My father’s funeral was typically middle-class. Only entering a church for the traditional hatch, match and his own dispatch, he had given me no indication of the type of ceremony he wished for (not surprising since he rarely bothered to speak to me in any meaningful way if the truth be known) and being told that his death was impending made him no less taciturn with his children. When that moment came, I dutifully held his hand, checked his pulse and felt it flutter against the pad of my finger like a trapped butterfly then ebb away. He spoke little of his sudden shock diagnosis of cancer and I did not dare ask because I knew he was not interested in having that conversation with his children. I have seen many many patients die and had conversations about death with many more but with my own father I was trapped behind a wall and his second wife did little to help us break it down.
I assume that he spoke about his wishes with somebody though. His second wife made the arrangements- sturdy mahogany coffin and high church, close family walking to the church through the village, me in stockinged feet holding my Louboutins which were too high to walk so far (I did wonder whether the scarlet soles were a bit Mary Magdalene) then hymns, a poem, readings. I gave the eulogy with one sibling at my side and felt her tremble with anxiety against me as we stood closely together in the pulpit. The temptation to knock the microphone and mutter ‘testing testing’ or some other grossly inappropriate soundcheck rose up in a bubble of hysteria as I looked out on rows of relatives and friends that I rarely saw. Agreeing to speak publicly was a handy trick that enabled me to keep my composure as I focused solely on delivering a ‘good’ speech and not on the body in the coffin to my left with its tasteful floral arrangement.
I seem to make a habit of writing and reading eulogies as concentrating upon tasks like these is an extremely efficient way of putting complicated grief on the back burner. I did the same for my grandfather (whose death truly did break me) although I had to bite back prickles of irritation at the many comments along the lines of:
“Oh you are so brave, I couldn’t do it- I am far too upset to give a reading”
Yes because your grief registers more profoundly than mine on the International Scale of Mourning and clearly, I, saying goodbye to a grandfather I absolutely adored, must be less upset because I can still speak. Delivering his eulogy helped stem the humongous tidal wave of grief and rage and pain that lay under the surface. A grief so messy and unseemly that Juliet Stevenson’s snotfest in the film ‘Truly, Madly, Deeply’ would have paled in comparison.
Going back to my father, the family sought refuge in the classic default Church of England funeral. Flowers arranged by the women of the village and the drama of ‘For I am the resurrection and the life’ which I defy even atheists to stand unshivering in the face of; the starched surplices and professional sympathy written on the faces of vergers, undertakers, choir and vicar. Then afterwards a slightly bizarre drive to the crematorium at Colchester to listen to CD recordings of ‘Don’t Cry for Me Argentina’ sung by Julie Covington (beats Elaine Paige hands down) and ‘Old Man River’ by Paul Robeson- a song sung to us in our early childhood by a father considerably less dour. We all jostled to be the one to NOT sit up front next to the driver although actually, in retrospect, it was the best place to be. Then the curtains went down on his life and his coffin went down the slipway so to speak and we all drove back to the golf club for that most peculiar event- tea and cakes and polite conversation and nobody, not one person, mentioned death. A few weeks later his wife was in a relationship with somebody else, my fathers prized engineering blueprints- the one thing this fairly unsentimental man had gone to the trouble of keeping- went into the bin along with most of his other possessions such as our childhood photographs (we weren’t asked if we wanted them) and our family shattered into pieces.
Some mourners want a celebration of a life and others plan something more profoundly sober and sad: mourners in bright colours and Monty Python songs or deepest black, hats and wrenching sobs emanating from bowed heads. There are people who want to obscure the earthier side of human life and death and want to hide behind euphemism. Gone to sleep. Passed away. Eternal rest- and there are others who prefer the naked truth. “He is dead”, “She has died”, the bluntness of those words slamming against them, assaulting them with the reality of loss. I am a slammer.
Most of us try to personalise funerals and memorial services not just because of the love or respect we feel for the deceased but because we all need to feel that we counted in the life of the deceased, that our lives made their mark upon this world and, in doing so, we are reassured that when our time comes, others will do the same for us. We are engaging more and more with death and we have ideas about what a ‘good’ death is like but where are we really in all this?
Looking back to the Early Modern Period of the 16th and 17th centuries, there developed a fixation with the idea that one had to end ones life in a state of grace and the last moments of life took on great significance because the fate of the soul hung in the balance.The threat of punishment as a sinner threatened to befoul the hope of a blissful eternity and by the start of the 16th century, Europe was deeply afflicted by death anxiety with any joy at the thought of imminent transformation from the earthly chains to eternal paradise giving way to fear, anxiety and doubt.
The Ars Moriendi (“art of dying”) movement advised people to prepare themselves for death at every stage of their lives and to teach children to focus on their own deathbed scene rather than develop too great an attachment to the folies and temptations of earthly existence. The good death was redemption and grace, a tying up of loose ends and unfinished business, and a moment of teaching and example to all: everything else was of little consequence. The dying were important role models and a great deal of commemorative portraiture was commissioned to depict this.
The onus was placed upon the dying to have a ‘good death’ as opposed to those witnessing it being under a compunction to provide this good death: it was not predicated upon the relief of pain or symptoms or anxieties: indeed these things and the way the dying person bore them all counted towards the way their approach to their death was judged. Suffering was to be borne and used as a Christian aid to the teaching of others and this included the way the dying person appeared to manage the pain of the impending loss of their own life.
Nowadays, a good death is very much the responsibility of those caring for the dying and is predicated upon the relief of mortal suffering and the addressing of their psychological needs. The rise of the physician in the late 17th century was the start of this process, made complete today by our modern hospice movement and the many organisations that work with the dying. Yet we are still, as a western Christian society, profoundly ambivalent about death and keen to keep it in its place.
In his book, A Brief History of Death, W M Spellman writes: “The dying are often kept tidily out of sight. It is not impossible to go through life without ever encountering a dead body outside of a funeral parlour.” Less than a hundred years ago it was the norm to die at home, to be visited by your general practitioner if his or her services were needed and for family, neighbours and friends to not only care for the dying person but to also offer comfort and sustenance to their family. Death was a public and shared event. Families would perform ‘Last Offices’- the care of the person immediately after death or they would use the services of a local ‘layer out’. They would wash and dress them, ensure that their eyes were closed, limbs straightened and prepare them for burial. The body would remain at home until the funeral and the family might eat, sleep and go about their daily business with the coffin in the same room. I have seen photos of families eating their evening meal, plates set around the table edge, coffin containing Mum down the middle. Sweetly scented flowers would be left in the room to help disguise any odours and here we see the origins of the funeral wreath.
Despite it being an ancient art and technique, bodies were not embalmed in the UK until circa 1900 as a result of a visit to London by American professors who gave the cities funeral directors instruction in preservation techniques. Initially these embalments were also performed in the home. As hospital deaths increased (in part because of the inception of the NHS) and chapels of rest in hospitals were created in the 1950s, bodies started to be transported to them to await the funeral and funeral directors began to develop services that combined pomp with discretion, moving the practicalities of death behind closed doors. The funeral business made itself indispensable and with death the only thing certain in life, it is a lucrative trade as a writer says in Leisure Hour back in 1862: “In numberless instances the interment of the dead is in the hands of miscreants, whom it is almost flattery to compare to the vulture, or the foulest carrion bird. . . the morality is, in their hands, to use a plain word, robbery.” Ironically, as social and cultural status became increasingly codified through the money and time spent on funerals and elaborate periods of mourning (indulged in by those with more money and time to do so) they began to be seen as evidence of finer feelings, of the superior sensitivity of the better bred. The inablility of the working classes to adhere to these rituals was seen, by some, as proof of their lack of respectability and general emotional and moral shallowness.
Some would say that these homely arrangements displayed a healthier less hushed attitude towards death, irrespective of the financial constraints that might render a ‘home made’ funeral a necessity. With wealth comes the ability to remove oneself from the nitty gritty of life and we start to pay other people to perform the roles that we once filled ourselves. The Victorians excelled at this and loved an ostentatious funeral, with their hairwoven souvenirs, millinery, dresses, cloaks, shawls, mantles (even servants were expected to wear mourning). They commissioned staged photographs of the dead, had jet mourning jewellery designed, used black sealing wax on black bordered stationery and town planners constructed lavish gothic necropolei- cities of the dead- (Highgate is an example) filled with towering angels smiting death with flaming swords and marble sarcophagi and by the middle of the 19th century, funerals had become so fiscally lucrative that Mr Punch felt obliged to comment, pithily observing that “there must be different qualities of grief…according to the price you pay. For £2.10s the regard is very small. For £5 the sighs are deep and audible. For £7.10s the woe is profound, only properly controlled; but for £10 the despair bursts through all restraint, and the mourners water the ground, no doubt, with their tears.”
Royal deaths also acted (and continue to act) as important forms of ritualised, symbolic and fashionable commemoration and they have helped shape our cultural responses to death and mourning. The death of monarchs such as Elizabeth the first and James the First saw elaborate ceremonies designed as ‘theatres of death’ which asserted status, prestige and influence. The other important role of the royal funeral was its stabilising function at a time when the death of a monarch could exert a significant level of maleficence upon the political and social order. The roots of the public reaction to the death of Princess Diana in 1997 and her memorialising can be traced back to the death of Prince Albert, husband consort to Queen Victoria, and although his funeral was private, it was accompanied by florid and collective public grieving. Victoria appeared to encourage this, benefiting from the image makeover her husband went through post death, from interfering foreigner to idealised husband and father. Her adoption of mourning as a way of life elevated the status of widowhood and set a precedent for the British public to interpret the life and death of the royals through the lens of their own experiences; the life of the royals started to lose its rarified air.
The relationship between public and royals developed totemic features and this reached its peak in the weeks after the death of Diana which saw the public question the old order and elevate her to status of quasi saint or spiritual leader. Diana in death became the loci of collective and personal pain, a conduit for all that ailed the British public and the governmental and royal decisions that were made immediately following her death became the loci for furious public criticism regarding protocol and even the continued existence of the royal family. Although the public like to see their own lives and emotions reflected in its royals, at that time it refused to allow the queen the same privileges it would have expected itself in the wake of loss and critcised the royals for choosing to remain in seclusion at Balmoral, comforting two children who had lost their mother. The public trantrum that followed resulted in the young boys being made to examine floral tributes outside Kensington Palace whilst the lens of thousands of press photographers clattered. The boys then had to endure a walkabout where they met the many ‘grieving’ people desperate to have their own feelings acknowledged and validated whatever the emotional cost to those two boys. It was the British public at its most self indulgent, selfish and self righteous. A similar phenomena occured after the deaths of Queen Caroline in 1821 and Princess Charlotte in 1817 in part because of public antagonism towards the Tory government and in part because of hostility to the Prince Regent who succeeded as George IV in 1820.
Nowadays, to care for dying people at home is not necessarily the default choice or setting for many families and arranging the help needed takes time, and sometimes, sharp elbows. Many families who do achieve this do not always carry out the personal care that is required after their loved ones has died, whether that is because they just do not want to or because the practical care of the dead has become so unfamiliar that they simply do not know what to do. I performed Last Offices on my own grandfather because I had shared his care with a sister, taking it in turn to watch over him, help him eat and drink, read the newspaper and fill in crosswords. I knew he was deteriorating from the brain tumour that would eventually go on to kill him, when, glancing at his half finished crossword, I saw he had filled in the little boxes with gibberish. A series of hieroglyphics and half spelled words were testimony to the malignant chaos in his brain as the tumour spread like a web. After he died, I washed him, dressed him in clean pyjamas, called the doctor and undertakers. Yes it felt like the honour and privilege my old nursing tutor talked about during the early days of my training but choosing to remain in the room when the undertakers came unmanned (or should it be un-womaned?) me. Seeing them tighten black leather straps around his body before his face disappeared beneath the zip of the body bag was too much reality for me. I was haunted by this for months and I do not recommend it. I knew it was coming, had seen it happen many times with patients and knew undertakers to be gentle and respectful but it was a mistake to remain in the room.
A lot of health and social care professionals may know less about death than they should. As a student of mental health nursing I attended the standard last offices lecture and practical class in the first three months of my training along with the adult nursing and midwifery students. I recall the nurse lecturer telling us that it “is an honour and a privilege to care for the dying” but the lecture concentrated mostly upon the clinical signs and care needs- the changes in circulation, the need for pressure area prevention, end of life care pathways and protocols, Last Offices, paperwork. There was no mention about caring for relatives or caring for ourselves, the latter gained a slight reference to ‘cry in the sluice room please’, but that was the only acknowledgement of the emotions of staff; that we might feel bereft too.
Death is a process as opposed to a single, definitive event but the training we received was scanty with no mention of cultural practices in death and dying, no mention of feelings, of how to talk to the dying about death or education about how it used to be approached and what might have changed. the hospice movement went unmentioned. There was no guidance or discussion surrounding our own philosophies, no attempts to help us manage the swirl of thoughts and questions in our heads and indeed, the findings in a recent poll by the Royal College of Nursing echo this- nurses do not feel comfortable broaching the subject of death and lack private spaces in which to speak to patients or relatives. A quarter feel they lack the right training and only 19% stated they could discuss care with patients. Quoted in The Times, Peter Carter, the chief executive says: “The nation and the health service needs to be better at acknowledging the importance of a good dying process” and many nurses are “profoundly troubled” by their experiences of trying to deliver care for the dying.
The role of nurses (and other health professionals) is to prioritise a ‘good death’, whereby relatives and patients define what this might be- which has the added advantage of helping ease relatives into their mourning. Our actions will go on to form a large part of a relatives’ memories and ensure they feel that not only did you care for their loved one, you cared about them too. How you behave as a health professional towards their dying loved one will be a memory that stays with them for life- we need to make it a good and emotionally healthy one.
Writing this, my mind goes back several decades and remembers a dimly lit hospital side room and a very old woman in a bed on her side: sheets pulled up to her ears, silver hair in a plait. I watched from the doorway as two male nurses moved around the room, trying to dim the light further to avoid the glare from the utilitarian metal lamp angled over the bed. They were measured, slow and light on their feet; only the barest of squeaks from rubber soled shoes and moved around each other deftly. The woman had two different disease processes, both moving her swiftly towards her death. She had been in great pain upon admission and was unable to comprehend what was happening, but was now calm and pain free. She could not tell us this but her smooth brow, relaxed hands, warm skin and stilled feet bore witness to the fact. Her breathing was slow but unlaboured. Her lips had been dry and cracked but now glistened with an application of lip balm and one of the nurses had sprayed a little lavender onto her pillow because he noticed the scent of it clinging to the clothing that had been hastily packed into her her bag. He wondered if maybe she might be comforted by it. I watched this tableaux. I learned. I saw how the institutional setting can be mitigated and how it can be soothing and comforting even when it is unfamiliar. I listened as the nurses explained what they did and why they did it. I saw how they watched and waited alongside her as death approached and did not leave her alone.
Even those of us who describe ourselves as agnostic or atheist (and I move between the two) are tempted to cling to or blindly follow the religious and cultural practices we were steeped in as children, when our minds are halved by grief. A cultural teabag, I soaked up the traditions of the church I was baptised in as a child and although I didn’t turn to the God or any God when family members or patients died, I still found myself opening the window to ‘let their spirits out’ a few seconds after death and, when my grandfather died, I stumbled out into the garden at 5 a.m, faced turned to the sky to ask “Where are you? Where did you just go?” It felt as if I was playing a game of chase with someone who had vanished into thin air, as if a rent had opened up in time and he had slipped through it, silently.
I could not and can not get my head around the disappearance of a persons life force, even though death is rarely a dramatic sudden event and rarely resembles the deaths we see acted on screen. There is usually a slow turning inwards: the blood is diverted from the limbs to the central organs and brain; legs and arms grow colder and faces become pinched and then there is the psychological drawing in. The dying person may look back on their life or start to detach from their relationships- is this so that the process of dying, of leaving all that you love behind, becomes easier emotionally? These are the aspects of dying that warrant open conversations in order to help ease someones passing.
In Before I Say Goodbye, a collection of newspaper columns by Ruth Picardie about the cancer that killed her at such a young age, her sister Justine and husband Matt finish off the last chapter because Ruth has by then died. They describe a bedtime story in a bedroom lit by lamplight and of Ruth sitting with one of her twins on her lap, listening. Suddenly her daughter climbs off her lap and goes to sit with her father. In the dimness Ruth appears half removed from life, both separate and separating herself from the living and it is possible, her husband believes, that the child has sensed this and instinctively gravitated towards the stronger life force of her father. It is a moving scene- one I have recognised over and over again in my patients and dying relatives. How do you find solace at times like this? How do you help a wife or husband grieving for the loss of their own life, the loss of watching their children grow up? I cannot frame this in the context of an afterlife, of a benevolent spirit looking down on me and this feels a totally inadequate substitute for the flesh and blood person anyway; a consolation prize that nobody wants.
For us unbelievers we have to find that solace in more creative ways. There is no comfort of eternal life, of rebirth or meetings with God and angels. We will not send feathers to our loved ones back on earth nor even lurk as benevolent ghosts in the hallway or garden or heaven forbid, the bedroom- (surely you can only believe in ghosts if you believe in an afterlife?) I am appalled at the idea of any spirit looking down on me by the way. It sounds spooky in the fullest sense of the word. Going to and arranging a funeral and being with a person when they are dying so very clearly separates the devout from the un-devout and an atheist is immediately faced with the finality of those last few days. But at least we do avoid evaluating the value of a persons in the light of where they might ‘end up’- whether that be the place of light or one filled with flame and the wails of the damned. Nor do we put off that which should be done now because we know we will not get a second chance. Not believing in second chances through an afterlife allows us to see this existence, framed by a beginning and an end as the main (and only) event. The onus is on us in the here and now although memories live on in the hearts and minds of those left behind and, as my nursing tutor said, ensuring the memories of those last weeks are good and comforting is one of the most valuable thing one human can do for another, whether that happens to be as a health professional, carer, family member or friend.
Saint Nicholas Hospice in Bury St Edmunds
Saint Elizabeth Hospice in Ipswich