ONE OF THE most popular Irish broadcasters and writers of modern times was Nuala O’Faolain. Abruptly, in the middle of an engaged and full life, she was diagnosed with lung cancer. Later, when dying, Nuala was interviewed on Raidió Teilifís Éireann, the equivalent of our ABC. Perhaps because of her fame and the popularity of this particular show, the broadcast became a national sensation. It was as if the whole of Ireland listened to this most intense end-of-life conversation, delivered not privately, at a bedside, but into the national ear. There was lightness and laughter, but there was also despair, openness and a tearful honesty.
‘As soon as I heard I was going to die,’ she said, ‘the goodness went from life.’ Reflecting on that life and the understanding she had gained from it, she continued: ‘It seems such a waste of creation that with each death all that knowledge dies.’
Yes, the goodness of life and the sorrow of loss. ‘A waste of creation’ is a phrase that tolls like a bell. We barely speak about this, but it is true. There is a gaining of knowledge well beyond the facts – true knowledge of this life in all its grand complexity – and then it is no more.
What matters most? To Nuala, it was life without a life sentence. But it was more than that. It was a life with friendship and travel and conversation and wit. It was a creative life. It was a life of Irish joy. She once encouraged people to ‘do the thing that is less passive. Do the active thing. There is more of the human in that.’
The presence, or want, of these conversations about life and death can mark the dying time. It is one of the greatest unspoken mysteries that the period leading up to a person’s death, however short, may still involve moments of grace, of openness to love, of reconciliation – of a conversation that can be remembered forever.
We are talking about presence and absence, yes. But between the presence and the absence lies something else. Leonardo da Vinci revolutionised painting by turning from traditionally sharp outlines to figures with softened edges: the technique is known as sfumato. For older persons there can be a gradation from complete independence to greater dependence, from fitness to frailty, from a full command of memory to names falling like water through the hands. Rarely instant, these are subtle changes, sometimes imperceptible. Summer becomes autumn: we have the seasons within us. But none of this is predictable or universal. And none of it speaks of an enlivening with age, of a sense of greater wisdom, of joy in the simplest acts.
In the ageing times, in this sfumato of self, there are many unknowns. Apart from one’s own mortality, there is one certainty. It is the mortality of others. Older persons begin to lose their contemporaries. Their parents first, their friends, the wide arc of their acquaintances, their brothers and sisters, and sometimes, perhaps most despairingly, their own children and grandchildren. The little griefs of their own loss of function are matched by these larger griefs associated with the loss of those around them.
One of the most profound and unspoken aspects of the life of older persons is loneliness. The progressive loss of loved ones adds to this. The pathways of a lifetime, from one to another, peter out in an open field. Ties of intimacy and friendship are sundered, one by one, and familiar voices fall silent. The adult children of older persons, preoccupied with their own lives, may barely appreciate this. Outsiders are oblivious. Grief may be compounded by an aching loneliness. Physical vulnerability can combine with less contact.
Tim Winton, the Australian novelist, opened his novel Cloudstreet (Penguin, 1991) with this scene:
Will you look at us by the river! The whole restless mob of us on spread blankets in the dreamy briny sunshine skylarking and chiacking about for one day, one clear, clean, sweet day in a good world in the midst of our living.
For those older persons who have lost someone close to them, where does the clear, clean, sweet air come? Will life regain this exuberance? When will they next gather by the river?
Come with me into someone else’s story.
SHE IS LEFT. She passes through time more touched by the past, for the past is more numerous, more peopled. She is no longer crowded. She searches for familiar faces, but they have gone. She visits them each weekend, careful to clear the weeds covering their names. Precisely, she cuts the stems of the flowers.
She knows where they lie, just to the left of the sapling, on the incline. She speaks to them now. Her son, little and already ill, asks why she cries. Her husband, evaporated with sadness, walks out upon the frosted lawn.
WITH THE LOSS of a loved one comes the fracturing of that sense of life as it is and life as it could be. With loss comes a new world, frightening sometimes, lonely often, empty always. That loss may come suddenly, brutally. It may come after a struggle with illness in older age, full of hospital visits, a life dictated by medical necessity rather than choice. It may come earlier than anyone ever expected.
In the practice of palliative care we witness all manner and shades of grief. We sit closely with it. We see it light and searing. We see it mixed with a relief that the trials of the illness are over. We see it expressed as sorrow, longing, regret, anger and a quiet pride in knowing this person. In a room of children at the bedside of their mother, we see it open as a hole that we know will never heal. Grief is a roar, it is a long, silent wave, it is inexpressible.
It is often seen to commence with the death of the loved one. Of course, it starts a lot earlier. It is a series of griefs felt by the ill person and the family – loss of health, loss of control, loss of independence and loss of a perceived future. In younger patients, there is a palpable sense of time shortened. For older patients, there is often an intense mutuality expressed: ‘It’s not so much me, but I am worried about how they will cope when I am gone.’ With dementia, the family often feels a progressive sense of loss of that person. Their memory, yes, but their personality, their vibrancy, themselves. Indeed it may be that with such a series of losses, death, when it comes, is welcomed as a release.
With time, health practitioners in this area learn to identify these griefs. To name them. The loss upon loss. To allow families to grieve even before the death. ‘Yes,’ families have said to me, ‘that is what we feel.’
In the time after a death it may be that nothing said makes sense – or at least sense with meaning; that the sight of a place or an object is instantly evocative; that the tenth time of telling a story of earlier days, of missing and yearning, may not feel easier. The grieving need to speak: they may not want to speak every time you see them, but at some time they will want to. It is an act of great care to be ready to listen.
Writing in The Irish Times, the clinical psychologist and columnist Marie Murray described listening as ‘more than hearing’:
It is heeding. It is concentration. It is paying attention…
Listening is silencing one’s own voice to hear someone else. It is wanting to know rather than wishing to inform. It is suspension of self in the service of other. It is not giving advice, providing solutions or solving problems. It is silent. It is unselfish. It is reverential. It is healing.
There’s a fascinating nexus between silence and grief. In the Bible, Job is afflicted by a series of catastrophic losses:
The news of all the disasters that had befallen Job came to the ears of three of his friends. Each of them set out from home…they decided to go and offer him sympathy and consolation… They sat there on the ground beside him for seven days and seven nights. To Job they spoke never a word, because they saw how great his suffering was.
We hear this echoed, more recently, in the poem ‘Working Men’ by Les Murray:
Seeing the telegram go limp
and their foreman’s face go grey and stark,
the fettlers, in their singlets, led him
out, and were gentle in the dark.
Whole books have been written about the experience of grief, but Murray’s poem captures its essence. In the four spare lines of ‘Working Men’, a drama of intense loss plays out. No glamour, simply the practical. But the workmen’s practicality is invested with a profound care, a selflessness, a striving to do their best. If commended, the foreman’s workmates would be puzzled. In their actions, necessity and generosity are one, unspoken. As natural as breathing.
This is a long way from comments I have heard made to those bereaved: ‘Please don’t upset yourself.’ ‘After his illness, his going must be a blessing.’ ‘Well, that’s life isn’t it?’ ‘After all, he’d had a good innings.’ Or, of the mourner, ‘Surely she must be over it by now.’
Well-meaning, perhaps, but sometimes cruel, these statements belittle the sheer size of what’s happened and of the process of grieving.
OUR LIVES ARE dominated by the unrelenting minute. The calendar stares back at us, expectant. But grief cannot be measured in these temporal ways; there is no calendar for grief. People who assume that grief will evaporate see with calendar eyes. They speak with calendar mouths. This is not the language of grief. And it fails to recognise a deeper truth – that grief ebbs and flows in its own time, at its own pace, with its own rhythm; it can never be hurried or silenced or stilled.
There is an Arabian fable. Once upon a time, a sultan plunged his head into a large bowl of magical water. In the few moments between submerging himself in and emerging from the water, he dreamt he had been on voyages, shipwrecked, captured by pirates, married a princess, fought in many battles and was now being led to his execution. When he lifted his face, dried his eyes and looked around, he saw that everything – his surroundings and the people who were present – was exactly as it had been.
Can we live both in and out of time? The grieving do. For the grieving, a clear memory can easily sit with a sudden thought that this was all a dream. In an instant, a simple reminder – an object, a familiar place – can bring forth a flood of memories and feelings. To the Scottish poet Norman MacCaig:
Everywhere she dies. Everywhere I go she dies.
No sunrise, no city square, no lurking beautiful mountain
But has her death in it.
Now. Listen to those words. ‘But has her death in it.’ Not just reminding him, but in it. And not just some places, but everywhere. And therein lies the mystery. We know our dead have gone, and yet they are everywhere. After they die, we walk around, part of us expecting to see them as we turn a corner. We see their faces in the half-light. When we think of them, time seems to open like a rose. The wife who cannot throw away her husband’s clothes, for surely, one day, one bright day, he will walk back in and need them. The grieving are in and out of time. They are suspended between the past and the present. The past when things were good, day by day, to the present, where hour by hour, they breathe this air, this clear air of sadness.
WHEN SPEAKING TO the grieving, no words can express the savage cool of loss: that no matter what we think, it is all about what they feel. When we sit and reach into the mystery of illness, death and grieving, we enter a land beyond language. Yes, we can speak of it, but we cannot truly know it. Only those who have been there can know. Older persons know. And each older person will know in their own way. Nevertheless, the gap between knowledge and language beckons us forever. Speak, speak, we hear ourselves cry, for what we say, the rough approximation of language to loss, is all that we have. For we are not perfect. And our language is never so.
One of the commonest mistakes we can make is to assume that simply because the person who died was elderly, the family will feel less grief. Grief is vast, grief is mysterious and grief does not respect age. Listen to the words of Simone de Beauvoir describing her reaction to the illness of her mother:
The knowledge that because of her age my mother’s life must soon come to an end did not lessen the horrible surprise: she had [cancer]: it is as violent and unforeseen as a plane engine stopping in the middle of the sky… There is no such thing as a natural death… All men must die: but for every man his death is an accident and, even if he knows it and consents to it, an unjustifiable violation.
On the New Year’s Day following the death of his father, the Irish poet Seamus Heaney wrote:
But I face the ice this year
With my father’s stick.
Heaney’s feet are stepping into an unfathered future. And yet he knows that his future will never be truly unfathered because the myriad legacies, sounds, sights and shaping voice will always be there. His parents will forever speak into Heaney’s ear. His father’s stick is both an inheritance and a guide.
Another mistake, commonly made, is to see grieving as purely a family experience. This denies, even sets aside, the grief felt by friends. For older persons, those friendships may span a lifetime, forged in younger years, tested through experience. The death of a friend and the bereavement that follows may be marked by comments said in and around the older person. They may feel doubly disenfranchised – that their grief is ‘for a friend’, and why grieve for the loss of another older person? Older persons yearn for a simple act of imagination by those around them: to recognise how a life shared is now lost and, further, that their friend is irreplaceable.
Imagination is equally important when we look upon grieving persons. With time, they seem better, less troubled. We do not think beyond their smile, too easily mistaking appearance for reality. In Shakespeare’s Hamlet, Hamlet’s mother, the Queen, chides him for continuing to grieve for his father:
Queen: Do not forever… seek for thy noble father in the dust.
Thou know’st ’tis common – all that lives must die…
Hamlet: Ay, madam, it is common.
Queen: If it be, why seems it so particular with thee?
Hamlet: Seems, madam! Nay, it is.
I know not ‘seems’.
’Tis not alone my inky coat…
nor customary suits of solemn black…
No, nor the fruitful river in the eye…
…Together with all forms, moods, shows of grief,
That can denote me truly. These indeed seem:
For they are actions that a man might play;
But I have that within which passes show –
These but the trappings and suits of woe.
See how Hamlet picks up the word ‘seems’ and speaks for all grieving persons to say that what is shown and what is felt may be starkly different?
WHEN A PERSON whom we love dies, part of us dies with them. They were here alive, with us, part of this world, and then they left. They are no longer battling the illness, the fatigue, the pain, but they have gone. And we cannot bid them stay. Has everything gone? Is the field of our life empty? It may appear so and we are lost in the dark hours, in ‘the blue unfriendliness of space’, as AD Hope described it in ‘The death of the bird’, yearning for their smile, their eyes, their touch. We may even yearn to be with them. For such is love and such are the cords that bind us. Through those cords the echo of them lives on in us. The quiet vibration of their lives resonates within us. The delicate balance of them – the good, the sometimes difficult, the precious, the sometimes frustrating. For we are remembering humans, not gods. For they were flawed and so are we. But where they have been touched by death, the bereaved are touched by memory. No, it is more than touched – the bereaved are drenched in memory. Grief and memory rock back and forth, tolling the days away, crowding the nights.
Memories make us. They shape our contours. The continent of self is lapped by the sea of memory. Clear often, vague sometimes, we reach back to them. Memories are the library of our souls.
There is a further, subtle mutuality between the dead and the bereaved. Not only has the person died, but their version of us has also gone. We were once something to them; we may have been everything to them. Their loss not only removes them, it diminishes us.
What, then, can make this process of illness and death easier for older persons? If the process itself is easier, then often, in our experience, the discussion around it is easier as well. First – and this is a core need – comes care for the ill person. Whether done by family or health professionals or both, it is paramount. No gentle preparation for death is ever possible where suffering reigns. Equally, no calm preparation for bereavement is possible when the family witnesses great turmoil. The longer I work in this area, the more I realise that whatever is done prior to the death will be echoed in the bereavement. If the death is traumatic and overwhelming, that shall be remembered. If the opposite occurs, that shall be remembered. And that memory shall enter the narrative of the family. That will inform their view of death.
But it is not simply what is done. It is what is said. The words spoken, and their tone, are a vital part of our professional approach to patients. More importantly, the words and their tone in the intimacy of family mark this period. The full span of our lives is precious, but this is a most precious time. I say to families: gather together, put aside any conflict, speak openly. Whatever is said now shall be remembered always. Do not regret that things were left unsaid. Reflect on your whole lives together. Celebrate the good they have done. For this one and unique person is soon to leave. They may not be perfect, but they are themselves.
If the time leading up to a person’s death is seen by patients and their families purely as a challenge, a burden, a misery, then they may miss an opportunity to reflect on that person’s life, to celebrate, to confide, to open themselves to one another. To move from the practical day-to-day conversations about what is happening to a deeper discussion that encompasses the whole life. To move, if you like, from the now to the always.
In that process, something may happen that is at once natural and mysterious. Families may move through an invisible membrane to a point where they are able to speak. They don’t so much speak another language as regain the fluency of the language that lies within them. In a land without language, they may regain their voice. And in that voice, that gentle articulation of what they mean to one another, lies great richness.
I RECALL A gentle man who lay in the hospice for many weeks. His wife as patient as a tree. The sense of love expressed and of life being lost was profound. His comfort ebbed and flowed. We did our best. One day he asked his son to bring in one of his paintings. With permission, the family took down the print on the hospital room wall and replaced it with one of the man’s landscapes. It was a simple act, but it marked the room as his.
‘I painted that on our honeymoon,’ he said. ‘It was a gift for Ellen.’ Every second or third day a new painting would appear on the wall. At each ward round, we would turn our faces from his bed to look at the next painting. He would talk about where he was when he painted it, what he felt, the colours, the shades. One day I realised he was teaching us. We all knew, especially the junior doctors, that the lessons only started with technique. Unable to move now, more tired, he could look up and live his life again, image by image, that house, this garden, the feel of that day. Yes, memories of contentment, but also times of grievous loss, times of worry, settled times. When he died we mourned him deeply. To this day, one of those junior doctors remembers him well. She said, ‘I did not want him to die.’ I replied, ‘None of us did.’
ONE OF THE greatest gifts we can give older persons is our attention. To resist seeing them all as the same. To resist their infantilisation. To be curious about them.
Two of the abiding principles of caring for older persons is preserving function and paying attention to illness when it comes. There is a wisdom there: no disease is inevitable, no illness preordained. All of us are unique, and in that uniqueness lies the challenge of modern medicine. One of the critical elements in educating health professionals is teaching them to identify that uniqueness. Curiosity plays a great role here. Through it may lie revelations about the person for whom we are caring. It also gives a greater sense of one’s own profession. Yes, I say to medical students, people expect your expertise, but they also yearn for your kindness. This is the confluence of many rivers. Cultivating curiosity about this one person – who are they, what is their history, what troubles them most? A recognition that this person, however weak, speechless and dependent they may be, has an inherent dignity that is untouchable by their illness. However brilliant you are, I say to the students, you will be known for these qualities.
Ours is a society that sees a problem and expects a solution. Our faith in technology sometimes threatens our faith in ourselves. Our days are filled with tasks. The problem with grief is that there are no solutions – or at least, no easy solutions. It is not a problem to be fixed. It is not a task to be completed. We understand its certainty, but we are not resigned to its particularity. We rail against this death, the loss of this precious person. Intellectually, we understand that death is universal, but we struggle greatly against the fact that it is also personal. There is an insistence that often lies at the heart of bereavement: do not attempt to fool me with platitudes or an appeal to memory, for the best is gone. I want the best back beside me. To the bereaved older person, it is a simple and incontrovertible fact. Such is love and such is the sorrow of loss.
IT IS LATE afternoon. The cicadas are full voiced and throbbing. It is the sound of her childhood. She sees her father on the veranda calling them in. The heat of the day is lifting.
She looks back at them, just to the left of the sapling. She will go home now. She will sit and try to eat.
Frank Brennan is a palliative-medicine physician based in Sydney. His work has been broadcast on ABC Radio National and published in the Australian Financial Review among other journals. His memoir ‘A doctor’s notebook’ was published in Griffith Review 17: Staying Alive.
- Murray M. (2007). The Art of Good Listening. Irish Times. https://www.irishtimes.com/news/health/the-art-of-good-listening-1.984061
- Murray M. (2007). The Art of Good Listening. Irish Times. https://www.irishtimes.com/news/health/the-art-of-good-listening-1.984061
- Murray L. (1991). Working Men. In: Murray L. Collected Poems, Angus and Robertson Modern Poets. North Ryde, Sydney.
- Shakespeare W. (2006). Hamlet. Act 1 Scene 2. In: Shakespeare W. The Complete Works of William Shakespeare. Harper Collins. London.