Inheritance from Mother

by Minae Mizumura

  “An extended-care hospital.”

  That night, the shock was so great that she and Natsuki met for dinner in Shibuya.

  “How could he say such a thing?”

  “She can’t sit up. And doesn’t even know it. Her internal bleeding hasn’t stopped, either. How in God’s name can he open a hole in the stomach of someone like that?”

  “Someone who never wanted it in the first place.”

  In their mind’s eye they both saw the same scene: a deluxe suite in the extended-care hospital at the end of the Toyoko line where for nearly a year a certain figure had been lying inert with tubes down his nose: Natsuki’s father-in-law, who would soon turn ninety-three. That dynamic, manly patriarch had seemed more likely to end his days with the flare of the ancient general Taira no Kiyomori, who, according to The Tales of the Heike, turned bright red with a fever so high that when cold water was poured on him it “burst into flames, filling the chamber with thick black smoke and whirling fire.”

  Yuji’s father had always gotten along well with Natsuki’s mother and was fond of Natsuki, and of Mitsuki by extension. Then in his mid-eighties he had developed stomach cancer and after a gastrectomy quickly grew frail. He suffered two severe strokes and was put on a liquid diet, ensconced in the two-room suite. Growing steadily more senile, he eventually contracted aspiration pneumonia and was hospitalized. He recovered but could no longer tolerate a liquid diet. As he had no stomach, he wasn’t a candidate for a surgical feeding tube and so was fitted with nasogastric tubes instead.

  The Shimazaki family had been summoned to the hospital and informed of the impending change. Natsuki, sitting next to Yuji, cried out despite herself, “Couldn’t you just leave him be and do nothing?” Yuji’s elder brother and his wife, as well as his sister, had been present too. As the wife of the second son, Natsuki had the least say of anyone in the room, yet she’d felt so strongly she couldn’t keep quiet. Watching as her hollow-eyed father-in-law was propped up in bed to have fluids poured down his throat had been painful enough; now they wanted to put in feeding tubes as he lay unconscious. As soon as she spoke, Natsuki realized her faux pas and looked around at the family. They were looking expectantly at the female doctor—they’d all been thinking the same thing.

  The doctor’s response, however, was unsympathetic. “In that case, I’m afraid the family would have to take over his care.” She added with emphasis, “But you should know that caring for an elderly terminal patient is far from easy. Often the patient ends up being returned to the hospital.”

  And so Yuji’s father lay unconscious in the deluxe suite with his neck immobilized and a tube down each nostril.

  A former classmate of Natsuki’s from the Yokohama conservatory said something one day that made her gnash her teeth with rage. Apparently the classmate’s own mother had suffered from Alzheimer’s, and when she developed trouble swallowing, the hospital in Sapporo, near where the family lived, agreed to let her die a natural death. She was gone in a matter of weeks.

  Natsuki had taken out her fury on Mitsuki over the telephone. “That high and mighty doctor, why didn’t she tell us we had that choice? That other hospitals do that?” As usual, she’d been calling from the piano room, where she had taken refuge with her two cats for company.

  She was venting her frustration on Mitsuki because neither Yuji nor his family shared her wrath. Unlike the Katsura family, the Shimazakis, as befitted a family of old money, were too genteel ever to question the system. Yuji’s father, the sole exception, ended up lying flat on his back in bed, a vegetable—a fate he would surely never have wanted. Lately the nutrition he was receiving had begun to show its effects; he was putting on considerable flesh.

  Back when their mother heard the particulars of Yuji’s father’s situation, she’d still been able to get around with a cane. “Oh, the poor man, what a terrible shame,” she had said in tears, for she’d been growing sentimental. After blowing her nose she had declared, “I wouldn’t want to go on living that way. What a waste of taxpayer money. When my time comes, tell them no thank you. And no poking holes in my stomach, either. Heaven forbid.” She reached for another tissue. “The poor man doesn’t even know he’s alive. When it’s my turn to go, I want to die on my own terms. You two are my only hope, so please do whatever it takes to keep that from happening. I’m counting on you.”

  Natsuki remembered the conversation, too.

  The sisters said good night after agreeing that never under any circumstances would they allow a feeding tube to be put in their mother. Mitsuki felt depressed, knowing that it was up to her to think of a way to keep that from happening.

  A SLEEPLESS NIGHT

  All that weekend, Mitsuki sat at her computer like one possessed and researched the topic of feeding tubes.

  Outside her window, the leaves of the hydrangea bushes were just starting to turn golden in the autumn sun. Six months before, those same hydrangea bushes had just started putting out tender buds. She had sat glued to this same computer, going through Tetsuo’s email correspondence with the young woman. This time she was spurred by something different, a kind of shock that went beyond the personal.

  Doctors recommending feeding tubes for patients in her mother’s condition, even when the patients expressly didn’t want them: to what extent had this become standard practice in Japan? To what extent was it standard practice in other countries with advanced medical technology? She researched the topic in Japanese and other languages and learned that feeding tubes, invented as a way to provide temporary nourishment, had begun to stir new ethical debates among those on the frontlines of terminal care. Once upon a time, a person unable to eat would die, but today it was no longer so simple. Scandinavia and various other countries in Europe had rejected forced feeding as a means of prolonging life; in the United

  States the practice was controversial, but in Japan, routine and unquestioned.

  Just as she had suspected. Still, it was maddening.

  On Monday she met with the doctor and pleaded that he continue just a while longer with the same approach.

  “All right,” he said. “A bit longer, then.”

  On the way home, the autumn sky was a clear blue. But the natural world seemed to have little to do with Mitsuki; indeed she was barely aware of its existence. She sighed and entered her building, then stumbled into her apartment.

  She had to hurry and find a hospital where her mother could die in peace. Natsuki had left everything in her hands, but she had no idea what to do. She threw down her bags and stretched out on her bed, only to get up again a few minutes later with an idea. Why not call the SDD, the Society for Dying with Dignity, and talk to someone?

  A soft-spoken woman perhaps in her sixties came on the line. Mitsuki explained the situation, and the woman promised to fax over a list of nearby facilities that would be more cooperative. She added sympathetically that “life-prolonging measures” usually referred to artificial respiration and cardiac massages. Whether tube feeding fell in that category would depend on the judgment of the primary physician.

  Hearing this, Mitsuki’s heart sank. Even if she spent the day calling each hospital in turn, how was she supposed to get through to a doctor who would respect her mother’s wishes? Wherever she called, the voice of a harried receptionist would come on the line. How was she to explain the situation to that harried voice, how and through what channels finally reach the ear of an understanding doctor?

  “Please take care not to fall ill yourself, my dear,” the soft-spoken woman said before hanging up. Mitsuki was left speechless.

  She stayed busy all day that day, now going over the list of recommended institutions, now stretching out in bed, now tackling the piled-up housework, now returning obsessively to the computer. She didn’t feel like telephoning her sister. Having her as a companion in indignation would accomplish nothing. There was simply no time. She had to come to a quick decision and act. Determination not to let anyone do anything more to her mother inflamed h
er. Even with a feeding tube in place, someone in her condition couldn’t last more than a few months at most. If she did by some chance last longer, was that what she would have wanted?

  Her mother was no longer able to understand that she couldn’t walk. Conversation with her was often painful. On her good days she would ask, “Mitsuki, why can’t I walk? Lying here like this all the time wears me out. I want to get up and go somewhere. I want to go outside.”

  “Yes, Mother, but even before you got sick you couldn’t walk. Don’t you remember?”

  “Really? I couldn’t walk?”

  “No.”

  “What if I used a cane?”

  She had used a cane for so many years that she seemed to remember that, but all memory of her days in a wheelchair was gone.

  From time to time she would say, “If there was a strong man around, he could carry me somewhere, couldn’t he? It’s no fun living like this.” And then she would murmur, “I’m so tired.”

  That night as she lay in her bed, Mitsuki shed tears of pity for her mother for the first time. She held them back, so there were only a few, but they were tears of genuine pity nonetheless.

  The liberation that their mother’s death would bring no longer seemed to matter. In old age, Noriko Katsura had faced up to her impending death with admirable practicality. Names in her address book were marked with a red pen: a double circle indicated those who should be notified by telephone, a single circle those for whom a card would be enough. She had also decided that she would rather forgo a funeral and have her ashes scattered, like their father. In her complete reliance on her daughters in old age she may have been following tradition, but in her staunch belief in a person’s right to have a say in how her life ended she was anything but traditional. Her mother’s life must not end in a way that she would have scorned.

  Mitsuki stared into the dark and pondered.

  Then it came to her: Tetsuo was away. She could take her mother in. That would solve everything. The tiny lettering on the list of medical institutions from the SDD danced before her eyes, but she lacked the patience to scrounge around in that data for the name of a doctor who would allow her mother to die. There wasn’t time anyway. She had briefly considered the hospital that let her sister’s friend’s mother die a natural death, but what taxi—even one for the handicapped—would carry a dying old lady all the way north to Sapporo?

  Caring for her at home was at once the worst choice and the best.

  Her mother probably would balk at having Mitsuki tend to her toilet needs, so they would need to hire help on a twenty-four-hour basis. Whether to continue the suctioning she didn’t know, but in any case it would be better to have a trained nurse on hand. If possible it would be better to withhold all artificial nutrition and hydration and just moisten the inside of her mouth with gauze.

  Whatever suffering came her mother’s way, she, Mitsuki, would have to be prepared for it. Long ago, that’s how people all used to die, right in their own homes.

  Since her mother’s fall, Mitsuki had had a number of sleepless nights, but never before had she felt such tension, as if her whole body were under compression. What lay ahead rose before her eyes: her mother lying face up in bed with a phlegm aspirator in one corner of the room, a heap of diapers in another. To what extent would she understand why she was there? How could she ever explain it to her?

  At the first gray light of dawn, she was reminded of how from ages past the morning has always brought relief to those who suffered through the night. She felt ready to face what would come.

  “I’m going to take Mom in.”

  Timing her call, she announced her decision to her sister. There was a pause. Then her sister said, sounding a little surprised, “You didn’t talk it over with Mrs. Kiyokawa?”

  The head caregiver at Golden still showed up at the hospital now and then with a bouquet of flowers.

  “You’re right.”

  How foolish and arrogant she had been to sit up all night in torment, convinced that she had to take on the world single-handed! Natsuki had assumed all along that she would seek help. She called Mrs. Kiyokawa then and there, and things proceeded to unroll so smoothly that her nightmare vision vanished into thin air. A clinic run by the doctor at Golden who had seen their mother once a week would take her in under the conditions they desired.

  Mitsuki couldn’t keep the excitement out of her voice. “No high-calorie solution?”

  “That’s right.” Mrs. Kiyokawa herself sounded curiously upbeat. “If that’s what the family wishes.”

  It took less than a week to transfer her to the clinic. Getting the clinic doctor’s confirmation took one whole day, and the next day when Mitsuki went to the hospital her mother was just having what was to be her final therapy session. As before, it occurred under the expert guidance of the doctor, the therapist, and a nurse, and as before it ended in failure. On cue, the doctor again suggested surgery to implant a feeding tube. Mitsuki swallowed the angry words rising in her throat and informed him that Golden was on good terms with a certain clinic where, in view of their mother’s condition, they planned to transfer her and then figure out the best course of action.

  The doctor’s face brightened; he looked as if a load had just been lifted from his shoulders. This Mitsuki had not been prepared for. She had been braced for a certain amount of resistance, but the look on his guileless face said as clear as day that he was relieved to see the last of a difficult patient. As he sat in front of the computer staring at numerical data, had his heart never once been moved by her mother’s plight? Did Japan’s current medical system leave him no other choice? Was he forced to give up feeling and thinking like a normal human being?

  The day of the transfer was soon set.

  On that day, Natsuki and Yuji came to help. The clinic had instructed that her IV be stopped before she was moved, and Mitsuki and her sister watched with emotion as the line was taken out. Never again would their mother be force-fed to postpone her death indefinitely.

  As a token of their appreciation, Mitsuki offered the doctor a big box of cookies to share with the staff. After first refusing it for form’s sake, he bore it off to the nurses’ station. Nowadays everyone seemed to feel the need to go on a diet, but she hoped at least some of the nurses who had looked after her mother might have a sweet tooth.

  The doctor and nurses all gathered in the hallway and watched ceremoniously as their mother was carried by stretcher into a specially fitted taxi, remaining out front until the family drove out of sight. Before getting into the taxi, Mitsuki and her sister kept bowing in some confusion. To the last, they never knew what was going through the doctor’s mind. His smooth, unreadable face seemed to symbolize the riddles of Japan’s medical system.

  Rocked by the motion of the taxi, their mother was carried along toward her new destination. Her eyes were closed, but it was impossible to tell if she was asleep. She had lost so much weight since the start of her ordeal that she looked almost skeletal.

  At the clinic, her attending physician was evidently taken aback on seeing her for the first time in two and a half months. After exchanging greetings, his first words were “I’m surprised to see how changed she is. She probably won’t remember me.”

  DON’T YOU LOVE ME?

  “In any case, we hope you’ll choose the path of least suffering for her,” Yuji told the attending physician, who seemed unable to recover from his shock at his patient’s deteriorated condition.

  They had asked Yuji to come because of what had happened with her previous doctor. Mitsuki and her sister talked it over and reached the conclusion that just to be safe, a man of the family—the more conventional the better—should lay out the crucial points. Yuji, although a cellist, didn’t necessarily dress like an artist. He certainly didn’t affect a “literati shirt.” The older she got, the more Mitsuki had come to appreciate his very conventionality.

  The doctor nodded and then said these heartening words: “Families who are the most at
tentive generally reach the same conclusion, that the patient’s own comfort should come first.” He might be saying this simply to make them feel better, Mitsuki thought, but she was grateful nonetheless.

  From then on, the sisters’ days were spent just waiting for their mother to die.

  The little clinic was new and clean. Examination rooms were on the first floor, private patients’ rooms on the second and third floors, six on either side of the corridor. Half of them were empty. In the other half, old people lay in bed, each with chin pointing up and toothless mouth wide open. The atmosphere was neither rushed, as in most hospitals, nor stagnant as in most nursing homes. Autumn sunshine poured through the windows, and time passed tranquilly. It was more like a hospice than a clinic.

  As they visited their mother, her death now a looming certainty because of the decision they had made, the sisters’ hearts too were tranquil. The clinic caregivers were all female, which they liked. Several times a day one would come in the room to swab the inside of her mouth, aspirate her, or change her diaper. She received two IV bags of low-calorie solution per day. She wasn’t wearing an oxygen mask anymore. As ever, her dark, cavernous mouth gaped wide open. Knowing that freedom lay around the corner, Mitsuki no longer found the sight terrifying.

  One day she fingered the base of her mother’s jaw on either side of her head and felt hard swellings. Weeks of breathing through her mouth to gain oxygen had stiffened the jaw muscles until they’d developed tight kinks. Mitsuki sat and massaged the swellings with her fingertips for a while. After she went home, she reported her finding to her sister, and the next day Natsuki said she’d spent over an hour massaging the same spots. Perhaps in these final days she was seeking reconciliation with her mother, and with her own past. She’d always been cleverer with her fingers than Mitsuki, and now was no exception.

  It was around then that Mitsuki began to sort the papers in the filing cabinet under her desk and try to work out how much money her mother would leave the two of them.