The In-Between: Unforgettable Encounters During Life's Final Moments

Vlahos’s overarching commitment to Transparency in the Face of Death continues to show through in these chapters, which detail further strange and seemingly inexplicable phenomena—e.g., Edith sensing a fire that hasn’t started and won’t start until after her death. Coupled with the quieter mystery of how Edith can recall and say Vlahos’s name in the end stages of her disease, this event seems to Vlahos to answer the question she poses about Alzheimer’s patients: “[W]here are they?” (133). Vlahos suggests that such patients may be even more aware of whatever is beyond life than the average hospice patient. However, in keeping with the idea that not all questions have clear answers and that many things are meant to remain unexplained, Vlahos presents this story without offering a definite conclusion or explanation.

Vlahos’s emphasis on transparency also reflects her experience that death tends to reveal what is important and encourage honesty about that. When Vlahos is worrying about her workload, a phone call about Sandra’s struggle with terminal breast cancer instantly transforms her perspective: Vlahos’s job constantly reminds her that other people have it worse, which puts minor feelings of annoyance or stress in their place while also making mundane days seem marvelous because of their lack of personal tragedy. Sandra’s wealth offers a similar lesson. Sandra’s life is ostensibly perfect—she has the kind of money and stability that Vlahos hopes to one day achieve—but at the end of her life, true meaning comes from her husband’s commitment and her daughter’s love. To aim for Sandra’s money or home, Vlahos suggests, would be to dismiss the meaning Vlahos witnessed in her death.

Similarly, gendered expectations prove insignificant in Elizabeth’s story. In this chapter, Vlahos recounts her lifelong struggle with an eating disorder—an attempt both to exercise control and to conform to female beauty standards. Elizabeth dies young and alone, yet her outlook injects her life with meaning and purpose, her only real regret being that she prioritized things like physical appearance over human connection and simple pleasures: “I wish I’d just eaten the damn cake” (97). Vlahos rephrases this lesson in the imperative as “Eat the cake” (97), and Elizabeth then repeats it back to her. A few pages later, Vlahos eats a piece of cake that she would have turned down had she not had this experience, showing the way in which Vlahos internalizes the words of her patients and transforms them into lessons about what is relevant in her own life.

The cake anecdote thus illustrates The Impact of Human Connection, while the cake itself symbolizes experiences that are fulfilling and enjoyable but perhaps are not productive, like hospice as an industry. Food can simply be a means to an end; one can eat to survive, not to enjoy it. In the same way, medical treatment often prioritizes survival over quality of life. Vlahos instead implies that the point is not simply to consume the cake but to take pleasure in doing so, which explains why she increasingly finds hospice more satisfying than other fields of medicine: In hospice, the goal is comfort. This requires a shift in mindset, as anecdotes like those involving Theresa demonstrate. However, as Vlahos becomes more comfortable with this shift in mindset, she begins to push back on the pressure to treat patients from an impersonal and cure-oriented perspective. She strives to truly listen to patients and their needs and even resists rules and regulations in small ways, as when she shares information about her own life with patients.

Vlahos’s compassion can be draining in her line of work, and it requires her to take a close look at what is under her control and what is not. She struggles to come to terms with the fact that random, horrible things like Elizabeth’s early death can happen and that there is nothing she can do to stop them. Because Edith’s death coincides with Babette’s worsening health, it hits Vlahos particularly hard, as evidenced by her conversation with Steve. Steve guides Vlahos in the direction of healing, asking about Babette’s journey and suggesting she think about going to therapy. While Vlahos herself is not yet ready to fully face the emotional effects of her job, Steve has the foresight to know better, and he becomes a recurring figure in the chapters that follow.

Even when recounting her darker times, however, Vlahos highlights that there is also comfort to be found in her interactions with patients. As Sue is dying, she comforts Vlahos in what the latter clearly finds a remarkable (though not unique) show of grace. Later, Vlahos suggests that Sue’s deceased husband was looking out not only for his wife’s well-being but for her nurse’s. Edith’s story begins on a comparatively bleaker note. John is devoted to his wife’s care, but the emotional effect of looking after her has clearly worn on him. He is so full of despair that he responds to the thought of a nursing home by saying, “[J]ust put us somewhere and forget about us” (113). John uses hyperbole to communicate the depth of his feelings; he has no hope for the last months of his life with Edith. Palliative care transforms not only Edith’s final days but also John’s experience of them. While his wife’s condition steadily deteriorates, access to hospice care gives John necessary perspective and assistance with what is a mysterious disease even to professionals. This enables him to connect with Edith in ways he previously could not, and the story ends up serving as another example of The Connection Between Peace and Suffering.

Vlahos frames her personal life in similar terms. Getting pregnant in college was not something Vlahos wanted, but it ends up proving vital to her sense of fulfillment, resulting not only in a child whom she loves but also her discovery of her vocation. Here too Vlahos points to something like divine intervention—in this case, a priest’s sermon days before she planned to get an abortion. Her relationship with religion is inextricably tied to her son’s birth and to her relationship with death—another pair of seeming opposites that Vlahos suggests frequently coincide.