It Comes All At Once

Days started to blend in my mind as my Mom and I planned each aspect of my Dad’s service.  While my father had explicitly and directly said, “NO SERVICE” my mother, who everyone calls Miss Gail, overruled her dying husband and proceeded with arrangements.

Pastor Bob came into the house offering condolences.  His measured manner and calm demeanor were a welcome distraction for my mother, and a way for me to focus on the technical details of my father’s final trip.  As I mentioned earlier, my father’s former boss offered to transport his remains for no cost.  This one gift was the difference in making the final days a bit less terrible for my mother and, by extension, giving me a bit more space for the moments leading up to my father’s death.

I wondered how much or how detailed I wanted to make my writing about the process of dying, and I came to the conclusion that I wanted to be as thorough and detailed as is reasonably possible.  Before I describe the final day and moments, it’s necessary to have a little insight into my belief and perspective on death and dying. Without too much detail, I practice Vajrayana Nyingma Buddhism, which is the oldest of the Vajrayana sects of Buddhism.  The transmission of these ideas comes from Buddha Padmasambhava in the 8^th century C.E. and has been passed down to the present through two teachers I follow and with whom I practice.  The first, Sogyal Rinpoche, introduced these practices to me over the past twenty-five years.  I was lucky enough to meet with him multiple times during his lifetime. After his death, I joined the community of Dzongsar Khyentse Rinpochewho is the incarnation of Dilgo Jamyang Khentsye.  Yes, it is a mouthful. The teachings I have been lucky enough to be given are all about death and dying.  I’ve been studying these practices for decades.  If you know nothing about ANY of this stuff, here’s the one thing to know: the Vajrayana practitioners have teachings on the process of dying in elaborate detail.  I have been taught and tested on these ideas.

During the last 36 hours of my dad’s passing, physical and mental changes happened in succession.  While 36 hours may sound fast, when you’re in it, time slows to a crawl.  Minutes stretched into hours, and I could hear the smallest sound.  My Dad could not stand to hear any noise in those hours, and we kept the room silent (or as silent as we could with a very chatty mother and sister intending to clean every inch of the house while I sat in the room with Dad).  Many people suggested music, and every time I attempted something like that, he said no.

In these final moments, I used liquid morphine Hospice prescribed for the struggle.  They warned me that he would experience, at times, intense bouts of pain.  He did.  Between 36 and 24 hours, he asked for just two things: water and morphine.  He remained aware and cognizant until the final hours of his passing.  Simply put, he knew what was happening.

Because he lost his ability to swallow without liquid falling into his airway, I squeezed drops of liquid into his cheek as he lay with his head on the pillow.  He would ask for more… meaning water… with a small syringe, I dripped it into his cheek. He was able to get some relief with this method.  He slept often, eyes completely open, mouth agape.  Around 24 hours before, his chest rattled with fluid.  Twice during the final couple of days, a hospice nurse came to check on his vitals…in the last visit, about 36 hours before his death, they could not register blood pressure and did feel a strong radial and carotid pulse.  My father had withered into a shell of himself, his BMI now around 10%.  He looked like a skeleton.  The image was stark.  Skin stretched over bone.  His hips were boney protrusions, and we moved him constantly to prevent bed sores.  Even in this state, he was alive and kicking.

During the final day, I stayed with him much of the time, reading as I sat by his side.  His breathing changed during the course of the day, starting with about 14 respirations/minute (normal for most folks) to a more hurried, shallow breath.  The rattling in his chest stopped about 6 hours before he died, as he couldn’t take deep breaths.  His heart rate spiked to 200 bpm as I consistently checked his pulse over these hours.  

I talked to him quietly into the evening, ensuring him that we were all OK, and that he could let go whenever he wanted.  

Between 6:30 and 7:30pm, he was clearly in distress.  The Hospice nurse had explained that I could increase morphine dosage and frequency.  I did.  From once an hour to every 15 minutes I gave him a dose.  By 7:30pm, he refused water by expressing no to me.

As an aside, in the final few days of his life, I was the only one who could understand what he wanted.  For whatever reason, I could hear him when others could not.  At first, I was frustrated that my sisters and Mom couldn’t understand him.  Then, as I watched them try to hear him, they literally could not understand what was clear to me.  That was among the weirdest moments in this entire experience.

By 8:30pm, he was slipping away. He stopped responding to my touch.  In the previous hours, every time I put my hand on his hand or face, he would look directly at me.  Now, he was gone. His arms and legs shook, and his body went through a series of tremors… not violent in any way, just a gentle shake or two.  The timbre of the air in the room had changed and a palpable odor covered the space. 

At 10:00 pm, he started making a moaning sound that was air passing through his airway.  When you hear something like that, it’s clear that it’s not an emotional or intentional reaction.  It was air moving through his body.  

My mother came into the room and was completely unnerved by the sound. My sisters were upset and angry that I was letting him suffer.  Explanations didn’t help, and I gently asked them to go into the den, and I would explain his situation to them later.  They left soon after.

As I added more morphine into his cheek, it took about 30 minutes for the moaning to end.  His breaths made another change, and his pulse was erratic: one hard beat/stop/two soft beats/stop.  No real pattern.  Hospice call this breathing Cheyne-Stokes, named in the 19^th century for the scientists that determined most people experience this breathing toward the end of life.  The rapid heart rate and shallow breathing go together.

After a while, around 1:00 AM, my mom came back into the room and lay in bed with him.  She asked if she could put her hand on his chest.  I told her, of course, and she felt his irregular heartbeat.  She asked me why it was so strange.  I talked about the dying process and said that it was completely normal.  She did not agree it was normal and, as is often the case, argued with me about what normal was.  I laughed inside, seeing that she still had that mom energy.

I headed to my room upstairs, as Dad’s breathing had stabilized into short, quick, shallow breaths.  Soon after, my mom called and said something had changed.

After changing clothes (it’s HOT here!), I went back to see him.  Mom had left the room to take some cough medicine (she’s got allergies and won’t take allergy medication…don’t ask), grab some water, and use the restroom.  She was in the kitchen.

“He’s not breathing.” Hmmm. I walked into the room and felt for a pulse; nothing.  His breathing had stopped, eyes and mouth still open as if he was taking a breath.  His hands were cold.  

The Hospice nurse had explained that in most cases, when a patient is aware of their situation, the patient cannot let go when people are in the room.  They want to remain in that place with their loved ones, even though they truly are not present.

My mother and I had left the room, and as soon as we did, my dad died.  Sure, maybe it was a coincidence.  I don’t know.  What I do know is the moment happened, at the end, all at once.

A phone call to Hospice and the Funeral Home happened soon after I checked my dad’s pulse.  Within twenty minutes, Dylan, our nurse, came in.  He was calm and kind.  My mother absolutely couldn’t be in the room with my dad at this point, and Dylan walked her into the den.  I called my sisters and told them what had happened.  They had left earlier in the evening, and I let them know the details.  My sister Whitney swooped in a while later and demanded to know why I was qualified to declare our dad dead.  Dylan came in and helped Whitney understand the circumstances.  One look at Dad, and she headed to be with Mom.

Dylan asked if I wanted to prepare my dad for his trip, and I agreed.  We turned him on his back, and we washed his body.  My sister and I had bathed him the day before, so things were clean.  I grabbed some clothes Mom wanted him to wear, and we dressed him.  I couldn’t help thinking about how I had similarly dressed my children when they were very young, pulling on pants or skirts as they fought with me the entire way.  My Dad, in his own way, resisted the clothing as we had to bend and stretch his tight legs and arms, his body beginning to stiffen.

The mortuary vehicle arrived, and Dylan and I placed my dad on a backboard, strapping him in place, checked by the mortuary staff.  My mother and sister wanted nothing to do with this process, and I helped guide my dad to the vehicle.  They placed him in the back on the gurney, covered in a thick cloth covering of tan with a black repeating pattern.

We all said our goodbyes.  My sister and I went into the empty bedroom and stripped the sheets.  By this time, it was 7:00AM.  About 4 hours had passed since my dad’s death.

My sister then went on a cleaning rampage.  She vacuumed, mopped floors, emptied the pantry, tossed canned goods that had been around for ten years.

I politely stepped away, finally lying in bed upstairs.  As soon as my head hit the pillow, the people next door started leaf blowers and lawn mowers. I lay there for a while, listening to the sound of machinery, just a few feet from my window.  I was pissed.  Then, I remembered my father, on Saturday mornings, dragging me out of bed to mow the grass, rake leaves, and do my work around the house.  I had to chuckle.  Thanks Dad, for one last laugh.