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Death Class

ONE

The Professor

When it came to death, Norma Bowe had the fearlessness of a swift-water rescue team; when everyone else wanted to get away from the force of the current, she went charging straight into it instead. Not many threats in this world seemed to rattle her: not guns, murderers, or the criminally insane, and certainly not death. With cheeks that swelled when she smiled as if she’d stuck a Tootsie Pop beneath each one and a high-pitched reverberating laugh, she made you feel as though, if you could only hold on to her hands long enough, you might just be the one person lucky enough to escape.

There was an air of invincibility surrounding her, a feeling so magnetic that long after class had been dismissed students found themselves wanting to hang out with “Dr. Bowe,” which was what they called her, despite her insistence that they call her Norma. They lingered in her office for hours, even when she wasn’t there. When she actually did get sick or injured, some of them reacted with stunned disbelief, as if they didn’t think a woman like that could be mortal. But she knew there was an art to surviving. That is what she wanted her students to learn.

Norma had a fondness for cemeteries and could spend hours perusing inscriptions on tombstones or kicking back on a freshly mowed patch of grass next to the grave of a stranger. If she had enough free time, which was rare, she might even bring along one of her favorite Jodi Picoult novels to read. When traveling to a new city, Norma did not think it at all odd to pay a visit to the local graveyard, snapping photos as if it were a regular tourist destination. She believed cemeteries held the stories that history books could not always document; they were the overlooked, underused classrooms beneath our feet, so it made sense to her to teach a lesson inside one every once in a while.

The Rosedale & Rosehill Cemetery in Linden, New Jersey, where her students convened one summer night, was bordered by an auto-stripping business, a school-bus yard, a truck repair shop, a warehouse, and a headstone company, Payless Monuments. As dusk fell, students parked their cars in a line as if part of a funeral procession along a quiet road that meandered through the cemetery. The memorial grounds would have been mostly empty without her class, except for the squirrels, crickets, and crows. Norma planned to give a lecture here on the biology of dying, and she had warned the students beforehand that it would be important to take notes; questions about it could end up on the final exam.

“Hi, everyone,” she said, waving with a wide smile as she pulled up late to the cemetery in her silver Mazda minivan full of students. Norma and her students jokingly referred to it as the “party bus,” because the van spent its days shuttling students on field trips to prisons, funeral homes, hospice care centers, mental hospitals, and morgues. Its bumper sticker read AMERICA NEEDS A WOMAN PRESIDENT, and its floors and seats were littered with pink highlighters, an unopened Doritos bag, a dozen stuffed purple bunnies, a Celtic Thunder CD, the sound track of Hairspray, and clusters of straws sealed in paper wrapping.

She emerged like a fairy godmother before her students, hopping out of the van and hurrying into the graveyard with all eyes on her, walking with a side-to-side wag, a slight stoop of the shoulders, her feet nudged outward like a pair of wings.

“Nothing like a good cemetery, right?” she asked, rounding everyone up.

She had long brassy hair that she usually wore down, like today, or in a high ponytail when it frizzed in humidity. Her eyes changed colors in the light, like speckled brown jade, and her skin was flushed in the face, more suntanned on the arms and chest with a spattering of freckles. Her underactive thyroid made it easy for her to gain weight and hard to lose it, and she barely ate with her nonstop schedule, subsisting on unsweetened iced Dunkin Donuts’ lattes. She was pear-shaped and pretty, with a sturdy frame that locked her soft edges into place. During non–work days, she dressed folksy: long, flowing skirts, walker’s sandals, turquoise and silver jewelry, and trinkets the color of bones. At work, she sometimes dressed as if she might be called to attend a funeral at any moment, which happened occasionally: black skirts, black dresses, black stockings, black heels. For color, she’d add a bright scarf.

Today she wore black billowy pants and a black cardigan over a pink blouse, with scarlet lipstick and a green gemstone bracelet. Her heavy key chain jangled as she walked, containing more keys than any one person could possibly need, along with membership cards for places such as Petco Pals, Borders, Brooks Memorial Library in Brattleboro, Vermont, and Curves health club for women.

“Guess what?” she said in her singsong voice, which always seemed as though it were stuck in falsetto. “There’s a crematory across the street.” That was where they burned bodies, she explained to the students, suggesting that maybe they could stop by and check it out later.

The professor led everyone on a tour of the grounds, straightening roses on graves and standing tipped-over fences and flags upright. Dandelions and white clover pushed through the ground as Norma took moments of silence to pay tribute to the bodies beneath.

The cemetery was divided into neighborhoods, mirroring a typical big city: Chinese, Spanish, Ukrainian, Polish, Russian, Greek.

If the Chinese section had been a real neighborhood, it probably would have boasted the highest property values. Its tall arched pillars bore the name Greater Chinatown Community Assn. Rows of polished pink or shiny gray headstone blocks, some as big as refrigerators, stretched into the horizon. Engraved into the facades were intricate bamboo designs and horizontal Chinese characters, but English lettering could also be found on some, names such as Low, Lam, Lau, Chung, Wong, Kong. Small red rocks balanced atop some headstones, as if placed there as offerings.

Norma parked herself here, sitting cross-legged in front of a thirty-six-ton granite sculpture of a 1982 diesel Mercedes-Benz 2400 with a license plate reading RAY TSE. Rising from a low stone slab behind a Roman-style pillared mausoleum, the memorial had been built to look like an entombed car, right down to the headlights, windshield wipers, door handles, and Mercedes logos on the trunk, nose, and rims—except for a missing hood ornament, left off because it would have been too easy to break off and pocket.

Students rubbed their fingers along the smooth granite. As the story went, fifteen-year-old Raymond Tse, Jr., had wanted his own Mercedes, but he had died in a car accident in 1981 before ever having a chance to earn his driver’s license. His millionaire older brother, the landlord and businessman Raymond David Tse, paid for the tribute, estimated at $250,000.

“When I think about what the body does when we die, it’s not like there’s a point where everything shuts down,” Norma noted. “It doesn’t happen all at once.”

She made clear that she was speaking of natural deaths from disease and physical ailments, not sudden deaths from murders or car accidents. In violent deaths, bodies don’t have time to make those little adjustments for our comfort. “It’s wild how the body works,” she went on. “Our bodies take care of us our entire lifetime, take care of us when we’re sick, when we’re ill. At the very end it does that too.”

“The first thing that happens is, the circulatory system begins to shift the blood supply to all of the major organs,” Norma said. “We’re very hardwired to survive, so the brain gets the message; rather than the heart pumping blood all the way to the tips of the toes and back up again, it really just starts to pool to the major organs, heart, lungs, brain, digestive system, kidneys, liver. So a lot of times people will begin to complain of feeling cold. They will ask for a blanket, even if it’s a hundred degrees in August.”

That meant death is near, she explained, three weeks away, maybe two. The body temperature can drop a degree or more. Hands and feet take on the frigid feel of refrigerated poultry. Arms and legs begin to look pasty, draped over bones like pie dough, sometimes gray or violet, blotchy, like a web of bruises. Nail beds turn blue; the lines around the mouth, blue too. Blood vessels protrude near the surface of the skin, like varicose veins. The blood lacks oxygen and is no longer cherry red, as healthy blood should be. Instead, it turns a deep, black merlot, so dark it appears blue beneath the skin. This, Norma explained, is called “cyanosis.”

Another sign of impending death: fading eyesight. A dying person might want brighter lighting, the curtains open. While sight is among the first senses to go, she said, hearing is last. You must not assume that a dying person doesn’t know what is going on around him or her, she explained, but carry on as if he or she can hear everything. You can read the newspaper to him or her, leaning close to his or her ears as you speak.

A week or so before death, the blood shifts again, this time away from the digestive system and to the kidneys, heart, lungs, and liver. “That makes it so people stop feeling hungry,” she said. “They don’t want to eat any more.” Favorite meals do not spark the same glimmer of delight. They won’t complain of hunger or thirst, even in the absence of intravenous feeding tubes. The body won’t miss the satisfaction of an overstuffed belly, won’t crave what it no longer needs. If you hold a stethoscope to the abdomen, Norma said, listen for bowel sounds: the contracting movement of muscles pushing food down the digestive tract—or peristalsis—has slowed, maybe even stopped. “So what do we do?” she said. We who love them want to feed them anyway. “We tell them, ‘You’ll like it, it’s good,’ ” she said. They might become bloated, nauseous, constipated, or begin vomiting. “We force-feed people,” she said. “It makes us feel better, folks, it doesn’t make them feel better.”

When the liver has begun to shut down, usually a few days before death, a person might become more agitated, shifting around in bed, and the whites of the eyes turn yellow. “It might look like they’re in agony,” Norma explained. Toxic waste has been building up in their bodies because the liver has stopped filtering it as it used to.

The breathing becomes rapid and shallow, up to fifty breaths per minute, mostly through an open, drooling mouth. The respiratory rate slows, the heart beats staccato. Death may be just hours away now. At times it might seem as if there is little attempt to breathe at all, a pause of ten seconds, as when a sleeping person snores deeply, then does not inhale for a few seconds, before letting out a long, rapid whoosh of air. “Those periods of apnea will get longer and longer,” Norma said. This phase might be accompanied by short heaving gasps or barking: the “agonal phase.”

Saliva, unable to be swallowed, builds up deep in the back of the throat, too deep for nurses to suction it out, causing a congested, purring sound—the “death rattle.”

This is known as Cheyne-Stokes respiration, named after John Cheyne and William Stokes, two physicians who first described and documented the breathing pattern in the nineteenth century. “Air comes into the mouth, and it just goes about as far as the trachea, that’s it,” Norma said. “Breathing is more rapid. Cheyne-Stokes breathing, when it starts, you have just a few hours, maybe twenty-four hours.”

“It is like asthma?” a student asked.

“No,” she replied. “With asthma, bronchioles are constricted, you can hear wheezing and people struggling to breathe.” Cheyne-Stokes breathing, she said, “is very peaceful. It’s just a little bit of air being exchanged.”

Euphoria sets in. The body takes care of the dying mind. The mind takes care of the dying body. “You know that great feeling, when you first meet somebody you’re really attracted to, when you fall in love? We’ve all had that feeling,” Norma said. It’s caused by seratonin, dopamine, and norepinephrine. “Those chemicals will continue to increase, and they are at peak in the moment when you die.”

The neurotransmitters that carry nerve impulses between cells, causing feelings of joy or euphoria, counter pain, even as the blood pressure continues to plummet, the skin turns a dull grayish hue, and the capillaries in the nose thicken. “Imagine, your dying brain gets flooded with this stuff,” Norma went on.

Little by little, the pulse rate and blood pressure go up and within an hour start to drastically drop. “Your heart rate will continue to drop until your heart stops.”

“Your breathing will stop first,” Norma said. “The heartbeat will stop last.”

The time of death will be recorded once the heart has stilled, she said. If you examine the pupils, they will look dilated and dull, vacant.

“The appearance of a newly lifeless face cannot be mistaken for unconsciousness,” wrote Sherwin B. Nuland in How We Die: Reflections on Life’s Final Chapter. “Within a minute after the heart stops beating the face begins to take on the unmistakable gray-white pallor of death; in an uncanny way, the features very soon appear corpselike, even to those who have never before seen a dead body. A man’s corpse looks as though his essence has left him and it has.”

The body temperature cools by one degree per hour. Livor mortis, a red marbling of the skin, sets in. Within twenty-four hours, rigor mortis, a stiffening of tissues, ensues, beginning with the face and moving down through the corpse. Then, as though thawing, the body again goes limp. Norma had seen all of this happen hundreds of times while working as a nurse, in places such as the neurology intensive care unit. But, she added, “there’s a lot we can’t explain. We just don’t know everything that happens when people die.”

TO EMPHASIZE THAT point, she followed her biology of dying lecture with a story from when she had been a young nurse on hospital rounds. As she explained to her students, patients often awoke from very bad illnesses or cardiac arrests, talking about how they had been floating over their bodies. “Mm-hmmm,” Norma would reply, sometimes thinking, Yeah, yeah, I know, you were on the ceiling.

Such stories were recounted so frequently that they hardly jolted medical personnel. Norma at the time had mostly chalked it up to some kind of drug reaction or brain malfunction, something like that.

“No, really,” said a woman who’d recently come out of a coma. “I can prove it.”

The woman had been in a car accident and been pronounced dead on arrival when she was brought into the emergency room. Medical students and interns had begun working on her and managed to get her heartbeat going, but then she had coded again. They’d kept on trying, jump-starting her heart again, this time stabilizing it. She’d remained in a coma for months, unresponsive.

Then one day she awoke, talking about the brilliant light and how she remembered floating over her body. Norma thought she could have been dreaming about all kinds of things in those months when she was unconscious.

But the woman told them she had obsessive-compulsive disorder and had a habit of memorizing numbers. While she was floating above her body, she had read the serial number on top of the respirator machine. And she remembered it. Norma looked at the machine. It was big and clunky, and this one stood about seven feet high. There was no way to see on top of the machine without a stepladder.

“Okay, what’s the number?” Another nurse took out a piece of paper to jot it down. The woman rattled off twelve digits.

A few days later, the nurses called maintenance to take the ventilator machine out of the room. The woman had recovered so well, she no longer needed it. When the worker arrived, the nurses asked if he wouldn’t mind climbing to the top to see if there was a serial number up there. He gave them a puzzled look and grabbed his ladder. When he made it up there, he told them that indeed there was a serial number.

The nurses looked at each other. Could he read it to them? Norma watched him brush off a layer of dust to get a better look. He read the number. It was twelve digits long: the exact number that the woman had recited.

The professor would later come to find out that her patient’s story was not unique. One of Norma’s colleagues at the University of Virginia Medical Center at the time, Dr. Raymond Moody, had published a book in 1975 called Life After Life, for which he had conducted the first large-scale study of people who had been declared clinically dead and been revived, interviewing 150 people from across the country. Some had been gone for as long as twenty minutes with no brain waves or pulse.

In her lectures, Norma sometimes shared pieces of his research with her own students. Since Moody had begun looking into the near-death experiences, researchers from around the world had collected data on thousands and thousands of people who had gone through them—children, the blind, and people of all belief systems and cultures—publishing the findings in medical and research journals and books. Still, no one has been able to definitively account for the common experience all of Moody’s interviewees described.

The inevitable question always followed: Is there life after death?

Everyone had to answer that question based on his or her own beliefs, the professor said. For some of her students, that absence of scientific evidence of an afterlife did little to change their feelings about their faith. For others, it put that much more pressure on this life.

In the cemetery that evening, the sky had turned the color of slate. Some of the students were sitting on a curb listening to the lecture with outstretched legs, their feet clad in flip-flops and sneakers. Others leaned against cars. One young man wore his fraternity letters. A couple of young ladies were dressed in business attire: white collared shirts, slacks, and high heels. No one could have known it that day, but a year from now one of those students—the short-haired woman in glasses, holding her spiral notebook, with a beige cardigan over her Kean University T-shirt—would be dead herself, a victim of a house fire that started after she had fallen asleep without putting out her cigarette.

Norma dismissed her students. They climbed into cars and SUVs, filing out minutes before total darkness fell.

MOST PEOPLE SAY they do not fear death or barely think about it at all, according to Gallup polls. But Ernest Becker, a cultural anthropologist who won a Pulitzer Prize for his book The Denial of Death, argued that we’re kidding ourselves; fear of death makes us want to engage in activities that render us unique, allowing us to reach a level of putative immortality. Death anxiety, Becker believes, is the powerful undercurrent stirring human behavior.

“What does it mean to be a self-conscious animal?” he wrote. “The idea is ludicrous, if it is not monstrous. It means to know that one is food for worms. This is the terror: to have emerged from nothing, to have a name, consciousness of self, deep inner feelings, an excruciating inner yearning for life and self-expression and with all this yet to die. It seems like a hoax, which is why one type of cultural man rebels openly against the idea of God. What kind of deity would create such a complex and fancy worm food?”

But if death is terrifying to most people, Norma knew that her job was to impart the more useful lesson about it: how to live a good life while always under the sharp tip of mortality. The narratives behind the bodies on the autopsy field trips to coroners’ offices on which she took her students told those truths. Like the seventy-three-year-old splayed on a metal table one morning, his face peeled from his skull, his forehead folded in a flap over his chin. The medical examiner’s report noted that he had hung himself in his garage. His wife had recently died, and it seemed that he could not bear to live on without her.

Displays of life’s daily horrors, usually hidden from the public’s view, ended up naked and spliced open by blue-gloved technicians, right before her students’ eyes. There was the married thirty-year-old father of three, his mouth open, his arms rigid and cocked. He had been shot in the head. Someone had found him at 9:41 the night before; his belongings had ended up spread across a white sheet on the medical examiner’s floor: a tangerine-and-red flame-colored T-shirt and sneakers that matched, a blood-soaked white undershirt, four packs of Newport cigarettes, a few dozen MetroCards for the New York City subway, $211 in cash.

And there was the boy who must have been about twelve. He had apparently hung himself in a basement with a dog leash. Norma just could not let that one go. After watching his autopsy on one field trip, she hunted down the information as to where the child’s funeral was being held and decided to attend.

There was no denying it: life’s edges brimmed with misery and cruelty. No wonder people often concluded that the dead were better off. In our youth, we looked forward to our futures, like “children in a theatre before the curtain is raised, sitting there in high spirits and eagerly waiting for the play to begin,” the nineteenth-century German philosopher Arthur Schopenhauer once wrote. “It is a blessing that we do not know what is really going to happen. Could we foresee it, there are times when children might seem like innocent prisoners, condemned, not to death, but to life, and as yet all unconscious of what their sentence means.”

By the time many of Norma’s students came to her, they were already exhausted and confused about life and looking to find out how not to carry it out like a sentence.

In 1985, two researchers from the University of Louisiana at Lafayette embarked on what would become a twenty-year study to solve this question: what kind of students take death education courses in college, and why?

Sarah Brabant and Deann Kalich surveyed more than nine hundred students enrolled in Brabant’s Sociology of Death and Dying course and found that nearly 24 percent wanted to deal with their own grief issues; but, most startlingly, close to half of the students surveyed had “seriously contemplated committing suicide at some time in their lives.” Even more distressing, 10 percent of the students said they had actually tried to kill themselves at one point.

Norma saw all of this in sentences sprinkled through her students’ essays. Like this one from a student who had been homeless: “I used to pray every day until one day I lost hope and it felt like it was pointless.” Or this one: “After I was raped I wanted to curl up in a ball and die.”

The professor referred students to the college counseling center on a regular basis. They called her in the middle of the night, in the early morning, during class, during lunch; they sent urgent text messages, knocked on her office door in tears, broke down sobbing with her in hallways. She kept a school mental health counselor’s phone number in her cell phone. But some students simply threw it away when Norma jotted it down for them. They didn’t want to talk to a stranger. They only wanted to talk to her.

So Norma’s message was that happiness takes hard work. It should be approached like a series of homework assignments. She kept a small book in her office, A Short Guide to a Happy Life by Anna Quindlen, which she often quoted to students from memory. This was one of her favorite lines: “Life is made up of moments, small pieces of glittering mica in a long stretch of gray cement.” Quindlen went on, “We have to teach ourselves how to make room for them, to love them, and to live, really live.”

Living a long life didn’t come with any promises that it would be a happy one either. Norma learned this lesson on her own when she was a twenty-something nurse in Virginia. On home visiting duty, she met a 110-year-old woman living alone in a trailer in the woods. Mary Manly was her name. Her only son had died in his eighties, and all she had left was a little black mutt with a gray chin that seemed as old as his owner, hobbling around on his little legs. Mary had a wound on her leg, and Norma stopped by to tend to it every few days.

One day, she treated the wound with a wet-to-dry sterile dressing, chatting with Mary. As she was leaving the trailer, Norma looked back over her shoulder. Through a window, she watched Mary grab a bag of cornmeal, rip off the dressing, and stuff the ground dried maize into her wound.

Norma went back later and confronted her. “Look, Mary, I saw the cornmeal. What was that about?”

Mary looked at her. “I don’t like the feel of the wetness!” she snapped. “I want it to be dry.”

“Okay, but you can tell me that,” she said. “Cornmeal is going to make it stay like a wound. It’s not going to heal.”

Mary turned quiet, looking embarrassed.

In that moment, Norma realized that Mary did not want the wound to heal. She had no family left, no friends, and no other visitors to speak of. She must have looked forward to the dressings. It was the only time she had face-to-face conversation in days.

Norma called up the local church to tell them about the 110-year-old woman in a trailer, suggesting that maybe they could bring her a pie once in a while. She also continued to visit Mary regularly, even if not summoned.

Still today, on a wall in her office, she kept a black-and-white framed photo of her younger self, kneeling next to Mary. From her patient, Norma had learned that the deepest wounds can never be healed with ointment and gauze. It was a lesson more valuable than anything found in a textbook or dissertation.

She always held on to that tenderness she had for the elderly like Mary, those forgotten and overlooked. It was the same kind she felt for forlorn strangers, her students, and her own children. They needed her. And she didn’t mind being needed.

So when it came to defining her Death in Perspective class, the professor developed the habit of handing out a poem by Khalil Gibran called “On Death” at the end of every semester. Part of it went like this:

Then Almitra spoke, saying, “We would ask now of Death.”

And he said: You would know the secret of death.

But how shall you find it unless you seek it in the heart of life?