Death, like living, is a unique experience. I have been at the bedside with many patients and their families during that poignant time when everything changes. I consider myself a privileged student of each of those great teachers. As a nurse, some patients and families stand out in your mind and seem to illustrate all that you have learned; such was the case with A.J.
A.J. was a person I had known as long as I can remember. We lived in the same places while I was growing up and had a close view of each other's lives. I knew him as a man who was committed to his responsibilities, and although he never seemed to have much to say beyond the weather, the traffic, and light conversational topics, he was just always there. He smiled easily but wasn't a funny person, and I don't remember that he ever told a joke. He liked babies and small children and was good at entertaining them.
A.J. worked with his hands as a carpenter and probably experienced his greatest moments of pride when he finished a job and he stood back to view it as his creation. He built some sturdy furniture pieces for his family and his church, which seemed to be his way of investing in others. His "uniform" for most days of his life was striped bib overalls, a blue work shirt, heavy high-top work shoes, and a striped hat-the kind usually worn by train engineers. He wore that outfit to work, to go fishing, to work on his old car, or even to relax with a newspaper after dinner.
At the age of 83, A.J. was diagnosed with prostate cancer after it had widely metastasized into his bones. The family knew I had been a hospice nurse for several years and sent me updates and asked my advice as they encountered the rough edges of the healthcare system. Reading their e-mail, I realized that his body was in a steady state of decline. I wanted to be there to help with the caregiver tasks, but mileage across the country was a barrier. I made plans to go at a time convenient for my responsibilities, but as the time drew near I heard from the family that he wasn't eating and at times was confused about dates, times, and places, and weakness was increasing each day. I really wanted to see him once more, so I moved my trip forward by a week.
When I arrived, there was a buzz of activity with visitors in the home. He was in a wheelchair at the table-not to eat, just to visit. He didn't seem to notice that I had joined the circle, there was so much activity going on around him, and it seemed like he thought I had been there all along.
As bedtime approached, I volunteered to do night duty. His tired family told of restless nights up and down over the past few days and I observed his strength wane in a matter of hours, so I expected uncertainty and restlessness through the night. The family had reported his restlessness to the hospice nurse when she came by to see about him early in the day, and she had obtained a prescription for Ativan to help him rest better at night. A.J. was blessed at this point in his life by something he had probably been born with: he didn't feel pain. That had presented problems earlier in his life because he didn't get the signals most people do when pain comes as a warning of need in the body.
We gave him some Ativan and everyone went off to bed, except me. I had a kitchen chair at the bedside, and the straight back helped keep me alert for the very busy night that lay ahead.
A.J. began to work on his transitional life, preparing for the spirit world, and seeming to have one foot in this physical world and one on the other side. I recognized his behavior as an example of what has been called "nearing death awareness," by Callanan and Kelley in their book, Final Gifts. 1
From the book and from being with so many dying persons, I knew that metaphoric speech is typical of this time, and conversations with unseen beings often occur. It was fascinating to listen to A.J.'s side of the conversation, ask him for clarification, and hear something about what he was seeing and who he was talking to. Even with a repeat dose of Ativan, A.J. talked all night long, in a clear voice. He didn't seem uncomfortable or stressed in any way; he simply had things to do.
He told me that he was going on a big trip and needed to get the "old car" ready. The "old car" was a 1932 Ford sedan that had been his vehicle for work and fishing most of the years I had known him. Because he had always done his own maintenance work on that car, I recognized that this was part of life closure for him, and his trip would be a metaphorical expression of his approaching death.
There in the bed, he mimed his activities with his arms and hands as he prepared his old car for one more trip. He struggled to reach up high and place the removable luggage rack on top of the car and secure the straps that would hold it in place. His next step was to align the "seal-beam headlights." He tinkered with the adjustment screws, then pulled his head back to get a view of the results, doing that several times. Intermittently he talked with someone else who was "helping" him. He called him Bill. Later his wife told me that Bill was a mechanic that A.J. always went to when he needed help, and that Bill had died a few years ago. Finally, he seemed satisfied that the headlights were adjusted-I took this to mean that he could now clearly see the "road" ahead. But there was one more facet of preparing the car-he needed to "reline the brakes." He struggled back and forth in the bed using his arms and torso and always seemed to end up with a look of consternation on his face and his left fist tightly closed as if he were holding something he might lose. I finally asked him what he had in his hand and he explained that he had five screws and he couldn't seem to find the place where they went. I offered to hold them for him, and he willingly transferred them to my hand, but soon I noted that his fist was clenched once more. When I asked again what he had in his hand, it was the same five screws that he needed to finish the brake job. I decided that he needed some help for this part of the job from his one and only son, who always worked alongside him on the old car. His son had gone home for the night to sleep after having been up with A.J. the past two nights. I waited for daybreak to call in his helper. When he arrived, his son entered right into the project, A.J. handed him the screws and they went "right into place." A.J. looked over things very intently as if surveying the entire car, and agreed with his son that it was now "ready to go."
His son volunteered to "put away the tools now" and A.J. methodically went through the motions of washing his hands, then lay back restfully on his pillow. He didn't mention the car again. (Because A.J. had five children, the family later pondered whether handing those five screws to his son was a symbolic transfer and completion of his fatherly responsibilities. Considering that a car's brakes offer safety, a sense of control, and protection, it seemed to be a comforting interpretation to the family.)
During the hours when the car was being prepared, there were other things going on for A.J., too. Periodically he would gaze as if looking at a great distance, his eyes sparkling with life (even the one that had been blinded for years!) and he would have a conversation with someone. One of those conversations went something like this.
A.J.:That sure is a beautiful green lawn you got. I don't think I've ever seen anything so alive and green... [pause]...Do you use Chemlawn?... [pause]...My wife and I used Chemlawn, but not this year. I'm going on this big trip and we decided to sell the house. [All true.]
I had to contain myself from laughter as I visualized A.J. talking to God, the keeper of the greens in the "Valley of the Shadow of Death," about Chemlawn! There surely was no sense of fear, and the words of Psalm 23 came to mind:"Yea, though I walk through the valley of the shadow of death, I will fear no evil." The rest of that Psalm became alive too as I watched him "dine" on a variety of foods he described as he went through the motions of having a feast-all of the foods were those that had been his favorites in life. He described seeing "throngs of people," and then would call someone by name and begin a conversation with that person. (Later, the family reviewed the list of names I wrote and found they were people from the family and friends of his life who were now deceased.)
He smiled often and had a sort of glorified glow on his face. At one point, he raised both hands as if in worship and said, "Praise You. Praise You. Give you all the Glory." What a sacred moment, for I had the sense of standing beside A.J. in the presence of God Himself! I knew his church did not do this as part of their services, and it was not characteristic for him to be demonstrative in his religious practice. This behavior was somehow related to his "new life," much more than his old one.
When morning came, A.J. began having some periods of irregular breathing and it seemed the end was near, but not quite. The family gathered and friends who heard of his condition came to say good-bye. He greeted each one, spoke their name, and thanked them for coming. With a boyish grin of pleasure, he bussed his lips and asked for his wife of 64 years to come closer so he could plant a kiss. Teenagers gathered in the living room for a birthday celebration for one of his grandchildren. They played lively music, laughed and enjoyed each other's company. One by one, those who either knew A.J. or were related to him made time to go sit beside his bed, hold his hand, and have a private moment with him. A.J. conversed with them, as well as the people on the other side-which was a new experience for each of those teenagers. A.J. commented that this was a special day for his granddaughter and he occasionally asked what time it was-until midnight came. It seemed he wanted to live through that day as a gift for her.
Throughout that day, A.J. entertained people with a great sense of humor and some outstanding statements-neither of which had been part of his character in life. For example, at one point, one of his daughters asked if there was anything any of the kids could do to help him in his transition. His reply was profound: "I came into this world by myself, and I have to go out by myself."
On another occasion he saw his son standing at the foot of the bed, and with a playful grin, he pronounced, "Well, well, well. If it isn't the clown and culprit!" (Those were such appropriate words and provided a two-word summary of the roles the family had always ascribed to that one and only son.)
When evening came, the house settled down from the flurry of activity. The lights were dimmed, no medication was offered, and A.J. fell asleep. His breathing had been irregular throughout the day, but now the periods of apnea became prolonged and more frequent. By 2:00 AM it was apparent that he was no longer arousable and the secretions in his throat told the story that life was coming to a close. With his last breath, his spirit left his body at 7:00 AM and his body lay quiet and motionless. His family gathered at the bedside, held hands, and between sobs sang the Doxology.
I realized that this man of humble means and genuine character had used his dying as a platform to teach everyone around him many things about death. We learned there is no need to fear, relationships can be completed, there is more to life than what we've seen so far, and that those last hours can lead one to a pinnacle of personal and spiritual growth.
When the family joined hands and sang around his bed, I was there. A.J. was my dad.
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