The Rev. Marci Pounders has written a book titled "Palliare:  Hard Edges and the Holy at the Edge of Life."  It is available by contacting Pounders, Wipf and Stock Publishers/Resource Publications, and on Amazon. $13 for paperback, $28 for hard copy.

Here is Chapter 2:  A Midwife to the Dying

It takes a great deal of energy to die. Most people do not know this.  They think death will look like what they have seen on television, a deathbed profession, a desperate last gasp, a sudden head-dropping-on-the-pillow, arm dropping off the bed type of end. I find this silly, because even in hospital emergency rooms, I have not found death to be like this. Even in traumatic circumstances, the end when it does come, is rarely so dramatic. One lives until one does not. The heart gradually stops, the ragged breath goes. That is the way of all the earth. I was privileged to travel this last journey with a hospice patient I'll call "Mami."  Mami was an elderly Latina woman who had breast and colon cancer. She also suffered from chronic diabetes and kidney failure. This time, she had not been able to bounce back, and she was failing.

When I first visited Mami, she was semi-lucid, but very agitated. This is common in patients with less than a week to live. Her neurological transmitters were beginning to shut down. She kept trying to get out of bed until the pain medication sedated her. When she did open her eyes, there was a wide, blank, almost bewildered stare into nothingness. When she closed her eyes again, she smiled and appeared to be carrying a conversation with someone. Her daughter J whispered, "She's talking with my dad. He died two years ago. She says that he is putting on his tuxedo to meet her.  He’s going to take her to a party, but he's being slow about it, and she's aggravated he's late."  Her daughter managed a tired smile. "He was always late, wasn't he, Mami?" Mami was seeing things we could not see. "How wonderful," I said. "She's going to be with him soon and he's there anticipating her arrival."  "Yes," replied J. "That makes me happy, to know they'll soon be together."

I have always been fascinated by deathbed hallucinations. Are they real?  To the dying person, they are very real. My own mother was convinced there were toucans roosting in the ceiling of her intensive care room.  One of my patients years ago was terrified of the wolves she believed were lurking outside her hospital room door. (My pastoral care duty on that visit was to shoo the wolves away and stand guard). Another patient saw ghouls that he described as looking like Gollum, from the Lord of the Rings movies. Another saw angels. One saw a beautiful woman floating at the foot of her bed. And yet another was convinced that the lovely painting of red poppies in his hospital room was a picture of Satan smoking pot. I could not convince him otherwise.

The brain does strange things when one is dying. Of course, medications such as morphine, propofol, methadone and fentanyl can cause hallucinations.  And urinary tract infections and a lack of oxygen and blood to the brain are also to blame. But I have been with too many dying people seeing angels, heaven, deceased loved ones and even Jesus to think that God in His infinite mercy does not reach out in some mysterious way to comfort his children on their way home to Him.  I wished so much that I could glimpse the mystery that my dying patient was seeing!

J was so very tired. She was her mother's only child, and there was no one else to relieve her long days at her mother’s bedside. She insisted on staying around the clock, because Mami would become anxious if J was not within her line of sight. One day, J asked me, "I don't know what to expect. I've never done this before.  My dad died of a heart attack, and we didn't have to camp out at the hospital all day and night like this," she said. "What will it, you know, death, look like?"

I thought of a classic episode of the old TV show, "The Twilight Zone," where the Angel of Death (a very young and ridiculously handsome Robert Redford) comes gently to a frightened elderly woman. (I didn't tell J that I sincerely hope on the day I pass from this earth that my death angel will look like a young, tanned, ridiculously handsome George Clooney).  "J, every person’s death is unique to them."  I talked gently about the usual signs and symptoms associated with one's last days.  There would be a gradual decline from agitation to somnolence, more hallucinations, loss of appetite, slowed, labored breathing, a shutting down of urine output, and finally the cessation of heartbeat and breath.  "Yes, but does it hurt? Will she be in pain?  Will she get hungry or thirsty? Should I feed her? What should I do?"

The most distressing thing to most folks is when their loved ones stop eating and drinking. We associate food with life, with love, and with the holidays and celebrations of happy times.  We think we are not doing enough to keep our dear one alive, or that they will “starve to death” without food. But when a person is dying, his or her body uses up every bit of energy it has just trying to keep breathing and to keep the heart pumping.  Digestion takes away from this, and it diverts energy away from the brain. Physicians advocate for “comfort feeding” such as popsicles, pudding, ice cream, milkshakes, or whatever the patient truly might want while they are still able to enjoy it.  (I once got take-out Kentucky Fried Chicken for a patient with the physician’s permission. She gummed away at it happily with the one tooth left in her mouth). But if a person is actively dying, food can cause more discomfort when it is forced. “You just need to be here," I reassured J.  "She's being kept comfortable with pain medication. Death shouldn't hurt at all.  Just like a deep sleep and a transition to the eternal. If she wants something, of course by all means give it to her.  But don't force her.  Her body knows exactly what it needs right now." J was somewhat less anxious about what to expect.

The next day, Mami was remarkably awake and aware of her surroundings.  She knew she was in a facility and not at home. She didn't know who I was at first, but after about ten minutes, she understood that I was the chaplain, and I was okay to be there.  I think what made me more “okay” was the big sparkly necklace I was wearing.  Mami loved jewelry. She kept looking at me saying, "That's so pretty!"  She would look at me, then back at her daughter. She would smile at J. Then she'd look back at me.  "Oh, that is so pretty!" like she'd never seen me or my necklace before.  I took the necklace off and let her hold it. When she didn’t want to give it back, J was horrified.  “Oh, Mami! No! That’s the chaplain’s jewelry!”  Mami frowned and clutched it tighter. “No, it’s not!  It’s mine!”  When J started to take the necklace back, I quietly gestured no. Arguing with patients who are confused or have dementia never works. It only makes them more upset. It was ok, I whispered to J. I could get it later. Then I told Mami how much we had in common, to like pretty things. She nodded and smiled contentedly.

Dying patients often rally and have one last big burst of energy before slipping into their final coma. The following day, Mami was very talkative. She held court with family and friends in the morning, oriented times ten.  Then in the afternoon, she crumped (medical slang for failing fast). J put in an urgent call for me.  Mami snorted that I was not the chaplain; I was someone else. Soon I had morphed into a friend from church and then a cousin who had been dead for years.  J gently corrected her again and again.  Finally, Mami looked at me and said, "Oh yes, she's the pastor, isn't she?"  And we all smiled. Suddenly out of nowhere, Mami farted. And I don’t mean a cute little fart.  I mean an Enormous Ghastly From The Depths of Hell Fart. The aroma was powerful enough to peel the paint off the walls.  J and I giggled, even as our eyes were watering. Mami’s eyes grew wide, and she looked just like a naughty child caught in mischief.  Shocked, Mami whispered, "Oh! I did it! It was me!"  "You bad girl!" we joked and scolded. And our sweet patient laughed too, for what else can one do?  You can laugh or you can cry. Both have their place, but in this case, it was more comforting to laugh. Then she needed the bedpan (we certainly just had ample warning!) and we called the nurse.

Mami did not want us to leave her sight, even while she was using the bedpan. Honestly, neither J nor I cared.  It was simply a part of life, this uncontrollable urge, this reversion to babyhood, this helplessness. We didn't want her to be any more agitated or embarrassed than she already was, so we let the nurse do her job, and we moved to another corner of the room to talk about nothing.  “Mi hija!"   "I'm here Mami."  "Where? I can't see you!"  "Right here, Mami. See, Marci's here too."  Mami took my hand and sobbed. "I'm so sorry. I'm so sorry.  I'm so sorry."  "What for, Mami?"   I knew what for. She was lucid enough to realize she had shit her bed, and someone had to clean her up.  She was losing control. She was mortified. She didn't want to be here.  "I love you so much," said Mami asking forgiveness for her helplessness. "I love you, too," I said, as I patted her hand.

The next day, Mami thought the trees waving outside the window were people. She saw her deceased husband, waiting for her.  She spoke exclusively in Spanish, the language of her birth.  She could not understand that I, not knowing much Spanish, couldn’t answer her. "Mami, this is Marci. She is the chaplain. She doesn't speak Spanish."  Mami shook her head and continued her conversation. It sounded most interesting. She was very certain about what and to whom she was talking. I could make out she was praying at some point. Then her eyes closed, and she gave herself over to her deep exhaustion. A great struggle was going on inside of her. She knew deep down she was dying, and something in her longed to go. But she was worried about J.  Who would take care of her? She was J's mother and mothers worry about their babies, even if they are grown.   "I love you so much," she repeated over and over. "I'm so sorry." J and I sat with her for hours in silence. I think that's why Mami asked for me by name. When she was disoriented, I didn’t push her back to reality. I didn't talk too much.  I didn't correct her. I didn't startle her. And I was not loud. Dying people do not like loud noises or loud voices. It is just too much for their short-circuiting senses.  Dying people need holy silence and sacred presence while they labor because death is so much like birth. Being with Mami was like witnessing a birth where the mother is not yet completely dilated.  Something big was about to happen, and she was struggling to get through it, but it was not time yet to push. Every movement that Mami made, every twitch, every start, every squirm, looked like a woman in labor. She was birthing into a new existence, surrendering to uncertainty and an utter lack of control. It was not sudden or dramatic nor was it easy. It took all her energy. It left her spent.

The last time I saw Mami, she was no longer responsive. Her breathing was slowing down, heavy with mucus, what old timers call the "death rattle," and what modern physicians refer to as Cheyne-Stokes respiration.  J was by her side, holding her hand. "She's in her final hours now. Her kidneys are shutting down."  J motioned to the empty bedside catheter. "Thank you for being here with us.” Mami was at peace. She had given birth and was now waiting for the afterbirth and the cord of life finally to be severed. I have no doubt that she knows J will be all right, for I have seen so many dying souls come to this place of peace. I have no doubt that Mami will be carried up to God on angel's wings. And I know her husband is fully dressed in his best formal attire, ready and waiting for her with open arms, to take her to the biggest party of her life where they will dance, feast, and love again in the courtyard of God’s Kingdom.