That Good Night

by Sunita Puri

During my last week of work, I opened up our electronic palliative care list to find a new patient with a Punjabi name. Even though I had trained in cities with good-sized Indian populations, I could count on one hand the number of times I’d cared for someone from the same region as my parents.

  Her name was Amrita Singh. She had suffered a sudden and large hemorrhage in her brain, so large that pooled blood had pushed her brain against her skull. She was just fine until one day she complained of a splitting headache and lost consciousness. Her daughter, Anu, called 911 immediately, and grew fearful and silent when the neurologist reviewed her mother’s head CT, telling Anu that her mother might die that night. But Amrita survived that night, and the next, though she hadn’t yet woken up and couldn’t seem to breathe without the support of the ventilator. The ICU team had requested my help talking with Anu about the possibility of a tracheostomy and feeding tube if Amrita survived the next few days.

  With her dark hair and smooth skin, wide smile and slightly hooked nose, Anu looked like she could be my cousin. “When I saw that CT scan, I just couldn’t stop crying,” Anu told me as she sat next to her mother’s ICU bed, stroking her hair. “I mean, what do you do with a picture like that?” She began to cry again, and I reached for tissues. The neurologist had asked her tough questions. “Have you considered what your mother’s wishes might be in this situation?” he’d asked. Anu was still wrapping her mind around the enormous implications of the CT scan she’d seen. Thankfully, she worked as a lawyer, and had helped her mother fill out an advanced directive the year before.

  “She is a firecracker,” Anu said as she described her mother. They had just attended a U2 show together. Amrita had bought Anu her first U2 concert tickets when she was seventeen. “She loves U2,” Anu said, smiling, “and she was right there with other fans screaming, ‘I love you, Bono!’” Anu had been planning their outing to the concert for a long time, and finally had convinced her mother to take a break from caring for her father. “I’m so glad we made it to that concert, but I just don’t know . . . I mean, how did she go from being healthy and totally loving life to how she is now?” A deep sadness stirred within me. Anu was just around my age, and her mother was just a few years older than mine.

  As we sat together, I studied Anu’s mother, whom I called “Auntie.” She wasn’t a blood relative, but I couldn’t imagine referring to her as “Amrita” or “Mrs. Singh,” the way I generally refer to other patients. It was second nature for me to call older Indian men and women “Uncle” and “Auntie,” and I did just that the handful of times they had been my patients. Auntie’s beauty reminded me of my mother’s. She had thick dark hair streaked with gray, and skin the color of almonds. Her eyes were always closed, but I imagined them to be just like Anu’s: large, warm chocolate brown, framed with long lashes that required no mascara. Although she was on a breathing machine, her face was relaxed, peaceful.

  I listened to her heart and lungs and pressed gently on her belly. Everything sounded and felt fine. Everything but her brain and mind. I did a complete neurological exam, ending by asking her gently, “Auntie, can you squeeze my hand if you hear me?” and I thought I felt her attempt, quivering fingers trying to close around mine. “Can you squeeze my hand if you are in pain?” I waited to feel the squeeze I’d hoped for. I leaned in close and whispered, “I am so sorry you are going through this, Auntie. I want you to know that you are safe and that Anu is right here with you. You are loved, and you are not alone.” It was something I would come to say often to patients who couldn’t speak either because of their condition or because of the machines they depended on to survive.

  I ordered her pain medications and spoke with her nurse to ensure that she’d check Auntie’s pain level as often as she could. Anu and I then sat down in a conference room in the ICU to talk more. “Mom was always the healthy one,” she told me. “My dad has Alzheimer’s, and taking care of him is her whole world even though he doesn’t recognize her. And now, even if I told him that she’s sick, he wouldn’t understand. He will never know that this happened to her.”

  Anu looked at her lap, twisting together and pulling apart the tissues she had.

  “I think it would devastate her if she were alive but couldn’t take care of him,” she said. “She would have such a hard time depending on someone to take care of her, or to do anything for that matter.”

  “I hear that so often from people in our parents’ generation,” I offered.

  “Totally! I think there’s something about them having survived Partition time and knowing they need to be independent to survive and take care of each other in a new country. I can’t imagine how she would stand being in a nursing home if she even survives this.” We sat in silence for a few minutes, and Anu told me that she’d have to leave for a little while to take care of some work at her legal practice, but that she’d be back later tonight. Her brother, a surgeon, would be flying in the next day and she hoped that we could all meet.

  “He might be more realistic about her situation than I am,” Anu told me. “I know she wouldn’t want to be dependent on machines . . . but I feel like we need to give her a chance to try to get better.”

  “I can understand that,” I told her, “and even when we might have a general idea of what our parents might want, it is one thing to know it and it’s another to honor it when there is a lot of uncertainty about whether she might recover.”

  “I just wish she could talk to me,” Anu whispered, looking down at the table and resting her head in her hands. “I wish she could tell me what to do.”

  * * *

  I drove home that night thinking about my own parents. I knew that they had drawn up wills and advanced health-care directives around the time I’d graduated from college, when they were both in their fifties. I didn’t admire their foresight. I instead refused to discuss their plans with them, becoming angry when my father tried to reason with me. “I don’t want to talk about that stuff,” I said, interrupting him as he explained that it was important for my brother and me to know their plans and to understand the intricacies of the document. “No,” I had said. “Nothing is going to happen to you.” My brother, then a college freshman, had a much easier time listening to my father. I’d learn years later that my brother knew all about the content of my parents’ wills and the very specific instructions they contained for handling every aspect of their lives. He hated talking about these matters, he told me, but it was a necessary part of life.

  Now in their sixties, my parents were quite healthy. Both exercised regularly, ate a vegetarian diet, and took their medications every day. Ever since his cardiac procedure back in 2004, my father hadn’t had chest pain, though I asked about it regularly. My mother’s arthritis flared at times, but she turned to Ayurvedic therapies to help her feel better—castor oil massaged into her knee, turmeric powder added to the glass of almond milk she drank every night before bed. But Auntie’s situation reminded me that everything could be just fine, until suddenly it wasn’t. I thought again of Joan Didion’s words: “Life changes in the instant. The ordinary instant.”

  * * *

  Auntie was neither better nor worse when her son, Ajay, arrived for our meeting. Auntie’s brother joined us, too. Just before our meeting, I stood outside Auntie’s room and watched her brother cradle her head and speak to her in Hindi, telling her to be strong, to fight through, to come back to the people who love her.

  Ajay listened quietly as I gave him updates on his mother’s condition. He’d reviewed her CT scans with the ICU attending, and knew that not much had changed since she first arrived at the hospital. “Have her ventilator settings changed much?” he asked. “She’s actually on pretty low settings,” I said, “but since she’s not waking up, it would be risky to try to extubate her. This is why the neurologist thinks that if we are going to keep trying to support her artificially, we should probably do a tracheostomy.”

  Anu remained qu
iet for most of the meeting, as she’d already heard my explanations. “We must give her a chance,” Auntie’s brother said, turning to me. “You know, miraculous things happen. One must never give up hope,” he continued, tears starting to fall from his eyes. “Yes, Uncle,” Ajay began, “but we also have to be realistic. If she isn’t going to get better, then why make her suffer like this on machines?”

  “No, no, I cannot accept that. We cannot just stop the machine that is keeping her alive,” he said firmly, shaking his head. “We cannot take my sister’s life,” he said, looking at me, his hands pressed together as though in prayer. I would have ordinarily reminded him of the purpose of the breathing machine, which was to support her as her body tried to recover, though I doubted that it would given the magnitude of her hemorrhage. But he spoke to me as though I were his niece or granddaughter, begging me for mercy in a way he probably wouldn’t have if I were of any other background. So much about the Singhs felt familiar and familial: Anu’s hand gestures, the mixture of English and Hindi that Uncle spoke, the unspoken shared history. I was tempted to bend the rules, to err on the side of comforting them rather than discussing the reality of Auntie’s situation. They need you to be a doctor, not a purveyor of false hope, a strong voice reminded me. Don’t let your empathy get the best of you just because they remind you of your own family.

  I responded in my gentlest voice to Uncle’s fear of losing her just as suddenly as she’d gotten sick. “Uncle, nobody is going to take Auntie’s life. I know this is very scary. Nobody could have predicted this would happen to her. No wonder it is so frightening.”

  “But the breathing machine won’t fix the stroke,” Ajay pointed out to his uncle before I could. “She may never be able to come off it.”

  “Anu and I spoke a bit about this, but I was wondering what you thought as well,” I said to him. “Did your mother ever talk about what she would want in a situation like this?” Uncle wiped his tears as we spoke.

  “No, not really,” Ajay told me. “She was always really healthy and everyone was really mostly concerned about my dad. But I seriously doubt she’d be okay living with a trach in a nursing home.”

  “Sorry, but what are the odds that a miracle could happen and she could get better?” Anu asked suddenly. “I need to know that.”

  “It’s natural to want to know that,” I reassured her. “But I think we need to be really clear about what getting better would mean for her. Sometimes, getting better means that she needs less support from the breathing machine. But that’s different from her waking up and being herself again. That sort of getting better might be very difficult to achieve,” I said. When I looked at Auntie’s CT scan myself, I couldn’t believe that she hadn’t died the night of her hemorrhage. Maybe that had been the miracle, the fact that she was still alive, able to sense the love around her, giving Anu and Ajay and Uncle a chance to say their good-byes.

  * * *

  Two days later, Anu told me it was time for her mother to be at peace.

  The ICU team had done another CT scan of Auntie’s brain and things looked worse. So did her physical exam. “I know I can’t be selfish even though I want to,” she said, her eyes red. “We all agreed that we just need her not to suffer like this anymore. She’s lived a good life, such a beautiful life.”

  Anu proceeded to tell me the things she would never forget about her mother. She told me that her father was supposed to have had an arranged marriage, but that he had met her mother and fallen in love with her, marrying her shortly thereafter. Anu had found some of the love letters they had exchanged while her father was pursuing a master’s degree in the United States while her mother was still in India with their two children. Love marriages were exceedingly rare in India in the 1960s, when Anu’s parents married; they required bravery, risk, and enough certainty about one’s intended to push back against the heavy weight of societal and parental expectations. “I keep telling her that Dad is going to be okay, that we’re going to take good care of him,” Anu told me. “I don’t want her to hang on thinking that nobody will be there for him.”

  “Telling her that is so important, Anu,” I said. “I am sure she worries for him, and she needs your reassurance that he will be cared for well. Are there other things that might be important for her, things I can help you in any way with?”

  Anu paused and spoke hesitantly. “Actually, yes. I know this is a really random question, but my mom loves my dog. I know you might think I’m crazy, but I just don’t think she can go without a visit from Buster.”

  I chuckled, shaking my head. “You are not crazy at all, Anu,” I reassured her. “Pets are family. I’m sure Buster also would want to have a chance to say good-bye. I think it should be okay, but I’ll double-check with the ICU nurses and staff.”

  “Thank you for everything,” she said, sniffling. “There’s just no way I could have made this decision without talking to you.”

  Although for many years I had chased the praise and approval of others, I now found it hard to respond to comments like Anu’s. I’d shrug them off and instead praise the patient or family for their own forbearance and courage. This time, I experimented with saying the simplest thing: thank you.

  “Thank you, Anu,” I said, finding it easier than expected. “You are so strong that you could have definitely done this without me, but the privilege is truly mine to help out.”

  “She would have loved you,” Anu said, and suddenly I began to cry without warning, hot tears spilling onto my cheeks. I covered my face in shame and told Anu that I was sorry, that I usually didn’t cry in front of patients and families. She gave me a hug and told me it was okay, that I was just as human as she. We cried together there in Auntie’s ICU room, arms wrapped around each other like sisters.

  * * *

  It happened to be my last day of work at the hospital, and I rushed around to sign paperwork, say my good-byes, and turn in my white coats and pager. I stashed thank-you cards and gifts in my office and rushed around to say good-bye to the patients I’d seen in the hospital. I’d said my good-byes to my hospice patients, giving their families my new contact information and encouraging them to keep in touch. As the day wound down, I wrote my notes and logged out of my computer for the last time, taking one last glance at the adjacent photos of my mother and me when I searched for our last name in the online physician directory. I sat at my desk in silence for what seemed like a long time, bewildered that it had been a year since my arrival. It had passed so slowly, and then so quickly. Time, at once as expansive and compact as an accordion, always beguiling.

  * * *

  That weekend, I went home to see my parents, thinking of Auntie as I drove. It was relatively early on Saturday morning and the traffic on the Harbor Freeway was minimal. I took an exit near my mother’s hospital, driving past the cluster of buildings that had been my second home. I drove along Anaheim Street as I’d done dozens of times on my way home in the past. On my left was a large factory with spirals of smoke twirling upward; on my right was a series of empty lots with patches of brown grass and green weeds. I drove up Hawthorne Boulevard alongside groves of pine trees and eucalyptus, past my old high school. Without thinking, I turned onto a street that led to my elementary school, parking my car in the exact spot where my mother would pick me up, a spot that had undoubtedly hosted millions of pickups and drop-offs since then. I continued, driving six blocks away to the street where we’d rented a home with a lush, verdant backyard and a kids’ room off the kitchen where I’d read The Berenstain Bears aloud as my mother cooked. I thought of our year in this home, our first in Los Angeles, when my father first took my brother and me trick-or-treating, when my mother took up gardening and taught me how to plant begonias and marigolds underneath a wilting banana tree. It had been nearly thirty years ago, but the clarity of my memories—the smell of the dirt around the flowers, the gentle grip of my father’s hand around mine on Halloween—suggeste
d otherwise.

  How many moments make up a life, I thought then, realizing how lucky I was to have had my parents with me for these thirty-five years. I thought of the ways they had nurtured and protected my brother and me as children, how they had thought about and prepared for every aspect of our lives. I thought of Auntie’s vulnerability as she lay in a hospital bed, how she appeared almost childlike in her rest, her future hanging in the balance between her family’s grief and medicine’s educated guesses. And I knew then that no matter how much I dreaded it, I had to talk with my parents about what they would want when—not if—their bodies failed them. That would perhaps be one of the greatest gifts I could give them—dignity and presence at a time of their own great vulnerability. I looked again at our former home, renovated into modernity with a gleaming oak door, a driveway free of deeply fissured concrete, and neatly linear flower beds in place of tangled knots of green-brown bushes and ivy. I remembered my father’s familiar refrain: Change is the only constant in life.

  * * *

  When I reached home, my mother was in the garden, drinking tea. She sat on a small terra-cotta-colored wall that bordered our small green lawn. A peach tree, a guava tree, and bunches of tomatoes and cucumbers crowded the other side of the wall. My mother often sat on the wall between the greenery, meditating, raising her face to the sun, playing with our cats, Snow and Winter, who mewed and napped next to her. I watched her from the kitchen window as she played with them, remembering her hesitance to pet the first kitten I’d brought home in 1986, fearing it would bite or claw her.

  I opened the sliding screen door and she smiled widely, her face glowing as though she hadn’t seen me in years. I inhaled the mixture of sandalwood and coconut oil in her hair as I hugged her. “I didn’t think you would be home till later,” she said, “and I haven’t made lunch yet!”