by Sunita Puri
“Don’t worry, Mama, I’m not even hungry,” I replied, suddenly nervous as I thought about how to open a discussion with her.
“So? How was your last week at the hospital?” she asked, squinting in the sunlight. Although she’d told me that she supported my decision to take the university job, I knew she was disappointed. We’d both relished being a mother-daughter pair in a large health system, our second home over the years.
I knew myself well enough to know that if I didn’t talk about it now, when I was inspired to, I might never do it. What followed came mostly from my heart rather than my head. “My week was okay,” I said. “Something happened that made me think a lot of you.”
I told her about Auntie, about how Anu’s description of Auntie made me think of her, of how both of them had defied Indian societal expectations of women to build alternative lives courageously. I told her that Auntie was a firecracker and she was, too. I told her that I couldn’t live with myself if something suddenly happened to her and I didn’t know what she would want me to do for her. I struggled to remember the questions I asked my patients and their families every day. Language, my reliable workplace ally, vanished as I looked at my own mother’s face.
“I don’t want to think about life without you. But I know I need to be prepared for it,” I said, leaning on her shoulder as she put her arms around me.
My mother stroked my hair, just as she had when I was a child afraid of the dark. I forced myself back into my doctor role, leaving my daughter role briefly. “What would you want me to do for you, Mama, if you got so sick that you couldn’t talk to me? What would be important to you at that time?” I was glad that we could speak about this in English; these weren’t questions or concepts that I could easily translate into Hindi. When I’d tried in the past, I spoke haltingly, my sentences confusing and awkward. There was simply no good way to translate “goals of care” or what one “might hope for when time is short.”
“I don’t want anything aggressive,” my mother said immediately, waving her hands. “I just want you to let me go.” Her response was so quick and terse that I realized she’d thought about this for years. Her words stung, and I reacted just as I’d seen many children react to their parents’ similarly expressed wishes in family meetings. But what about me? Don’t you want to try to stay alive for me?
“But what does that mean exactly?” I pressed, trying to remain in doctor mode. “If you had something reversible, something like a pneumonia, and needed to be intubated for a few days, wouldn’t that be okay with you?” I was back in daughter mode. I couldn’t imagine my mother forgoing a few days on a ventilator for pneumonia, especially when she’d intubated so many patients in far worse situations. “You’ve intubated and taken care of so many people who were on the vent for no good reason,” I thought aloud. “How could you possibly say no to someone else taking care of you that way for a few days? Wouldn’t it be worth it to you to have more time with Siddarth and me and Daddy?”
I could sense my mother softening her stance. “Yes, okay, I think if it was something reversible, then yes. You can tell them okay if they need to intubate me for a few days. But no tracheostomy, no nursing home, none of that. I wouldn’t want all these things we do to patients.” This didn’t surprise me. Most physicians I knew noticed the irony inherent in our offering patients intubations, CPR, tracheostomies, dialysis, and so on, when many of us wouldn’t choose such interventions for ourselves in their circumstances. We often joked about wanting DNR tattoos and generous doses of pain medications at the end.
But there was more than just this to my mother’s reasoning. Stories about her life structured her thoughts about her death. She described how her life had always bulged with dizzying amounts of activity—medicine, child care, volunteer work, engaging with our spiritual community. She couldn’t stand the thought of drawn-out debility, forced by disease into a state of dependence. If her organs were failing, or she had an incurable diagnosis, her main concern was living well. She didn’t want therapies that would just prolong her dying process. “And I would never want you and Siddarth to have to take care of me,” she admitted.
“But why?” I asked, hurt and angry. “How could we not? You deserve the same love and care that you gave us. We would both do whatever it took to make sure you and Daddy were okay. Don’t you have that faith in us?”
“Yes, but we don’t want to be dependent on you both,” she explained. “You have to understand that your father and I are completely self-sufficient. Nobody gave us a thing when we moved to this country. You see that, na? It would be very hard for us to start depending on others at that point.” I knew this was true. While they readily responded to the needs of others in crisis, they asked for help only with small matters, like feeding the cats and collecting their mail when they were away.
“I know that you are both very independent,” I said, validating her words in the most doctorly way possible. When I was doctorly, I enunciated words clearly and slowed the pace of my sentences. Keeping a professional distance actually helped me to have this very personal conversation with her. This meant trying to look at my own mother as though she were a stranger. “But Siddarth and I would both want to take care of you if you needed that. Can you accept that from us?” She said she would, but that she couldn’t live well without her independence. If she could not take herself to the toilet or sit in the garden with the cats or move without severe pain, she would take these signs as God calling her. “Then I would want only comfort. I wouldn’t want anything more than my family and God’s prayers at that point,” she said. I tried to push aside my anguish at this thought, reminding myself to be doctorly and not daughterly, to listen carefully to what my mother was saying. She wasn’t saying anything remarkably different from what many of my patients told me; most valued their independence and quality of life with their loved ones, and wouldn’t want medicine to sustain their bodies at the expense of the quality of their days.
But then she said something that most people don’t tell me, words that captured the essence of who she and my father are. “Sunita, your father and I are not afraid of dying. We will miss you, but we will never leave you,” she said. “I know that my Lord is waiting for me, and that gives me so much comfort. I know in my heart that you and Siddarth will not have to make many hard decisions because He will make them for me and your father.”
I let her words sink into my mind like handprints on wet concrete, hardening into permanence. Everything she now said echoed everything she had always said. The same faith that propelled her from poverty to medical school, from the challenges of immigration to the stability of her current life, would of course be her main guiding light as she aged. She wanted to die as she had lived.
“It is very important when I am at that point to pray,” she continued as I looked past her at the hummingbirds floating between the leaves of the peach tree, a crow perched atop its highest branch. “You must pray continually and keep Swami’s photo on my chest, over my heart. Just stay next to me,” she said. “I will be ready when my Lord takes me back.”
A breeze rustled the grass and stirred the cats from their nap. A bee zipped around us toward a patch of lavender. I looked at my mother’s face for what seemed like a very long time. I noticed the patches of gray hair that glistened in the sun, the dark brown circles underneath her eyes, the mole atop her upper lip surrounded by faint peach fuzz, her hazel eyes, the ones my brother inherited. She’d passed on to me the shape of her torso and her wide smile; my first strands of gray hair showed up just above my ears, exactly as hers had. She and I even both suffered from a patch of eczema on the same part of our left legs.
She was half of the DNA in my cells. She’d literally live on in me, in every cell of my body, long after she left me physically. But my inheritance from her was more than just physical. She’d also passed along her dreams. I followed her into medicine not only to heal others as she did, but also becau
se, in some way, I wanted her cherished role in the world to live on through my own work. It brought me immeasurable comfort to have heard her thoughts directly from her. My task at some point—a point I couldn’t fathom—would be to follow her careful instructions. It would be to use what I knew of her to allow her peace, knowing that my love for her would make her immortal.
“You will know what to do for me. You and I have a direct connection,” she said, leaning in and pressing her forehead against mine. I thought of the day when sitting next to her on this ledge would be another memory in my mind’s kaleidoscope. “Don’t you know that I’ll always be with you?” she said, her face close to mine.
* * *
My father had watched our conversation from the kitchen window as he prepared lunch. He eyed us with an amused expression as we walked hand in hand, Snow trailing behind us mewing for treats. “So, what were you discussing?” he said, chuckling as he noticed my serious expression.
“Come on, don’t tease her,” my mother said as she approached the fridge. She had always rescued me from my father’s jokes. “Are you making the salad or should I start it?”
“Are you having doubts about the new job?” he asked, eyebrows raised, a joking half smile on his face.
My mother snatched away the radishes and lettuce he was washing. “You need to sit down and talk to her. This is important,” she said, winking at me as she forced him to take a seat.
“Okay, Krindy,” he said, using my childhood nickname as he always did. “Your mother is being dramatic again,” he said, laughing as he glanced over his shoulder at her. “What is it that you want to know?”
Leave the emotion out of it, I reminded myself. Doctorly, not daughterly. “I know that I haven’t wanted to talk about this in the past,” I began, “but I really do want to know your thoughts on what you would want from your medical care if you couldn’t tell me yourself.” I had carefully rehearsed this sentence on the drive down from my home, particularly in preparation for my discussion with him. Thirty-five years of knowing him had taught me that he responded best to logic. Because he had the mind of a rational engineer, I gave him the context behind my question. I told him about Auntie, about the questions that her situation had made me ask, and about why caring for her had compelled me to talk to him.
“Well, here is how I see it,” he began. “The body is like a machine. Sometimes you can easily fix a problem, and other times you can’t. If there is something to try to fix a problem I have, like when I got the stent ten years ago, then do that. If there is something not fixable, then don’t let me suffer.” He spoke with the same even tone of voice he’d used when he taught me algebra in middle school. The image of him hunched over a legal notepad with me, teaching me the Pythagorean theorem, came to me. It was a warm summer day and he’d insisted that we do math problems together instead of going to the YMCA to swim. “If you solve the problems, we can go swimming,” he offered as a compromise. “You have your whole life to swim, but now is the time for your father to teach you math.”
“Okay,” I said, “but sometimes it isn’t that simple. Remember Rajiv? The doctors fixed certain broken things in his body, but the way he ended up . . . would you want that kind of life?”
“No, absolutely not,” he said firmly. “If I become so dependent on others that I can’t go where I like, do what I like, then I think that’s it.”
“What about being on machines temporarily if you needed that?”
“Well, you are a doctor! I would trust your judgment. If you think that a machine or the CPR or whatever it’s called would help me, then you can tell them to do it. But if I will just be in bed, weak and with a nurse doing everything for me, then just let me go.”
“So you don’t want to be like Lieutenant Dan, then?” I said, smiling, knowing that the mention of his favorite character from Forrest Gump would cheer him.
“Well, Lieutenant Dan wasn’t just lying in bed doing nothing,” my dad pointed out seriously. “He just had this idea that he should have died on the battlefield like his ancestors. But who are we to think we can plan exactly how we are going to die? Some people have this very silly idea about all this stuff,” he said, laughing, then suddenly serious.
“Do you remember another movie we watched, Gandhi? Do you remember what I always pointed out to you, the most important moment of the movie?” he asked, and I immediately knew which scene he was referring to. We must have watched the film when I was around ten years old, and the scene I remember most vividly was when Gandhi was shot, when the last words that he murmured were Hai Ram, one of the many invocations of God in Hindi. I was sprawled on my stomach on our thick brown carpet, and I remember my father telling me then that the most important thing at the time of death was to say God’s name.
My memory was accurate. “Remember in the Gita that at the time of death you must always remember God. But to train your mind to remember God at the very end, you must remember Him all the time,” my father said. “You know, I don’t even think there will be a need for you or Siddarth to do anything for your mother or me,” he continued. “I really do think, and I feel this in my heart, that He will just come and pick me up one day. He will say, ‘Okay, time to come with me.’ None of these machines or anything will be needed. I will just go quietly.”
I couldn’t imagine which was worse: making a decision for my father to make use of life-sustaining technology or waking one morning to find him gone, at peace but without a chance at remaining with us.
“Okay,” I said, doctorly again, trying to be objective as I summarized what I’d heard. “It seems to me that you would be okay with some interventions if Siddarth and I and Mama thought that you had a reversible condition,” I began. “But if you were going to end up dependent on machines or mostly bedridden, that wouldn’t be what you would want.”
“Yes, Krindy,” he said, smiling. “That is all correct. Make sure also that you and Siddarth are there with me, praying. This is what I would want the most.”
I wondered if my brother and I would be able to remember my parents’ words when we needed to, or whether our fear and disbelief might lead us to act like Teresa and Ray, whether our shock might prompt us to hang on like Anu. As I sat in the thick of this discussion with my parents, I could identify with each of their reactions and with the reasons why they probably hadn’t had this sort of discussion with their parents. I could barely get through it even though I had these talks for a living. I recognized that not all people would have such discussions, that it would naturally be tougher for those who weren’t close to their loved ones or who had strained relationships or who had to negotiate multiple family members’ input about these matters. But though it had been challenging now, I couldn’t imagine broaching these topics in the midst of a true emergency. Still, even though I had heard and understood my parents’ words, I knew that I would need to rely upon a wellspring of strength to honor to their wishes when the time came.
“One thing I can say for certain is this,” my father continued. “I don’t think I’m going anywhere anytime soon. I’ll be around to bother you when I’m old and walking with a cane and yelling at you!” He started laughing, which I’d also expected. Standing up from the chair, he shuffled over to my mother, leaning on an imaginary cane. “Hey, don’t laugh about this!” she said, shooing him away.
“Hey, don’t laugh about this!” My father imitated her as he swiped a handful of chopped bell peppers and broccoli and munched loudly.
Our usual routine resumed. I pulled out the bag of cat treats stored beneath the sink and tossed a few out to Snow, who gobbled them quickly and mewed for more. My mother plunked a handful of garlic and ginger on the counter. “Please cut them up.” My father went to the adjacent living room and began to watch Indian news in Hindi just as he always did after completing his part of lunch preparation. I chopped the garlic and ginger as methodically as I had when I was in eighth grade, handing th
em to my mother. Outside, the crow returned and leaped around our yard, cawing. The breeze rustled the trees and disappeared, leaving behind crystalline tones of a wind chime.
* * *
I drove back to my home the next day, pensive. In my kitchen that evening, I picked at a burrito I’d grabbed from a food truck down the street. I drove home starving, but lost my appetite after a few bites. Outside my window, Sunset Boulevard was a river of light, a constant stream of headlights and bike lamps, colorful blinking restaurant signs and fluorescent streetlights. In a shadowed parking lot, dark figures moved quickly toward cars.
Something weighed on me, though I couldn’t articulate it precisely. It wasn’t about my conversations with my parents, which had brought me a deep peace. I wandered around my place, sitting on my couch and moving to a chair, picking up a book and setting it down to watch TV instead. I turned the TV off and considered going to bed early. Maybe a good night’s sleep would fix my restless mind.
And then a question surfaced. What if what happened to Auntie suddenly happened to me? Her situation had at first reminded me of my parents’ mortality, but what of my own? Perhaps this crossed my mind because Auntie and I shared a common heritage, and she had suffered a sudden catastrophic event, which could happen to anyone regardless of their age. Maybe the fact that I had faced another transition point, my last week at my first attending job, contributed subconsciously to my mind’s sudden insistence that I consider the meaning of endings. Whatever the reason, I began once again to consider my own answers to the questions I had asked my parents.
I knew that I was mortal, that at some point my body would shut down. But though my rational mind knew this, sometimes it felt like mortality didn’t apply to me. I was a doctor. I was there to tend to other people’s mortality. I thought back to all the years I’d clung to the idea of delayed gratification, the times when I’d put my life on hold until I’d completed an educational milestone. If I persisted in my studies, I’d told myself countless times, I’d someday have all the time in the world to enjoy life. I panicked now as I considered what my life would mean if it ended tomorrow in an accident.
