoms that the body is shutting down.”

  Win continues looking at me, her eyes narrow, as if she is weighing her next words. “I like you,” she says finally. “You don’t bullshit me.”

  “I’ll take that as a compliment.”

  “You should,” Win says. “How did you get into this business, anyway?”

  “My mother died in hospice, and it turned out I was good at helping people prepare for death.”

  “You must see some crazy sad stuff.”

  “Some of it’s crazy sad,” I admit. “Some of it is just crazy.”

  “I can’t imagine some of the things you must have been asked to do,” Win muses.

  “During my internship as a social worker, I was paged to the ER for a man who was brought in dead on arrival—along with his kids’ sixteen-year-old babysitter. He was having an affair with her, and they decided to do meth, and since he’d already taken Viagra he had a stroke and died. The girl was hysterical, and the nurses were trying to get in touch with his family. The wife and kids showed up, but the dead guy still had an erection, so I had to ask the doctor to figure out a way to hide it so the kids wouldn’t see it. We wound up taping it to his leg and covering him with six blankets. Six. Then I slipped out of the room to put the babysitter into a taxi. She asked me if I thought she should go to the funeral. I told her I thought she should reconsider her life choices in general.”