I saw a man in the intensive care unit last night, close to brain death. Tubes and monitors all around. The hospitalist on duty is carefully explaining to the family of this forty-three-year-old man the sequence of events likely to take place over the next several hours as his skull continues to fill with blood following a fall earlier in the day. The blood at some point will put so much pressure on his brain stem that too many of the brain cells that support his breath and heartbeat will die. Determining the point of death in such circumstances seems to be an imprecise art as the patient is tested for the presence of several key reflexes. The final check, however, seems to be the delivery of pure oxygen into his lungs as the ventilator is shut off. By testing his blood in the minutes that follow, it is possible to see if his body is doing anything useful with that oxygen. If not, he is said to be dead and the ventilator is restarted in order to keep his organs in the condition needed if they are to be “harvested” for possible transplant.

All said carefully with care and compassion to the family. But I’m watching them trying to figure out when in this progression of events their brother, nephew, son actually dies.

Here’s what is filling me as I watch and listen. Go back a few years ago. It’s early evening and the rooms and corridors of my mother’s nursing home are still and quiet. Mother is dying, her hospice nurse earlier saying, “maybe tonight, maybe tomorrow.” I’m alone with her, singing what I can remember of “Swing Low, Sweet Chariot.” I’ve been counting her breaths ever since arriving at her bedside that morning. My brother-in-law calls to ask how she is doing. To give him some form of a quantifiable answer I say, “I’ll count her breaths for you. There’s one…” I wait. There are no more. Her nurse comes in, listens to her heart and chest and says, “I’m sorry.” It’s 8:45 pm. And she is dead. I say goodbye to my brother-in-law, not quite absorbing that her death would be so distinct. This said by a hospital chaplain who has watched many dozens of last breaths.

I’m alone now, still hearing the sound of her last breath, coming as it did from far off down the arroyo she knew so well in Santa Fe and then sweeping onward, up the slopes of the Pecos Mountains to the east. A breath of air that never really had a beginning or an ending, just a puff that filled her for the moment and then was gone. Death was clear and certain. Clear in a way that was not to be available to that family in the ICU that night.

(with thanks to Paul Kalanithi for the title phrase)

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