Book Review: Words At The Threshold: What We Say As We’re Nearing Death

With all of the years of chaplain experience that I have, rare is the book about dying that raises my awareness of how to do my job better. The author Lisa Smartt is a linguist and the essence of the whole book is that the talk of persons who are going to die relatively soon, from a few hours to a few weeks, reflects “consistent patterns that emerge in language at the end of life.” Her data consist of 1,500 English utterances gathered over a period of four years. Some of the patterns she found include paradoxical statements such as, “I understood everything everyone said, but not a word was spoken,” metaphors such as “Yellow bus…lots of angels are driving that bus,” or visions such as seeing ancestors or spiritual figures.

After I read Smartt’s numerous categories and examples, I started to notice this special pre-death talk more often while doing my own hospice work. I then found myself responding to this special way of talking in a much more tuned-in manner than before, letting myself explore what the person was trying to convey. Just the other day a gentleman who only leaves his room in a recliner to relax in the sunroom informed me, “I have to go to a meeting.” I asked, “What is the meeting about?” (Other staff might have tried to “reorient” him by saying there was no meeting he had to attend.) He said, the meeting “is about everything.” I echoed, “Everything?” and then reflected, “That’s going to be a really really long meeting.” Chuckling, he agreed with that. I thought to myself, he might have been referring to what professionals call “life review,” i.e. the kind of run-through of our life story that some people do during the period of time before the very end as well as at other key moments of their lives.

Another characteristic this book includes is intensified language, or what I would call heightened sensitivity. I will never forget the time a patient said to me, hours before dying, that the water I gave her “was the most delicious thing I have ever tasted.”

If you find these examples engaging or touching, you will find anecdote after anecdote in Words At The Threshold, some of which are very poignant. One is about a woman who kept referring to five boxes she had to organize. Her daughter thought maybe the boxes stood for her and her four siblings, and at that her mother got agitated and exclaimed, “I need to find a place for them!”  She did not calm down when her daughter mentioned where each one of them lived.  Finally when the daughter said to her mother she could keep them in her heart, she became calm and relieved. A lesson here for all of us who may in our personal or professional lives be with someone talking near the end, is to not be too literal and instead get at deeper things such as love and other values.

Besides sensitizing me how to better connect with patients when they engage in “threshold talk”, this book also teaches me to recognize it as an indicator that patients may be nearing the end. So many times, as families struggle with uncertainty, they ask me how long their loved one has. Not even nurses always get this right, and we do not want to increase anyone’s distress by guessing wrong. Especially way wrong. But at least threshold talk can be a guide, and I can let families know that not a whole lot of time may be left. Another benefit of this book is that it  shows us how to make the most of a loved one’s end-of-life talk, for example by keeping a journal of all of the utterances to look for patterns of meaning among them, and by thinking of conversing with them as if we were learning a new language in a new land.

My only caveat is that at times, Lisa Smartt thinks that threshold talk hints at an afterlife, partly because the language is like what people who have had near-death experiences use. She thinks of these people as having died and returned, and that the similar language they use is suggestive of consciousness after death. But one could reason the reverse: that since people use such language on other occasions that do not have to do with their actual final death, that this disproves anything about threshold talk pointing to the existence of an afterlife, as comforting and moving as that would be. The author is a poet as well as a linguist, and so I take her comments about consciousness after death in that spirit.

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Not The Last Word On Last Words

There is a mystique out there that a dying person’s last words will contain rare wisdom or will give us a clue about what awaits us in the Beyond.  Emily Dickinson’s last words were supposedly, “I must go in, for the fog is rising.” Even if she did say this, for the overwhelming majority of us, the idea of our last words being jam-packed with significance is just a romanticizing of the end of life. The death scenes in many movies of a loved one saying a few brave words, letting out a sigh, and then turning their head away as they painlessly depart are no closer to the truth.  Also, I am skeptical of people having the presence of mind at the very end to be witty as in the famous quote by Oscar Wilde, purportedly his last: “This wallpaper and I are fighting a duel to the death. Either it goes or I do.”

Sorry to shatter this myth, but my experience on the job as a hospice chaplain is that last, or close to last words, are often mundane or consist of expressions of discomfort. “I am thirsty.” Or “I’m dizzy.” Or, “What time is it?” Or, “Oh my stomach hurts and I have to go to the bathroom” is more likely. Or something confused, as when I gave a woman some tepid tap water and she said, “That is the most delicious thing I have ever tasted.” There may not be any words at all, of course, if the patient is unresponsive or can no longer verbalize or is unintelligible or incoherent.

If it is any consolation, “next-to-last” words of a person still relatively clear-headed and sans dementia, can have more significance. “I love you” is very common, as are expressions of concern that the patient’s loved one will be able to get along after the patient is gone. Sometimes I do hear questioning of what their lives were all about, or declarations of faith or what has mattered most. One of my patients talked at length about some poems he wrote in a book he gave me as a present. He loved having me listen to him reading a few aloud and getting my reaction. He even asked if I would promote his book in my blog, something I could very much relate to as an author myself. Not many days later his life ended. In his memory I will mention the title of his book: Lifelines by Ben Verona (He chose this name, a pseudonym, because he thought it sounded Jewish and romantic and would attract female Jewish readers!)

Perhaps we want to think literally about final words because of the unknowability of death itself; as if part of what death is all about “seeps” into the final moments of life, throwing us a clue here and there. But unlike a novel or a film, alas for us real people, loose ends are left loose, and the ending after the ending is left undisclosed.

Standing Astonished in the Swirl of Existence

Here’s a paradox, and one that accounts for why any agreeable person would take on such work as preparing a body for burial, or in my case, serving as a hospice chaplain: being present to the dying the dead and the bereaved  has intensified my sense of being alive. Just as a malevolent character in a novel can heighten the goodness of the hero, being near the dying or the dead can serve as a foil to life. Sometimes as I step outdoors after visiting a hospice patient, everything I encounter seems more firmly anchored in the here and now. Birdsong and the patter of rain make of me a rapt audience. A swaying traffic light beams out with more redness; a wind kicking up and vacillating between cool and cold bars my way from any warmer crosswinds. How can all this be happening around me while someone is about to cut loose from the moorings of her life?  I stand astonished in the swirl of existence.

Where does this intensity come from?  The closer I am to reading the end of a piece of fiction, the more weight the sentences bear. Each succeeding word seems to take on a deeper significance. Likewise, as I am talking with someone who is nearing the end, whatever they are saying is more poignant given that backdrop. I think that is why so much is made of hearing a person’s “last words.” We assume they will be loaded with wisdom, or that they will enlighten us regarding something we had never understood about that person or about ourselves.

Those of us who care for the dead and the bereaved, get a continuous sneak preview of our own final crossing over the inscrutable edge between life and death. As with any rehearsal, we reap benefits that could never accrue if we were to simply improvise when the time came.

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This is a reprint of my guest post in the blog, Expired and Inspired, in the Los Angeles Jewish Journal, November 25, 2015. The precise link is: http://www.jewishjournal.com/expiredandinspired/item/astonished_in_the_swirl_of_existence