Goodbyes

"Man's best friend"

The goodbye stories I've shared so far have all involved people. But pets are family members, too, and saying farewell to a treasured cat, dog, or other animal can be heartbreaking and heartwarming, too.

This summer, we visited a colleague of mine in northern Maine. Alex had just lost his cherished dog, an Italian Spinone named Monty, after 14 years of companionship, and he kept us grinning with tales about Monty's passion for cake and lasagna, among other endearing qualities.

Alex and his family buried the shaggy white-and-brown dog under a tree between the barn and garage, "in the spot where he used to sit and watch me," Alex wrote. The mound is marked with a marble tablet that Alex carved to read, "MONTY, 1993-2008. good boy, good boy"

To help with his grief, Alex composed a tender tribute that I'm including here -- with our cat Puck lying by the keyboard. As Alex noted about Monty, "We should all live and die so well."

Nearly 15, Monty Dies Peacefully

Monty died peacefully the afternoon of August 11, 2008, following several months of declining health. At the end, he was deaf and blind and could no longer get up by himself, nor take more than a few steps unassisted. His passing was soft, and full of love and sadness.

Born Nov. 27, 1993 in West Sussex, England, the son of the champion Italian Spinone Fiume del Gaesten (and before that a long lineage of English champions), Monty came to New England at 14 months. All his life he retained the slightly superior attitude of a servant who was higher born than his master. Having lost his English family to the arrival of a new baby, he stayed as aloof and resentful as a teenager for a couple of years before conceding.

Monty loved girls and women and missed them when they were gone. He always checked my door first when I drove in, and then went around to the passenger door to see if someone more interesting would emerge.

Typical of his breed, he had little aggression, and simply waited patiently for people to approach him, as they usually did. He was good with children this way, for he would play with them up to a certain point, and then walk away. He liked children, but was wary of them. He established the rules with an urbane sophistication.

Monty had faults, but they seem minor now. He was a terrible food thief, and could snatch a sandwich without disturbing the plate. Any child's snack was considered fair game. On his hind legs he could grab a cake from the very back of the kitchen counter. He was quick, stealthy and entirely without shame or remorse. Stealing food was a sport for Monty. He seemed to have a kind of pride about it, and could listen to my scoldings with the look of a teenager's "whatever."

He also loved to get up on sofas and beds no matter how much he was warned about it. He had a living room armchair that he claimed as his own, and could somehow fit his 105-pound frame into the seat, rest his chin on the arm, and sleep peacefully for hours.

He is buried in a small field between the barn and the garage, in the spot where he used to sit and watch me. At the burial my nieces and grandchildren spread flowers and ripe blackberries on his body, wrapped in a blue blanket. He was surrounded, at the end, by those who loved him and who will remember him as the regal, sweet and playful creature he was.

There lives a generation of my family who cannot remember the world before Monty.

His affability and sense of fun made him a marvelous companion, and like the good dogs of this world, could make life, even in its dark hours, seem normal and fair.

Dying people are living, too

While gathering stories about goodbyes at the end of life, one message keeps reverberating in my head: People who are dying are still living, and we should do everything we can to treat them that way.

Randy Pausch, the computer science professor who delivered the famous "Last Lecture," certainly followed that creed until his death in July. Faced with pancreatic cancer, he squeezed as much out of life as possible, for instance taking his young son swimming with dolphins and enjoying a scuba-diving trip with three close friends. "I'm living like I'm dying," he said. "But at the same time, I'm very much living like I'm still living,"

There are many other terminally ill people who take the same approach -– and who teach their loved ones about cherishing each day. I found several examples in the New York Times health blog "Well," as part of a post called "A Lesson on How to Say Goodbye."

Here are a few stories that resonated with me:

When Linda's mother learned she had liver cancer and roughly one year left, "she went on living the remainder of her life here as she always did. Nothing special. No Hollywood "Bucket List" or any of that crap. No, she continued to see her friends, get her hair styled, spent time with her family, went out to dinner with everyone, read the papers, cooked, etc., until she couldn't do any of these things anymore.
     "Toward the end," Linda wrote in early May, "when she was drifting in and out of consciousness in her own bed at home, I spent a lot of time with her, talking with her. They say that your sense of hearing is one of the last things to go. I didn't know that then. I just kept telling her how much I love her, that if I could ever be half the mother she was, it would be quite the achievement. One day, while telling her how much her children love her, she opened her eyes and smiled. I'll never forget what she said: 'Then I'll be okay, wouldn't I?'
     "To die with dignity is extremely important. I wish that for everyone. But it wasn't until I witnessed my mother's own passing that I learned what it meant to die with grace. Even at the end of her life, she never stopped being a mother. She never stopped teaching her children."

 

"My beloved grandmother was diagnosed with congestive heart failure not long after her 100th birthday," according to KS. "I left my job in another state and took her from the hospital to do in-home hospice care. It was her wish to die at home and I felt I had to honor that wish, rather than allow her to be placed in a nursing home.
      "In the month I had with her before she died; she told me many tales of her life that I had never heard before. She talked about her teen years and how she had loved to dance. She talked about all the young men who chased her; and the men she chose to later marry. She outlived her last husband by 35 years and outlived all but 4 of her 11 children.
      "Before she slipped into a coma, I videotaped her singing one of her favorite songs, "A Cottage for Sale." Later, I gave copies of the video to her surviving children. It was hard for them to watch; but I cherish it. And I cherish the time I had to spend with her. We didn't really say goodbye -- it was more like, "see you on the other side."
      "Immediately after her death, I kept leaping out of bed thinking that I heard her calling my name; as she had when she was dying in a hospital bed at home. A few months later, I dreamed that she came to me and assured me that she was doing fine. I felt great relief that her suffering was over. Now when I dream of her, she is laughing, singing and dancing. It reminds me that I should do the same while I can."

And one more . . .

Dr. Rosy is a family doctor who makes a lot of home visits, often to patients who are dying. "Caring for someone at this time of their life can be an intensely spiritual and moving experience," the doctor wrote. "I teach medical students and often take them with me. Many times they will say to me that we didn't "do" anything for the patient, just sat there. I need to remind them that "just sitting there" and bearing witness to their suffering is important.
     One patient I will never forget was a 61 year old with gastric cancer. I told him -- as I tell many patients -- 'If there is anything you ever wanted to do or anything you need to tell someone, do it now.' He left the hospital, bought a motorcycle and drove across country, calling us when he reached the West coast, triumphant and exhausted."

Finishing the race

Karen Lyons lost her husband, Joe, suddenly last summer, when he suffered a heart attack while swimming during a benefit race. He was participating in the Cohasset Triathlon on the coast of Massachusetts to raise money and awareness about juvenile diabetes. Joe was 38, athletic, and determined to help find a cure for the disease that his 8-year-old son, Sam, has faced for much of his life.

The fact that Joe never finished the race gnawed at Karen. Her husband was, according to news accounts, an "end-to-end guy" who always completed what he set out to do. During a spinning class last winter, Karen began to picture herself cycling through Cohasset, a quaint seaside town south of Boston, on the triathlon course. "I started feeling I have to do this race. I have to finish it for Joe," she said.

And she did.

The Newton, Mass., resident signed up for the June 29 triathlon. She also invited friends, relatives, and former colleagues to join her, and Team Lyons grew to 52 people from nearby and around the country. Some completed all three legs of the swimming-biking-running event, while others took part as relay teams. Her son, Sam, served as official starter for the race, which drew roughly 900 participants (some of them elite athletes) and garnered $279,000 for the Juvenile Diabetes Research Foundation; Team Lyons contributed nearly $64,000.

The cause is an important one. Children like Sam with Type 1 diabetes can no longer produce insulin and must take it daily through shots or a pump. Their blood sugar levels have to be checked around the clock, and they face multiple complications if they don't manage the disease properly.

Taking on the Cohasset Triathlon gave Karen and the team an opportunity to honor Joe and "give Sam another chance to be proud of his dad as we follow in his footsteps."

I found the stories about Karen and Joe Lyons extremely moving, as they show the power of continuing a loved one's mission and of turning anguish into something good. After the triathlon, Karen reflected on what the team had accomplished. "We finished the race today, but I don't think we ever really finish what anybody starts," she told the crowd. "I think we just keep walking the path."

Consider this . . .
Carrying on someone's work is one way to say goodbye.

You can read more about Karen Lyons here and watch a poignant video series called "We Will Finish What You Started" here, under the Videos tab.

Giving permission to die

Bob knew that his mother, Eva, had lived a long and fulfilling life. She had raised three children, held several different jobs –- including nurse, waitress, and limousine driver –- and had a cluster of close friends and relatives. A caring, thoughtful woman, she was also resilient and cherished her independence.

By the time she reached her 80s, this longtime smoker was in declining health, with high blood pressure and kidney problems that required dialysis treatment.

Several times a week, Bob told me, Eva would board a public bus near her upper Manhattan apartment to travel to the hospital for dialysis, a procedure that can take several hours to help rid the blood of toxins. She continued those treatments after moving to a senior residence, which provided meals, housekeeping, and other amenities that enabled her to live on her own.

By the summer of 2007, though, Eva had become extremely weak and short of breath, and she was hospitalized for an infection that was hard to diagnose. During a conversation with her doctor about plans for medical care, Eva expressed that she'd had enough. However, to discontinue dialysis would require a meeting with a psychiatrist to make sure she was competent to make such a decision.

Bob could understand why his mom was ready to stop. Eva had shouldered many emotional and physical hardships over the decades, from escaping Nazi Germany as a teenager to losing a husband and two of her three grown children. Her spouse had passed away in the 1970s, her youngest son had Down syndrome and died in 1995, and her oldest son suffered a fatal massive stroke at age 48 in 2002. And now she was losing her strength and independence.

Bob also realized she probably wanted permission from her only remaining son. "I told her, 'Nobody wants to lose a parent, but I see what you're going through, and if this is what you want to do, I'll support you,'" Bob recalled one recent day, as we sat in his Newton, Mass., home. "She seemed relieved and said something like, 'You know what, that's what I'll do.' My mother was not one to deliberate at length about anything. She would make up her mind and stick to it."

Bob's wife, Tammy, remembers what happened after that conversation: "She called here and asked if it was OK with me. She definitely needed permission. And I told her right away, 'You have every right to do whatever you want with your life. We don't want to lose you, but we don't want you to suffer."

After a week or two in hospital, Eva had become bedridden and barely had strength to eat, Bob says. Eventually gaining consent from her medical team to stop dialysis, Eva decided to stay at Columbia Presbyterian Hospital instead of transferring to a hospice setting. Bob remained in New York and visited his mother during the day; at night, he would catch up on work (he is a controller for a clinical research organization) and answered calls from family and friends.

Mother and son talked about everything from the weather to her funeral arrangements, Bob recalls. She informed Bob that she wanted a short graveside service, and to not use a particular funeral home "because they charge too much." Tammy and the couple's daughter brought Eva bananas at her request, since they were supposed to accelerate the dying process. A rabbi who visited urged Bob's mother to tell her loved ones thank you, I love you, and I forgive you/forgive me –- the "four things" recommended by Ira Byock, M.D., a well-known leader in palliative care.

"She seemed very comfortable and at peace," Bob says. After about a week, Eva became sleepy and sedated and died in September 2007, just shy of her 88th birthday.

For Bob, spending that time together was reassuring and invaluable. "At least I knew she wasn't going to fall on the street and end up in some strange hospital, or waste away in a nursing home," he told me. "It was a relief for me, and I think it was a relief for her because she wasn't alone, and her life ended on her own terms. She was by herself at night, but she knew I would be back the next day and was not abandoned."

"The lesson for folks," he added, "is to try to be there as much as you can."
       

Consider this . . .

It's OK to give someone permission to let go.

Take time to be with someone who is dying.

Advocate for yourself and loved ones in the hospital.