We had been running errands for a few hours, and Rosemary was worn out by the time we returned home. With one smooth move, she slipped the dentures out of her mouth and laid them between us on the coffee table. “I’m so comfortable with you that I’ll take my teeth out in front of you,” she said with a chuckle.

She stretched out on the sofa with a sigh and anchored an oxygen tube in her nose. “I’m comfortable with you, too,” I said, slipping out of my bra and tossing it over the back of my chair. We laughed so hard that she choked, and I almost wet my pants.

When we settled down, she moved a hand to her forehead like she was testing for a fever. “I’m ready to die,” she said out of blue.

“Dying is a spiritual process, and death is nothing less than a miracle. But most of us miss the miracle”

I took the bait and responded quickly. “It gives me peace of mind to know that you’re ready, but are you prepared? Have you done the death-related work that will make it easier on you and your loved ones when the time comes?”

She turned to look at me. “Are you talking about those damn papers again?” She asked the question with the slightest bit of playfulness.

“Yes, I am,” I gently replied. “You’ve got me here, and you’ve got the papers, so we might as well take that one off your bucket list.”

Short Bucket List

According to Rosemary, that list is short. At 81, she lives with one breast long gone to cancer and half a thyroid. Chronic obstructive pulmonary disease has tethered her to an oxygen machine. She walks with a cane, wears sunglasses outside and in, does not hear well, and suffers sleeplessness due to chronic pain. “I’ve gone everywhere I wanted to go and done everything I wanted to do. Now I’m ready to die, and I want to die here,” she said, with emphasis on “here.”

I know she means “here,” right here, in her tranquil apartment. Here, where her friends can easily find her to hold her hand. Here, where her books and music and photos and favorite things create harmony. Here, in the sacred space of her home and not- please not- in a hospital.

We moved to the dining room. She fumbled around in a cabinet, and then tossed a folder at me where she had stored the healthcare directives form I had given her weeks before. “Let’s do it,” she said with conviction.

As I laid out the papers, I told her that she can change her end of life preferences any time she wants. “But when there are no directives in writing, you give away your power to control the way you’ll be treated if you can’t speak for yourself when Death arrives to claim you. The big decision is whether you will want medical technology to keep him waiting, or will you want to reach out and take Death’s hand?”

I started to write her name on the form, but she seized the pen and reminded me- firmly, “I can do that myself.” Humbled, I apologized. The first section of the form asks for personal details, and it took her only a few minutes to complete it. In the next section she was to commit the name of the person she most trusts to make medical decisions as her proxy, decisions that would influence how she lives or dies. She stopped writing and said, “If I fall I don’t want to go to the hospital.”

I told her the idea was ridiculous. “Of course you will go to the hospital if you fall. A broken bone is not a terminal condition. If you’re found on the floor and alive, whoever finds you will- and should- call an ambulance.”

Designated Advocate

If something worse were to happen, though, and a hospital put Rosemary on life support, she would need a designated advocate to follow instructions and ensure she received only the treatment she wants. “Let’s say you have a stroke and can’t talk or breathe or swallow and are in the hospital and you need a ventilator to breathe or a feeding tube to eat. Do you want to live in that condition or be allowed to die?”

Rosemary was thoughtful and told me slowly, “For me, that would not be living.” Then she added, “If I can’t talk, will you speak for me? Will you pull my plug?”

It is an awful expression. As if pulling a ventilator plug or removing a feeding tube is the same as pulling a vacuum cleaner plug. I took a moment before I replied, understanding the impact of what she was asking. “Rosemary, if you are asking me to speak for you and accompany you through your death, I would be honored to accept.”

Treatment Choices

I put my hand over hers and pointed out that her body is accumulating years. It has a disease process that will continue to cause changes and, eventually, death. There will be turning points when medical treatment choices must be made, and she will need to consider when and if she might refuse a treatment that would prolong her life. “One day, you may have to weigh longevity against the quality of your life,” I said, looking into her eyes.

“In the book Tuesdays With Morrie, Professor Morrie Schwartz, who was dying of ALS, said that when he couldn’t ‘wipe his own ass’ he would call it quits. But when that time came, he accepted help and he lived longer. So each of us may define our limits theoretically, but in my experience-the will to live will push beyond those limits.”

I told Rosemary that she might reach a point when the burdens of treatment are greater than its benefits. She may decide that her quality of life is worse than death. That’s when she can stop the treatments, request palliative care to relieve suffering, get medications for comfort, and die here. As long as she has mental capacity, she can make her own choices.

“Everyone stops eating before they stop breathing,” I continued. “Plants and animals stop taking in nutrition before they die. That is one of the universal behaviors in the process of natural death. If living gets to be too painful, you can even voluntarily choose to stop eating and drinking.”

If Rosemary should choose such an option, naturally or on purpose, I told her she would need 24-hour care to keep her comfortable and keep her company. “Maybe you’ll get in a few hands of bridge or a game of Scrabble, get a massage, write a poem, or send letters to your loved ones. It will take one to two weeks to die after you stop eating.”

A Miracle

With preparation, the end of life can be immensely transformative. “Dying is a spiritual process, and death is nothing less than a miracle,” I told my friend. “But most of us miss the miracle.”

Her eyes opened widely. Her mind was running fast. She squeezed my hand and returned her attention to the paper work. We finished the form, and it took only an hour to have this intimate conversation and write down her most important wishes.

One hour. In that one hour, Rosemary and I grew closer to each other in a way that would never have happened without us having this brave conversation about the reality of her death.

She signed and dated the document and held her hand up for a victory slap. I pressed my palm firmly against hers, where the contrast of our skin made me aware that she is a mirror into which I see my future.

She shouted, “I feel wonderful! I’m so glad this is done!” Rosemary stood, wrapped her arms around me, and whispered in my ear, “Thank you. I love you.”

Rosemary returned to the sofa, replaced her teeth and turned to me, glowing with renewed vitality and contentment. I saw her filled with grace and gratitude. In that instant I felt the kind of love that would make me wipe her bottom, clean up her vomit, rub her bony back and hold her cold hand as she lay dying. I would feel privileged to serve her in her helplessness. I would even pull the plug for her, because that is what she wants.