Shelley Schoepflin Sanders, MD, MTS, FACP

Portland, OR

"Sure, I'll take her ashes."

I heard my own voice from far away, but with real clarity I knew the decision was right. I know what to do with ashes. I will do something beautiful for Genevieve.

The kind hospice nurse helped me finish signing Ginny's Medicare benefits over to hospice, "Not as her doctor, but as her friend."

As her friend? I walked slowly to her room to say goodbye, wondering how it could be possible that I was Ginny's only loved one.

I'd been her doctor for years. I had listened to her delusion that the washing machine repairman was trying to move into her house, supported her transition to a senior living community, and remained mildly surprised when the new housing seemed to work out.  I knew her main love was her cat, and she knew my main loves were my two living boys. At the end of every visit, no matter that I had failed to cure her annoying chronic cough, she would always ask about my boys by name, her face lighting up with delight.

When she broke her hip and was in the hospital for weeks with complications, I visited several times. We held hands for most of each visit, her curved arthritic fingers forcing fingernails into my palm. I asked if she wanted to move toward a more palliative approach. "Oh no, my life is good. I have my cat."

Now, on the third hospitalization in as many months, the social worker and nurse care manager had each stopped me in the hall, asking if I knew "the woman in 753."

"Oh yes," I answered easily, "She's my sweat pea."

"Sweet pea? She practically threw me out of the room! She needs placement. Will you go in with me tomorrow?" I was not Ginny's attending of record, even though I was on service on the same ward that week.

The text page came right after rounds, "Ready to go see Sweet Pea with me?" Her sarcasm felt like a slap. Sweet Pea was also my special name for my one-year-old boy. 

The pregame talk went as expected: "She doesn't have any money, but she won't sign up for Medicaid. She's been here 11 days. She can't go back to independent living, and she can't go anywhere else until she signs up." 

Walking in, Ginny looked the same as always. I squatted by her bed, held her hand, encouraged her to listen to the well-meaning social worker, and left the two of them to try to work it out.

The next morning, walking by her room, I saw a nonrebreather mask. She'd aspirated in the night and had been placed on comfort care. Her attending had ordered hospice as there were no friends or relatives, but would I sign over her benefits, as her friend?

Having signed the papers and volunteered to care for her ashes, I was back to say goodbye. This time, there was no response when I took her hand. The tears streamed down my cheeks as I kissed her coarse grey hair, disrupting the oxygen saturation probe stuck to her forehead and bringing an anxious nurse in to interrupt my whispered, "I will remember you." I was reeling. Who are you Ginny? How can you die and have no one but a cat?

On the phone with the funeral home, I had no idea how to answer what I was now learning was the "friend's" part of the death certificate. Did she graduate high school? Was she in the service? What were her parents' names? Where was she born? Scrambling through chart notes, I answered as best I could, numb from a line I'd known, but forgotten, son Jacob died at 30.  There were some things with her, the carefully mournful woman's voice interrupted my reverie – a teddy bear, a watch – would I like to have those?

Finally beginning to understand my bond with Ginny, I smiled at my office partner's raised eyebrows and made one more phone call, this time to the only emergency contact in the chart, marked in capitalized italics NON-RELATIVE. Yes, it turned out, someone was caring for Ginny's cat, and the apartment manager would make sure that if the cat was headed to the pound, I would get a call first.

I stood in Ginny's musty apartment, staring. She liked Picasso, Japanese glass fishing floats, and Igor Stravinsky. Not a penny to her name, or at least not enough to pay for groceries or cat food, according to Kate, the caregiver who let me in. But here is a flat screen TV that has outlived her and framed art and classical music playing for a 17-pound Russian blue cat who is happy to see us.

I don't understand death when I see it, and I see it too often in the hospital. The breath leaves and the soul departs, and then so strangely stuff remains behind. Usually stuff and touched tender raw people are left behind, but in this case, there is not. Except me. I am touched.

In the parking lot, yowling cat stuffed into Prius, I stand with Kate to chat a few more minutes. "What do you think will happen with her ashes?" Kate asks.

"I said I would take them. There was no one . . . unless you want them, or know of someone?"

Kate looked relieved. "Oh no. It's just she told me her last caregiver sprinkled Jacob's ashes in her garden. She was really mad. But I found his remains in her storage unit."

"Oh," I said. I wasn't really surprised. I think I remember Ginny telling me the same thing. "They should be together. Can you get him for me?"

I don't understand death, but I understand Ginny. Grief makes you a little crazy. Ginny understood me, too. Like many of my patients, she saw my belly get round up to 32 weeks, and then she saw me shrunken back to a shell of myself, breasts bursting with milk for a mouth that would never suck.  Once they were safely born, she always asked about my living boys. 

It was her way of opening.

There's a poem that says it best,

The heart opens and knows it won't last and will have to open again and again . . .                         Susan Browne, Buddha's Dogs

Being a doctor is this, bringing what we know and what we do not – opening, integrating, bringing our whole selves to our work. I know what to do with ashes. Ginny and Jacob will be together.

 

 

 

 

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Shelley's son Rainier Aiden Sanders was stillborn on October 7, 2008. His ashes are on the mountain. Ginny's cat Stravinsky has a new home with a friend of Shelley's. 

 

Shelley Sanders grew up in a deeply religious community that considered the human body sacred. On Friday nights before the days of HIPAA her father would share stories of his patients, and Shelley knew she wanted to be a doctor. After completing a Master of Theological Studies at Vanderbilt University, she pursued medicine and quality improvement whole-heartedly. She is currently working on sepsis, the Modified Early Warning System, and an Accountable Care Unit using skills learned at a fellowship with the Innovation Advisors Program through the Centers for Medicare and Medicaid Innovation.