Dying Well

Tamara Mann

For twenty-nine years my grandparents taught me how to live; in my thirtieth year they taught me how to die. My grandfather's death was orchestrated, my Nana's improvised.

We all knew how my grandfather wanted to die: at home surrounded by his wife, his children, and his grandchildren. And so, despite the efforts of lifting his body out of the hospital bed, wheeling him into an ambulance, driving across town, and refashioning his bedroom with a hospital cot and oxygen tanks, my mother and uncles made it happen.

For three more months we lived peacefully in that bedroom. My Nana held his hands, sang Yiddish songs, and repeated the phrase, "I hit the jackpot with him." We would all sit beside him—my cousin, my brother, my uncles, my mother—patting his hand, and he would pat right back, smile, and say, "good good good." His hands were soft. They smelled like the lemon cream my mother would rub nightly on his chapped skin. The night before he died he ate pea soup with butter, even though the doctors told us he would stop eating. My grandfather never stopped eating. He seized every last bit of joy from life—even while horizontal, even while in pain. The next day his breathing changed, his eyes closed, and my mother called us in. We were there when his chest rose and he took his last breath.

In the same way we knew how my grandfather wanted to die, we knew that my grandmother still wanted to live. "Go on your vacation," she begged me. "Go go go and live it up. Live it up for me." And so I went, knowing that she would spend that week moving into her new apartment. Everything that day was perfect. My Nana got her hair done, her nails done, and arrived in her new home feeling, in her words, "like a bride." The apartment was majestic, filled with light pink and the floral motifs that my Nana so loved; each flower elegantly placed to convey a sense of peace and purity. When my Nana saw the room, she cried. "Look what my daughter has done for me." That night when she went to bed she couldn't breathe. An ambulance rushed her to Mount Sinai Hospital. Would it be OK, asked her doctors, if the new residents came in to witness the conversation, it is their first day. "Yes, let them come in," she said as she rose taller in the bed. She was regal, said my uncle, like her name, Malka.

The doctor continued: "You have late stage emphysema. You can continue to live in the hospital intubated or you can choose not to be." In an instant, she chose not to be. "I want to live, I want to live very badly," she said to the young, teary residents. "But I don't want to live like that. I'm ready." Her children were beside her. "Wait," my mother pleaded, "wait for the grandchildren, wait wait wait." She couldn't believe it. No one could believe it. It happened so fast. Before my Nana died she held her children's hands and told them, "Family is a like a rug, quick to unravel. Don't let it unravel." As she drifted quietly from her children, from me, she whispered, "Love much, love much, love much."

My grandparents had the great gift of engaging with death, of choosing their path, and of dying with medical assistance. They had the gifts of Medicare and hospice, of pacemakers, defibrillators, second opinions, and morphine. They knew how to ask and how to say no; how to talk to doctors and family members; how to retain authority in an environment that often tried to strip them of agency. Most Americans are not so lucky.

Death, for many aged Americans, has become a lengthy, undignified, and infantilizing process. While the majority of Americans wish to die peacefully at home, elderly men and women are repeatedly shuttled between nursing homes and hospitals during the last months of life. Emergency room visits, unnecessary procedures, and countless tests continue to mark too many Americans' final days. Medicare alone recently paid more than 50 billion dollars to keep aged Americans alive in the final two months of life. Modern medicine has created the blessing, the illusion, and the burden of choice.

When it comes to death, choice can be a misplaced ideal. The ethicist Daniel Callahan makes a valuable distinction between choosing how we die and choosing to die. As the space of death moved from the home to the hospital, he writes, "illusions of mastery" overshadowed the physical reality of frailty, disease, and death. Doctors, patients, and politicians alike began to describe death itself as a choice. They came to believe that men and women died of medical and technological failure, not of disease. Thus, all forms of intervention became necessities and withdrawing intervention became murder. My grandparents didn't choose between life and death. My grandfather died of heart disease; hospice aids taught us to turn off his defibrillator. My grandmother died of emphysema; she decided against further medical intervention. They didn't choose to die, but they did choose how they wanted to die.

My grandparents each died differently, but our rituals of mourning stayed the same. When my grandfather died, the chevra kadisha came to the house and sat with his body. Women from the synagogue arrived to cover the mirrors and help us prepare for the day ahead. Within twenty-four hours, he was buried. Each one in the entire family—great uncles, aunts, cousins, and small children—had taken a handful or a shovel of dirt to cover his body. We returned home, washed our hands, and began the seven-day process of bringing him, through shared memories, back into our lives.

Three months later, we began again.

The chevra kadisha arrived at the hospital while volunteers prepared our house. In less than twenty-four hours, we buried my Nana next to my grandpa. We arrived back at the house where they both had lived, and where my grandfather had died, covered in dirt. We washed, we sat, and we began the process of remembering again.

For fourteen days that spring and summer, we replayed their lives. And again and again we came back to their deaths. We talked about their bravery and their dignity. The way Nana held Grandpa's hand, the way she spoke to the young residents, and the way he clung to life. This is the gift they gave us. They allowed their family to see their deaths as the final moral act of their lives.

Death is defined as much by the metaphors we use to describe it as by the technologies we use to stave it off. It is not simple and it is not clear. It can feel definitive, the last breath or heartbeat. It can feel long and obscure, as with the slow breakdown of organ function. How can we learn to talk appropriately about something we don't understand? This is the true challenge of end-of-life care. We have to trek through the political, medical, and emotional thicket to fight for dignity, without the advantage of clarity. We have to learn to talk about death without hurtful metaphors, to give up the phrase "death panel," and to abandon the battle cries of war. As a society, we have to find better words and phrases to cope with the unbending reality of death.

To die well, we need to learn to talk well about death. We need to figure out its place in the spaces of technological intervention—the hospital and the nursing home—and in the emotional spaces of our relationships. We need to face the horror, the pain, and the possibility, however rare, that the process of dying can be filled with a kind of beauty. My grandparents taught me the value of facing this final act as we face all others, with bravery, with confidence, with compassion, and with dignity. Not only for ourselves, but for everyone we leave behind.


Tamara Mann, MTS '05, is a doctoral candidate in history at Columbia University, completing her dissertation on the early history of Medicare, "Honor Thy Father and Mother: Old Age in a New America." Her writing has appeared in The Washington Post, The Huffington Post, and My Jewish Learning.