The only things certain in life are death and taxes. At the Hospice of Metro Denver's Aurora Care Center, the days leading up to April 15 went by peacefully and, for the most part, quietly, but death was still in the neighborhood, and some twenty patients, men and women, all elderly, were waiting for their appointments. If you stood in the hallway, out of the way of laundry carts, medical equipment and food deliveries, death wafted gently out toward you, like a smell. And sometimes a smell is what it was: the incontinence at the end of life, or the last breakfast someone would toy with, or the KFC someone's kids had laid in for the long hours of hand-holding ahead. In the night, and in the day, people "passed," "passed over" or "passed away." That's what the staff called it, and that's what they said it looks like. With what it sounds like, you get a little more variety--the rattles, the sighs, the total silence.
From the hallway, it was possible to hear: "Someone? Someone? I seem to have a cough."
"I'll get that cough syrup," the charge nurse said. The man who had requested it was emaciated but in a pleasant humor. Cough syrup was a drop in the bucket of his pain medication. His prostate cancer had spread to the lymph nodes, the brain, the bones. "I'm getting money back this year, it turns out," he told a visitor. "So life is good!"
A guy named Harry was fatigued, the certified nurse's assistant said, while Janice was "fearful, struggling." They put her mattress on the floor so that if she became agitated and fell off it, she wouldn't hurt herself.
"Nurse?" another woman asked timidly. "I've just woken up, and was I snoring, do you think? I live alone, so I never know."
"We have unlimited visiting hours," a staff member told another visitor. "Even for pets. Usually dogs. Fine with us."
In the room where staff and volunteers took hurried breaks, there was always food. It came in themes--deli sent over from a recent widower, leftover birthday cake, Chinese.
"I understand there were deaths over the weekend," someone said.
"Oh? Well, probably," was the answer. Two thousand people had died at the Care Center since it opened five years ago.
A patient named Pauline had asked to be rolled over next to the door of the staff bathroom, and that is where she spent most of the next two days. When her husband came to visit, they argued in the rutted, not unfriendly way of the long-married. When he left, she fixed beady eyes on the reception desk and homed in on the gossip, which interested her much more than well-meaning discussions of death--available any time with a social worker or a chaplain. "Who cares?" she said. "I'm just in here to get something done about my blood pressure. I'll be out soon."
Meanwhile, Pauline enjoyed serving as the Care Center's official cantankerous patient. The only time she needed cheering up was when a troop of well-meaning, and well-amplified, accordionists tried to do it on purpose. "Close the door, nurse," she said. "They stink."
At regular intervals, people would ask Pauline if the bathroom was occupied, and she enjoyed having that piece of information to dispense--"Because when you gotta go..."
"Yeah?" said Joy, the CNA who'd become Pauline's particular friend, partially because of the aide's excellent frozen milkshakes. "Try having to go and also having to change someone's catheter." Joy had been on the job for four hours, during which her duties had been half-menial, half-psychiatric--or, in the case of the milkshakes, both.
"Let's see--I got here at 6:30 this morning," Joy said. "I did the morning care and baths; I went to a team meeting. It's a good job. You get to meet people at an unusual time in their life. You get attached."
A small boy, maybe six, ran down the hall making "vroom" noises with a truck. His mother followed, apologizing.
"He's okay," Joy said. "He's absolutely fine. Someone's family," she added. "Yeah, so. You get attached."
A few miles away, in a modest Aurora apartment building, Eileen, now less than a week from her 88th birthday, remembered Joy, who had given her baths and told her jokes during a recent hospice stay. "That's right, I'm a hospice dropout," she said cheerfully. "I started doing stuff like making my own bed, so eventually I had to leave. But that Joy, she was always poking her head around the corner, making me those milkshakes. What a sweet gal."
Patsy, Eileen's daughter and roommate, continued the hospice-dropout story. The preamble went like this: Patsy's husband had been cared for, and eventually died, at the Care Center, and Eileen had grown to like the place. Two years later, stricken by colon cancer and living in a nursing home, she began to think of checking into the center herself. "She had not been eating too good," Patsy recalled, "and her body just shut down on her. She wanted to be where she was familiar."
But as soon as she got there, her condition improved. The meals were good; the staff was loving. Eileen got up and began to walk the halls. If it hadn't been for one particular aspect of hospice life, she said, she'd still be there. "But I lost three roommates," she remembered. "I had not expected to be there, in the room, when someone went beyond. I have my bad days, I have a terminal illness, and I'm not afraid to die, but I had worked with the wounded during the war, and I had heard that rattle, and I wasn't ready."
"But you like the people," Patsy prompted.
"Oh, that place changed my whole concept of life and death. I began to think about it: Do I want another operation, or would I like to just go out on my own? Just knowing that I can go back there where they live so nicely, knowing I can pass out of this world without any extra pain."
"It makes you feel good?" Patsy asked.
"Why, they have volunteers who are men," Eileen said. "At the nursing home, it was all old ladies who were petty. Nothing to talk about. At the hospice, I was dumbfounded--a male person came by just to talk to me. I'm the type that likes that. I don't think, for instance, that I'm supposed to have salad in my condition, but my idea is, let's do it!"
"You had fried shrimp for breakfast," Patsy pointed out.
"Sure, if I want. I went down to Captain D's on Senior Night. There were leftovers."
Back at the Care Center, two sisters were drinking coffee from cardboard cups and spelling each other on hand-holding shifts. Their older sister Phyllis, in the last stages of breast cancer, was semi-conscious, breathing oxygen from a tube, her teeth removed and her grayish-black hair spread over the pillow in a way that made her seem younger than her two sisters, who wore their hair in stiff, short perms.
"She looks peaceful," one said doubtfully.
"I'm sitting here thinking so much," the other said, weeping silently. "Remember, she was such an avid reader from the time she learned to read, and I'd get so tired of waiting on her at the library and just go home?"
"She kept on with that," said Sister 1. "She worked in accounting. She was an office manager."
The facts on Phyllis pour out. Married. No kids. She'd been nearly this sick since the day three weeks ago when a doctor at a local hospital had told her the cancer could not be contained.
"And she says, 'Why, take me home with you,'" remembered Sister 2, in despair. "And I just couldn't! We are in the process of moving to Missouri. I didn't know what to do."
"But you did fine," Sister 1 assured her. "And she is fine. It is so good to see her out of her suffering." She paused. "Which has lasted such a long time."
Twenty-five years, it turned out. Back in the mid-Seventies, Phyllis, now in her late sixties, suffered a mental breakdown, was divorced and moved into subsidized housing. Sister 2 thinks the breakdown could have been precipitated by a botched hysterectomy--or was it the ex? "She never was right after that," she remembered. "Even last month, when the doctor told her how it was, she said, 'Forget it, I'm not gonna play your crazy games.' And I heard her say under her breath, 'I never thought about death.'"
Charge nurse Marcia Johnson, who has heard most of the Phyllis story and so many more like it, doesn't believe you have time to think much about anything in a hospital. "My father died miserably," she said. "A hospital death. They told us on a Friday to take him home on Monday. I am an only child, there was a barrage of doctors but no primary-care physician, and I didn't know how to care for him, and neither did my mother. We were frantic. The doctor said, 'Oh, darlin', not to worry, he won't live through the weekend.'"
And he didn't. Still, Marcia had detested feeling helpless and decided to do something about it. A self-described late bloomer, she became a registered nurse in her forties and went to work at a center for head-injured patients.
"I hated it," she said. "Thirty patients--herd them in, herd them out. I will never forget one morning, one of my gentlemen kept saying he wanted to go back to bed, and I kept thinking when I was back from my rounds I would care for him. He was obviously ill. But when I got back, he had passed away."
Looking for a job at which she could pay more attention to fewer patients, she came to the Care Center three years ago. "And now I can really observe," she said happily. "They can't always tell me what hurts them, but I can observe. And I can help them with the things they're afraid to talk about, the bed sores, the hemorrhoids, the constipation. People are embarrassed, but you can bring them comfort," she added. "Here's what you do: You whisper."
On an average of one and a half times each day--but never that predictably, of course--the whispers are interrupted by the sound of the cast-iron bell that hangs to the south of the nurse's desk. "It's not that loud, and we're used to it," explained Toby DuBon, the nondenominational chaplain who usually does the ringing, "but people still come out and say, 'Who? Who passed?'"
Toby had just come out of the weekly meeting at which staffers discuss every patient, how long they might last and how to keep them comfortable. Like the staff social workers, he'd been asked his view of the patient's spiritual and mental health--or lack thereof. Dr. David Nowells had dealt with a case of chest pain, a rash and a sudden inflammation around a feeding tube. Don Vecchio, the consulting pharmacist, battled the same complaint every week.
"Pain," he explained, "which I thought at first was nothing but a niche market. This was 33 years ago, and I was just a guy with a small neighborhood pharmacy. I thought it would make business sense to be emergency pharmacist for the hospice. But imagine how it felt--say it's 2 a.m., and someone is in a lot of pain and is anxious and also can't swallow. And say I can figure out a way to get them some relief--and there are a lot of great ways to give the meds, and the big drug companies don't always make them. I began to make a lot of them myself."
One standard, a super-concentrated form of morphine, is known around the Care Center as Green River. "It comes from the mint and sorbitol I put in it so people can take it sublingually," Don said. "No one likes to get stuck all the time. I tinkered a lot with that one, and it's pretty effective."
As he spoke, a third of the patients drifting on the Green River were younger than Don. Thinking of this, he suddenly decided to take the trip to Hawaii he knew he couldn't afford. A side effect of hospice work, he admitted, is a tendency to move fast.
"You never put off anything," agreed Candace Malley, a volunteer for the past five years. "I say things to people. I don't stay mad at anyone. When I realized I'd always wanted to kayak, okay. I took the lessons."
Candace had spent this morning making Xerox copies and was taking a break in a garden where the names of the deceased, handwritten on strips of paper, rustled in a tree. Earlier, she had dropped by the homes of two patients who used her however they saw fit. Quite recently, she took a terminally ill woman to the Cherry Creek Tattered Cover to buy a journal. "She wanted to leave that to her grandchildren. And she felt up to it," Candace said. "As long as we were there, we went to the Fourth Story and had lunch. Wine and everything. Once my job was to pull recipes from a woman's file and make the casseroles she liked to eat, because she couldn't anymore. Once I drove to the Aurora Mall, over and over again. In a way that is hard to explain, I've found my calling."
In the beginning, Candace was afraid her patients would be screaming in agony, unwilling to meet death head-on. When her first home-care patient, whose letters she'd written for eight months, sank into her final decline, though, she went painlessly. "But angry," Candace recalled. "She had a strong faith in God, and she got mad at him near the end for letting her hang around when all she wanted was to go. They are hard conversations to hear."
Now it's been years since Candace feared a discussion of death. Her own is all picked out, she said, the way younger women design a wedding. She knows what nurses she likes and which room she'd request. "There's that term, a 'good death,'" she said. "That's what I want."
In the meantime, though, there was small talk to make. What a nice robe that is, or my, what attractive flowers. The picture on your table--is that a grandchild?
"They don't want to dwell on the end of life," she said. "They prefer to talk about the small, wonderful things."
Rusty had been at the Care Center for two weeks. Carefully positioned around her bed were: a bottle of olive oil for use as hand lotion, two mink teddy bears, a small camera and a photo album, because she liked to take a picture of anyone, however fleeting, who walked into her room. While dying rapidly of cirrhosis and liver cancer, she had developed a sudden interest in journalism and decided to go for it.
Outside, the transition from pre-Rusty to the present was more extreme. A lifelong gardener, she had ordered her younger relatives to uproot the juniper bushes from the tiny strip garden outside her room. Then, one plastic pot at a time, she planted primroses and pansies. When visitors came, they often found her outside, grubbing slowly in the dirt, or dozing in a lawn chair, a straw cowboy hat over her eyes. Donations of potting soil and bedding plants began to show up in her room. Residents of the nursing home that shares the building began wheeling over in their chairs to get a better look. A couple of ducks from an undeveloped marsh took up residence.
But just as Rusty was about to become famous in her own lifetime, she slipped into the state of half-consciousness so familiar to hospice workers. Her husband rolled the piano from the family room down the hall to the door of Rusty's room and played "What a Friend We Have in Jesus." The CNAs thought it was the most romantic thing they'd ever seen.
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The next morning Rusty woke up again, raring to talk asparagus.
"What you do is, you dig a trench," she began. Then her granddaughter came to visit, and her husband called about the business they run, and Joy came by with a milkshake.
"You fertilize the heck out of it," she continued, more than an hour later. "Oh, if I could get down on my knees, I'd show you, but I'm swollen up. I'm yellow, too--see my skin? Terminal. Anyway, plant them in there and wait three years before you dare to eat one. It's worth it."
After that, she covered tulips, lilacs and tomatoes. The phone rang many more times. It had been an exhausting, exhilarating day. The next morning, Rusty lay in a half-sleep, listening to a hospice volunteer who was singing hymns and suggesting horticultural visions. "Imagine, Rusty, if heaven were all lilacs, and lilies, and roses..." Sometimes Rusty made a noise that sounded like a phrase of a song, but mostly she slept, and three days later, she died.
It was hard to imagine that there had been a time, a recent time, when she had grabbed a visitor by the hand and said, "Oh, what hands. Such warmth. Your hands are so warm. Hold me.