The Last Day: Facing Death with Dignity


The gravel absorbed most of the fluids except for when we had a rainstorm or when they re-plumbed the water pipes and converted them to run bleach.  The fog in our masks allowed us to discriminate between wet and dry, we could see matter, chunks, knowing the liquid was most likely vomit.  The diarrhea was usually watery, rarely just a loose stool, so most “dark water” was presumed blood or feces.  To track patients, you could follow wet footprints, imprints on the cool cement.

She looked up at us like a tourist sitting on a bench in a park yearning for the glance of a stranger she could entice to come over and ask for directions.  There was a smile on her face that, from a distance, looked as if she was enjoying her time sitting on the stoop by the unit in the sun.  It was warm, one-hundred degrees outside, most likely one-twenty in our full-body protective gear.  She looked towards us, then at the sun again.  Her squints at the sun betrayed winces of pain, her smile was a reaction to the cramps in her abdomen.

It was not until she reached both of her emaciated arms up to us, fingers carelessly curled as if too weak to reach full extension, that we saw she was sitting in a pool of her excrement.  Her legs were soaked, her lappa cooled with urine and stool.

She stood with our assistance, Kim under one arm and me the other.  Susie guided her hips up.  Kim asked her if she wanted to go inside and she affirmed with a wary nod.  Her eyes were nearly closed when she turned her face away from the sun and towards the ground to watch each step she was about to make.

Elderly at 32 years old.  Breasts flat against her ribs, skin that was plump days earlier hung at her waist.  There was no more muscle in her arms and her legs supported her weight, the only support she had left.  Her eyes focused beyond each step, focused on another goal, but she took each one intentionally and fully, beyond a goal of not falling, she moved to move along with us.

Despite her frailty, she gripped our hands with grace and balance–more grace than balance.  Perhaps we were dancing as we supported her body weight in the twenty paces it took to bring her back to her mat on the floor. The dance was clumsy with death as our lead.  We moved together and no one fell.  She, then death, then us.

And at the moment when I thought we had put death in third place, she froze, a rigor mortis set into her living legs and she gasped what air was before her.  Her breath was light and high-pitched, a whimper, nearly sexual but far from pleasurable.  And her knees unlocked; she quaked in our arms.  Her head dropped and she looked to the concrete below.  Her bare feet wide on the floor, and then the splatter of water, stool, clear feces and mucus fell.

She did not move her feet, or any part of her body for that matter as a liter of fluid soaked the porous stone below.  We saw the strength that relied on her toes, supporting her 80 pounds of weight.  And the roots by which she held strong calmed the rest of her shaking body.   Like leaves in the wind, her fingers wound themselves around our hands as she looked to us on each flank.  The spiraling fingers stopped firmly like her feet, and she was ready to move again.

Five more steps.  Every muscle in her lower body pulled her forward; she owned each step, each one was precious. Again she paused.  The filth that her body was letting fall, her sloughing digestive track, pouring from her was to be left on the floor, none for her bed.

I removed her lappa.  Her bare body, now shook from a new fever, or hypovolemic shock. Her body was a straight line that drooped in all aspects but her eyes.  Her shoulders too maintained a heroic tension that pushed against my triple layered surgical gloves.  Kim and Susie found rags and cleaned her again.  I stood behind her and held her under her shoulders.  She looked over her left shoulder and I retreated more from her sightlines.  To be eye to eye with her while she stood there naked, this young mother whose job it was to clean dirty children, sustain her family, provide all for her community, did not feel right.  I hid behind her.

She looked the other way, swatting her right arm as if to shake me off or gesture me closer.  I hid again, as if I could not be seen, a child playing peek-a-boo. And then the fresh lappa came into my foggy field of vision.

I could see only what was directly in front of me.  Peripheral vision would have been a luxury at that point.  Sounds amplify when vision fades, the moans of patients behind us and laughter of a child outside.  Our protective suits, in a constant state of rustle, produced a hollow, cavernous sound with every movement.  At this point in the Ebola treatment unit (ETU), after more than an hour, one could cool himself by shifting his arm or leg in a manner that allowed a new piece of personal protective equipment (PPE) to touch the skin.  Sweat from other parts of the body, that had attached to the interior of the suit and slid downwards, outwards towards the extremities, would briefly touch a piece of skin and bestow coolness.   I leaned my head forward, slowly like an inebriated chicken plucking for a foggy vision of a seed.  My hope was to feel fresh sweat that had migrated from my head kiss the back of my neck.

“Tim.  Tim, take it.”

Susie snapped me out of my trance.  She shook a fresh lappa in front of me.  I imaged the cool air that shaking a lappa would produce if we were not enveloped in this gear, how soothing it would feel to us, how soothing it should feel to our patient, standing naked before us, now clean, and with a fever of 41 degrees Centigrade.  105.8 degrees Fahrenheit on her forehead, 100 degrees outside, 120 degrees in our suits.

“Here, take it.”

Her muffled voice from behind the n-95 mask, just louder than the moving suits, sounded angry, exhausted.

I wrapped the lappa around this woman’s waist.  While tying it about here, I leaned my shoulder into backlight enough to let her know she could lean into me but not so firm that she toppled over.

Kim was now at her shoulders and Susie prepared her bed.  Kim shifted towards her right shoulder and I tied a knot in the lappa at her left hip. A bony ledge met my knuckles and though she had nothing left, she stood proudly looking down at me covering her waist.  Once she was tied I stood in front of her, Kim and Susie, no longer in physical contact, looked at her bed now dressed with one lappa and a folded sheet, a makeshift pillow.

While we cleaned and dressed her, her eyes maintained a royal gaze.  We preened her, maidservants attending to her every whim, which now, we think was simply to die easily.  The paradox of grace, rooted acceptance, boldly facing the fear of an untimely and painful death poured from her heart.  And above all else, dignity prevailed.  This regal woman had howled days prior, a witness to the deaths of eight year olds who began to seize in the middle of the night alone, the caretaker for infants whose mothers died after their breasts became flat and dry of nutrition, the bearer of bad news, who would meet the teams as they entered the ETU daily alerting us to who had died the night before.  And now she stood here peaceful and valiant.

Violently impermanent, this moment shifted and fear returned.  Her eyes grew as if her soul was pushing forward to exit, finally, from her eye sockets.  Wide-eyed she gasped and fell forward.

I stood, just below her, rising from securing her lappa.  Her eyes glowed beyond me but then met my gaze as I helped catch her fall. As she looked though my translucent face shield, her arms, full of force, extended and found themselves behind me. Susie and Kim found purchase in her shoulders and I leaned forward hands open, and palms upwards landing on her scapulae.  There was no more falling and we once again supported her weight. She looked over my right shoulder now; Kim and Susie relaxed.  We were ready to lay her down.

Someone said, “OK,” no one remembers whom.  But we all moved in unison towards the bed; the patient did not follow.  She leaned against me, into me.  She counterbalanced my gesture and when I moved back to try again, she pulled me into her body as if falling, but completely in control.  After I caught her again, I realized she did not want to be caught.  The gesture she proposed had been foreign to me since our arrival in Sierra Leone six weeks prior.  She hugged me.

Our “no touch” policies and chants from children in the neighborhood “ABC—avoid body contact” were taken seriously by our staff.  No handshakes, no hugs.

She hugged me, she grasped me, she completely controlled my movements.  There was a strength present that did not make sense.  She was out of her mind, we thought.  We were wrong.  She pulled me to against her body, her palms opened across my middle back.

She was beautiful.

Her head rested on my right shoulder and into the cavern of my neck.  With arms gripping me like twin snapping turtles, soft hands caressing my back and her head gently resting on me, she sighed.

The oil and water of intimacy and fear in this moment could not have been more chaotic.  I felt a warmth within my body that I had not felt for some time. This heat crossed all boundaries of compassion a caregiver should share with patient.  This feeling felt pure, it stirred vulnerability and removed defenses.  Sensuality passed through me, I would say us, but I fear speaking for the dead.

And the feeling passed and left my body in return for defecated fear; an unreasonable fear justified only by witnessing death daily from this unforgiving disease.  And I was afraid to be this close to her despite the coverage I had from my suit.

Susie knew this fear, “Tim, are you OK?”

No response.  I could only think about moving this woman away from my body.  A bipolar moment thrashing my humanity.  I moved her away and she held on.  My strength overtook her and when she released I followed with the empty words: “You OK, You OK, You OK.”

The three of us retook her weight the moment she gave up.  Her knees were not hard to bend, she allowed me to lower her backwards to the mat as my hands slid from underneath her shoulders down her upper arms, to elbows, wrists and hands.  This time I held her.

Gloved hands squeezed her bony fingers.  And I held on.

Susie and Kim, one or the other said, “You good Tim?” I lied, “Yeah, see you at doffing,” and they made their way to our colleague who would soon spray our white suits in bleach so we could safely remove them to exit the red zone.

And I held on.

And she looked at me, her eyes reaching out for another embrace.  So instead I said something useless to her then laid her hands upon her chest.






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