Susan Levenstein
Aventino Medical Group, Rome, Italy (Winter 2018)


 Mourning scene at the 9th-century Buddhist temple of Borobudur on Java. Author photo.

I remember the first time I was awakened to pronounce a death, at Morissania Hospital in the Bronx. The body was still warm, and alone under the half-illumination of a bed lamp I listened to the heart and secretly gave him a shake, panicked at having to declare the end of a life, terrified he would awaken in the morgue, in the coffin. The second time I felt more confident, newly armed with a trick passed down from generations of scared interns: I assembled my ophthalmoscope and peered through a pupil to check that the arteries of the retina were reassuringly fragmented into what has been called the “boxcar sign.” The nurses, who knew death when they saw it, found us ridiculous.

Those lonely hospital deaths were unusually decent. George Washington – his real name ­– signed out against medical advice as soon as he stopped vomiting blood from the fragile varices in his esophagus. He had had ten such hospitalizations in one year, and wanted to go home to die. He collapsed on his front stoop, blood spurting from his mouth. Carried back to the hospital, he refused treatment and for half an hour gushed red out of both ends as we all stood helplessly watching. The moment he lost consciousness, the hovering medical team plugged ethically questionable transfusions into both arms, like stopping the tide with a colander. Unique among the patients I saw during my training, Mr. Washington died the death he had chosen.

Once when I was an Emergency Room intern an ambulance brought an emaciated old woman who was notbreathing. We did cardiac massage, brought her heartbeat back, hung an intravenous line, and sent her to the ICU on a respirator, when in walked her physician son who had called the ambulance. He said, “What a blessing for my mother to finally die after all her suffering from cancer.” Everybody started yelling at once: why hadn’t he ridden with her, why hadn’t he telephoned, why hadn’t he sent a note along, why had he called the damned ambulance in the first place? I walked out of the ER in a fugue state, my mind not knowing what my body was doing, took the elevator up to the ICU, turned off the respirator, waited until there were no more blips on the cardiac monitor, came back down, and told the crowd they could stop arguing because she had died. I did not weigh the pros and cons of performing this act any more than I could have debated whether to run out of a burning building.

Several times during my medical practice I have been taken over by a shudder when death’s minions have caught me unprepared. The variegated hills and valleys of an advanced melanoma casually unveiled when a patient took off his shirt. The rock-hard spiny tip of a cancer felt on a rectal examination; when I pulled out the finger I saw not a patient but a dead man walking.

Illustration by Suzanne Dunaway.

The worst: you turn a familiar corner on a routine exam and there in front of you is the guy with the scythe. Reaching across to examine a patient’s left breast, the edge of my hand knocked accidentally against the sharp edge of a two-inch cancer in the right one. Examining a man with earwax I felt an obscenely enlarged, plainly malignant spleen; I remember clutching the examination table with my other hand, afraid I would faint,  my voice remaining calm.

But then death is always at our side. My third year at the Mount Sinai School of Medicine I was at Beth Israel Hospital when a boy with a mop of curly red hair looked down at our feet in an elevator and said, “Hey, we’re both wearing Wallabees.” Kevin was a nineteen-year-old high school dropout who pushed wheelchairs for a living. I was twenty-five  and nearly a doctor, and for some reason we clicked. I was making the dazzling discovery of what it was to be part of a committed and supportive couple  when heading home across the Brooklyn Bridge Kevin’s bicycle was hit by a truck and he was smashed on the street below. Those arduous hospital clerkships got me through the first months after the accident, occupying my mind during gaps between guzzling whisky and staring at the pill bottles on my shelves to gauge their suicidal potential.

I moved to Rome in 1978. Not many patients have died under my care here: major illness drives Italians into the arms of the public system and makes foreigners pull up their stakes and head home. One of the few was Doris, whose liver simply crashed – not the inevitable endpoint of cancer, the lightning strike of a heart attack, or the trailing off of old age, but a reminder that death always triumphs in the end and can drag off the strongest of us. In my few minutes alone with her jaundiced body in the ICU I remembered how every time I came near Kevin’s coffin over the three days of the wake I would muss up his hair to be as he wore it, how the funeral parlor people kept combing it back down, how he smelled of greasepaint. Remembered a flock of vultures eating a dead zebra at Masai Mara game park in Kenya, and a mile further on a zebra mare licking the amniotic sac off her newborn colt. Remembered the Clarissan nuns on Ischia who prayed every day before the clothed corpses of the sisters who preceded them, propped up on stones with hollow seats to rot slowly into clay bowls placed underneath, knowing that they themselves were destined to sit, eventually, on those same chairs.

In May 2005 my mother died in my arms. At eighty-eight  every system except her mind was faltering, and she only pretended she could still see St. Peter’s out my window and follow the dialogue on TV. She had arrived from New York exhausted, and could not handle more movement than from guest room to kitchen. The fourth night we heard moaning through the wall and I found her tossing and hot in her bed, breathing once per second, and radiating fear. I called an ambulance, slid her arms into a sweater, held her and promised she would be all right, and watched her fight terror-stricken to breathe. Then she stopped breathing and the light went out of her eyes. I frantically, competently, uselessly blew my breath into her mouth and pumped her heart all the way to the hospital.

She had thought she was ready for death, until the moment it actually came. For weeks afterward in my dreams, she found more peaceful ways to die. Deaths in hospital were nothing like this unbearable moment of transformation, as holy in a contorted way as a baby’s first cry.

I had a patient who escaped unhurt from a bad car crash but remained haunted for a year by a paralyzing awareness of the dangers around him: any cornice he walked under might fall and crush him, any bridge collapse under his feet. Automobiles, which hurtle headlong down skinny strips of asphalt under the control of inattentive humans, were out of the question. Our everyday lives depend on maintaining a fiction of invulnerability, which when broached leaves us crippled by fear.

After my mother dared disappear while I held her, I was crippled like that. An invisibly hovering Death could appear at any moment; my husband went into the kitchen and I imagined him dropping lifeless to the floor. In the office,  I was assaulted without warning by a split-second vision while I measured someone’s blood pressure or palpated his liver, of the life suddenly fading from his gaze. I had experienced something similar during my internship at the  end of a neurological exam: while I wiggled the young woman’s toes and asked whether it was up or down, she fell silent. I looked toward her head and to my horror saw her eyes roll up and her back arch into the grand mal seizure of barbiturate withdrawal.

For months I found it hard to tolerate touching patients. I lost the essential professional delusions of knowledge and power, capable of going through the motions but feeling utterly impotent. Medicine seemed a card trick, an exercise in futility, its successes insignificant.

When very elderly patients came in I resented them for surviving when she had not.

For a long time I felt uncertain about every diagnosis and ambivalent about every prescription. I had always had the professional vice of creating complications – asking too much, explaining too much, offering too many alternatives – but now it went over the top. I lost my grip on the usual orderly process of information gathering, diagnosis, and treatment, distracted by everything that could go wrong, fussing over the microdifferences among cases, overindividualizing my prescriptions. My charts consisted more and more of my patients’ own thoughts and descriptions of their symptoms instead of my translations into medicalese.

I already knew about mourning. Now I learned about post-traumatic stress disorder, since any reference to death – they happen, in my job – triggered flashbacks, adding insult to injury. For years when reading medical articles I had to skip over paragraphs mentioning cardiopulmonary resuscitation.

For once I was on the receiving end of my patients’ support. Their concern left me grateful, confused – who was supposed to be helping whom? – and surprised how many of those relationships were revealed as genuine, even deep. My way of relating to patients changed forever, becoming more equal and reciprocal. But I have never forgiven one man who insisted on maintaining his appointment for a routine checkup three days after my loss, shrugging dismissively to my secretary who called to cancel it, “We all have our problems.”



SUSAN LEVENSTEIN, MD, moved to Rome shortly after becoming Board Certified in Internal Medicine in 1978. She founded a primary care office practice in 1980 and, in her research, has explored the influence of psychological factors on diseases such as peptic ulcer, inflammatory bowel disease, and hypertension, with more than 60 scientific publications. She is now working on a book about her adventures with Italian health, lifestyle, and medical care. You can read more of her writings on her blog, Stethoscope On Rome.


Hektorama  |  End of Life