Having nothing more to offer by way of treatment for her multiple myeloma, Dr. M. refers my wife, Marilyn, to palliative care, the branch of medicine which focuses entirely on reducing pain and making patients as comfortable as possible. Marilyn and I, accompanied by our daughter, Eve, have a long session with Dr. S., the chief of palliative care, a warm and gracious woman who takes a complete medical history, conducts a physical exam, and prescribes medications for Marilyn’s symptoms—her ongoing nausea, disturbing skin lesions, and extreme fatigue.
Marilyn patiently answers all her inquiries but soon turns to the topic paramount in her mind: physician-assisted suicide. Dr. S. answers all of Marilyn’s questions in a gentle and caring fashion but makes clear that she does not favor this step. She emphasizes that her work is to make sure that her patients do not suffer and to allow them to die comfortably and painlessly from their illness.
Moreover, Dr. S. informs us that physician-assisted suicide is a complex step requiring considerable administrative paperwork. Marilyn, however, persists and asks Dr. S. if she would agree to be one of the two required physicians who would sign the order. Dr. S. inhales deeply, hesitates, then agrees but repeats that she hopes this will not be necessary. She then raises the issue of referring Marilyn to a hospice. She explains that the hospice staff would regularly visit our home and make sure that Marilyn is without pain and as comfortable as possible. Very soon thereafter we are visited by the hospice nurse and social worker, and two days later by Dr. P., the hospice physician. He spends an hour and a half with us. We were both impressed and soothed by him. I regard him as one of the most caring, empathic physicians I’ve ever encountered and silently hope he will be available to take care of me when it is my time to die.
About 15 minutes into our discussion with Dr. P., Marilyn can’t hold back and again raises the question of doctor-assisted suicide. Dr. P.’s answer is astonishingly different from any that we had previously encountered: he is highly sympathetic to the idea, though he prefers the term “physician-attended dying.” He reassures Marilyn that he personally would facilitate her dying when the appropriate time comes. He assures her that if she makes that choice, he would remain with her and would prepare an emulsion of the pills that she could sip through a straw and easily swallow. He tells us that he has participated in over a hundred such deaths, and he agrees wholeheartedly with this choice whenever the patient is in much pain, with no hope of recovery.
Those words have a powerfully calming effect for Marilyn—for both of us—yet, at the same time, it makes her death more real. Marilyn is going to die soon. Marilyn is going to die soon. Marilyn is going to die soon. That thought is too much for me, and I continue to shove it from my mind. Denial reigns. I turn my eyes away. I don’t, won’t, look this straight in the face.
A few days later, two of our children sleep over, our oldest, our daughter, Eve, and our youngest, Ben. I wake up early, walk down to my office, and spend two hours going over the editor’s proofs of a chapter in the new edition of my group therapy textbook. About 10:30, I come up to the house where Marilyn is sitting at the table finishing her breakfast, sipping her tea, and reading the morning newspaper.
“Where are the kids?” I ask. Kids indeed! My daughter is 64, and my son is 50. (My two other sons are 62 and 59.)
“Oh,” Marilyn says in a calm, matter-of-fact tone, “they’re at the undertakers, making arrangements for the funeral, and then they’ll be visiting the cemetery, checking out our burial sites. We’ll be right next to my mother.”
To my own surprise, I burst out crying and my tears flow for several minutes. Marilyn hugs me while I try to regain control of myself. Between sobs, I say, “How can you speak so lightly about this? I cannot bear the thought of your dying. I cannot cope with the thought of living in a world without you.”
She pulls me toward her and says, “Irv, don’t forget I’ve been living in pain and misery for 10 months now. I’ve said to you again and again that I cannot bear the thought of living like this any longer. I welcome death, I welcome being free of pain and nausea and this chemo brain and this continual fatigue and this feeling awful. Please understand me: trust me—I’m certain that if you had lived all these months in my condition you’d feel the same way. I’m alive now only because of you. I’m devastated at the thought of leaving you. But, Irv, it’s time. Please, you’ve got to let me go.”
This is not the first time I have heard these words. But perhaps it is the first time I let them penetrate my mind. Perhaps for the very first time, I truly grasp that if I had gone through the last 10 months of what Marilyn has experienced, I would be feeling precisely the same way! If I had lived with that much anguish, I’d be welcoming death, just like Marilyn.
For a moment, just for a moment, I feel some of my old physician-words clustering together struggling to become a rebuttal: You don’t have to suffer pain. We’ve got morphine for your pain, we’ve got steroids for your fatigue, we’ve got . . . we’ve got . . . But I couldn’t give voice to such inauthentic words.
We just hold each other, both of us weeping. For the first time Marilyn talks about my life after her death. “Irv, it won’t be so bad. The kids will always be visiting. Your friends will be dropping in all the time.”
I interrupt her: I had vowed to myself I would never impose the burden upon Marilyn of worrying about my life without her. I hug her and tell her for the thousandth time how much I love her and admire her and owe every particle of my success in life to her.
As always, she demurs and speaks of my talent, my creation of so many varied worlds in my writing. “You had it in you. Your own creativity. I just helped you uncork it.”
“My success came from my brain, my imagination—yes, I know that, my darling. But I also know that you opened the window of the creative world for me. If not for you, I would have done exactly what all my close buddies in medical school did: I would have gone into practice in Washington, DC. Though that would have been a good life, not a single one of my books would have ever seen the light of day. You introduced me to higher forms of literature—remember I rushed through college in only three years taking a premed science curriculum. You were my only link with the classics, with great literature, with philosophy: you broadened my narrow view of the world.”
That evening our close friends Denny and Josie visit, bringing a homemade dinner. Denny is a colleague, one of the best psychotherapists I’ve ever known and also a jazz pianist of national repute. When Denny and I take a stroll alone, I lay out what I’m facing. He knows well how overwhelmingly important Marilyn is in my life (as is his wife to him). I knew he would agree with Marilyn’s decision to have physician-assisted suicide: he had often voiced his support of anyone’s right to end one’s life when the pain is unbearable and without hope for recovery.
I tell him that this is a horrific time of life for me, that Marilyn is off all treatment for multiple myeloma, but someday soon it will inevitably make its reappearance. That, day by day, I wait fearfully. That I’ll never forget the original onset when Marilyn awakened me, screaming with back pain from a fractured vertebra caused by the myeloma.
Denny is unusually quiet: generally he is extremely responsive and articulate, one of the most expressive and intelligent men that I know. His silence frightens me: I fear I laid too much on him.
The following morning when Marilyn and I are at breakfast she mentions, in passing, that she felt some pain in her back. I gasp silently: I thought, of course, of her fractured vertebra and her terrible pain—her first symptom of multiple myeloma. I feel terror arising: I have been dreading the cancer’s reappearance. Were my worst fears coming to pass? I haven’t done physical examinations for scores of years, but I could have easily put my hands on her back and applied a little pressure on each of her vertebrae and identified the location of the pain. But I could not bring myself to do this. No loving husband should be in this position. Besides, my daughter, also an MD, would be arriving shortly, and I could ask her to examine her mother’s back. How horrible to think there might be no relief from her pain aside from morphine . . . and death.
I begin to berate myself. After all, I have worked with so many bereaved individuals, and the great majority of them suffered the same loss that I am facing now. Yes, without doubt: I am experiencing my suffering as worse than theirs by repeatedly emphasizing the uniqueness of my loss—how long and how much I have loved my wife.
I have worked with so many bereaved spouses who eventually improved—I know it is slow, between one to two years—but it will happen. And yet I sabotage my efforts to comfort myself by immediately focusing on my many burdens—my age, my memory problems, my physical problems, especially my balance problems, which make it difficult to walk without a cane or walker. But I have a quick rejoinder to this dark self: Irv, Good Lord—look at your advantages: your knowledge of the mind and how much you know about overcoming painful moments. And, Irv, you have a great many supports—four loving devoted children and eight grandchildren, none of whom would refuse any request from you. And think of the large number of friends who surround you. You have the financial means and the ability to stay in your beautiful home or enter any residential community. And, Irv, most importantly, you, too, like Marilyn, have no regrets—you’ve lived a long and gratifying life—you’ve had far more success than you would have ever imagined—you’ve helped so many patients, sold millions of copies of your books in thirty languages, and receive reams of fan mail every day.
So, I tell myself, it is time to stop whining. Why are you exaggerating your despair, Irv—is it a plea for help? Are you still trying to show Marilyn how much you love her? By God she knows that by now. And the depth of your sadness only makes her feel worse. Yes, yes, I respond. I know she does not want me to sink into terminal despair—she wants me to be happy and to prosper—she does not want me to die with her. I do not have to keep on displaying my pain. Time to give myself a kick in the ass.
There is an endless procession of friends and acquaintances wishing to see Marilyn, and I take the responsibility of protecting her from exhausting herself amidst the sheer numbers of loving visitors. I act as timekeeper and, as courteously as possible, limit visits to thirty minutes. My daughter has set up a website that will allow Marilyn’s friends to receive news about her condition.
Marilyn soldiers on. When friends join us for dinner, I admire how she keeps the conversation going, asking questions about people’s lives and helping everyone enjoy themselves. It’s true I have skills for talking and working with my students and patients, but her general social skills are unparalleled. One or more of our four children often visit and spend the night. I always enjoy their presence, and invariably there will be animated discussion, often chess games, and sometimes pinochle.
But however much I love our children, I greatly treasure my evenings alone with Marilyn. For several months, I have had total responsibility for meals: Marilyn’s stomach is extremely sensitive, and she eats the same simple food every day—chicken broth with rice and carrots. I fix some simple dinner for myself or occasionally order a takeout dinner from a restaurant. Then the TV news, and Marilyn’s prayer that Trump be impeached while she is alive to witness it. Often we search for a film—not an easy task because Marilyn’s memory is too good and, almost always, she prefers a new film—and watch half of the film one night and the other half the next day.
Tonight after dinner, we enjoy watching the old film Arsenic and Old Lace with Cary Grant and Raymond Massey. We hold hands. I can’t stop touching her. Enjoying the film, I gaze at Marilyn in amazement as I think how little time is left for us. I know . . . we know . . . that she is going to die fairly soon, probably most likely within the next four weeks. It seems surreal. We’re simply waiting for the multiple myeloma to wreak havoc on her smile and her beautiful body. I am frightened for her, and I’m amazed at her disposition and her courage. Not once have I heard her say she’s frightened or dismayed by her bad luck of being visited by this disease.
I am extremely aware of my own deterioration. Too often I am confused about my schedule and look at the wrong page of my schedule book. I thought a patient was coming at three today and she came at four. I thought we would be meeting on Zoom and she arrived in person. I feel I am beginning to lose it. I feel incapable. With one exception: when I actually start a consultation with a patient, I feel my old self and almost without exception I sense I’ve given each patient I’ve seen, even in a single session, something valuable.
I haven’t looked deeply at my future nor seriously considered hiring someone to live with me. I think I refrain from spending much time thinking about it because I consider it a betrayal to Marilyn. I’ve talked about it the last couple of days with friends, all of whom support my inclination to stay in the home I love so much. I’ve lived and worked in the same community for a great many decades, and I’m surrounded with family and friends and, for the time being, I’m determined to stay in my home. I imagine that between my friends and children, I’d have company three evenings a week and be perfectly comfortable being alone the rest of the time.
Basically I’m not a highly social person—my wife has always filled that role in the family. I remember my first meeting with Marilyn: I was a teenager, gambling in the bowling alley (I did have a penchant for gambling—still have remnants of it). Someone, not a close friend and a fairly disreputable guy, suggested that we go to a party at Marilyn Koenick’s home. It was so crowded that the only way we could enter was through the window. In the midst of a packed house, there was Marilyn, holding court. I took one look at her and made my way through the crowd to introduce myself to her. This was a highly unusual act on my part: never before or after have I been so socially bold. But it was indeed love at first sight! I phoned her the very next night—my first phone call to a girl.
As I think about life without Marilyn, grief and anxiety flare. My mind is acting primitively: it’s as if thinking about my future without her is a betrayal—a traitorous act that might hasten her death. Traitorous feels like the correct term: when I make plans for my life after Marilyn’s death, it feels like treason. I should be entirely consumed with her, our past, how we spend our time now with one another, and our all too brief future.
A sudden inspiration! I ask myself to imagine how it would be if things were reversed. Suppose it were I who was dying, and Marilyn who was taking loving care of me as she has always done? Suppose I knew I had only a few weeks to live. Would I be concerned about how Marilyn would fare without me? Absolutely! I’d be very much concerned about her and wish nothing but the very best life for her. An instantly therapeutic thought. I already feel much better.
Excerpted from A Matter of Death and Life by Irvin D. Yalom and Marilyn Yalom, published by Redwood Press, ©2021 by Irvin D. Yalom and Marilyn Yalom. All Rights Reserved.
Illustration Source: Gary Waters
Irvin Yalom
Irvin Yalom, PhD, is an emeritus professor of psychiatry at Stanford University and the author many books, including Becoming Myself: A Psychiatrist’s Memoir.
