— Author Hadley Vlahos watches people die for a living. Here’s what she’s learned.
Hadley Vlahos is a 31-year-old hospice nurse, mother of three, and, as of this past summer, a New York Times bestselling author: Her debut book, The In-Between: Unforgettable Encounters During Life’s Final Moments, recounts her journey to end-of-life caregiving, delves into some of the more mystical things she’s witnessed as her patients die, and explores the impactful relationships she’s made along the way. The In-Between—SELF’s November Well-Read Book Club selection—is a deeply moving reflection on many of the fears that plague all of us, bringing inevitable life experiences like illness, pain, and death gently to the surface.
I recently chatted with Vlahos about her job, caregiving, grief, talking to her kids about dying, and how to support the people you love when words simply don’t feel like enough.
SELF: What advice would you give to a first-time caregiver for someone who is living with a terminal illness or dying?
Hadley Vlahos: Don’t be afraid to ask for help and take it day by day. For many people, caregiving is a marathon, not a sprint. I come in during the last six months of someone’s life—by that point, it’s not uncommon for patients’ caregivers to have already been in that role for many years. It’s not sustainable to care for someone else for that long without a break. If your neighbor offers to sit with your loved one so you can go get groceries by yourself or take a nap, take them up on it! There is no shame in asking for or accepting help.
Do you have any tips for caregivers on how they can take care of their own mental health?
Recognize that anticipatory grief—grieving a person who is still physically alive but no longer themselves due to their illness—is completely normal, but it does make the task of caregiving more difficult. If it’s feasible, I would absolutely recommend getting a therapist or licensed mental health counselor. Caregiving can be isolating and overwhelming. Having someone to help you through those emotions can make a world of a difference.
Is there a part of death and dying that you used to be afraid of but no longer scares you?
I used to be very scared of the unknown. What happens when we die? Does nothing happen? Is it going to hurt? Now that I’ve been with so many patients as they’ve died, I no longer fear it. I witness patients process their inevitable death and come to peace with it. I watch patients see their deceased loved ones before they die and feel very comforted by their presence. For me, I now know that no matter what happens at the end, I have the option to be comfortable and calm. Knowing what a good death looks like and that I should be able to have it makes the thought of death not scary for me.
What’s a common misconception about death that more people should be aware of?
I think that most people feel like their death is out of their hands and out of their control. Many patients feel like they get a terminal diagnosis and are told what to do and when to do it: Get this surgery, get labs drawn, take this medication, etc. They feel like they have no other choice.
The reality is that patients are allowed to say “okay, enough,” and elect to go home on hospice care. Patients are allowed to prioritize what’s important to them at the end of life. For some people that is treatment, but I often hear that patients were not aware that they could choose hospice sooner than they did.
What do you think more people should know about hospice care?
It isn’t as depressing as it seems. I know, death seems depressing, but the reality is that it is unavoidable. I think that most people think of death as an if instead of a when. Death is going to happen to all of us. Hospice care is attempting to make it better by putting the patient’s comfort as the priority. I think that’s beautiful.
I’m curious to hear your take on what planning and logistical discussions about death we should have with loved ones, but also what we should be asking them about life in general. Have you noticed any patterns after guiding so many families through the process?
Absolutely! Practical questions should include “What does a good death look like to you?” This is different for everyone. Some people absolutely want to be at home, while others would rather be anywhere else. Some people want all of their loved ones there while others want privacy. At some point, you should find out your loved one’s funeral wishes as well—are religious traditions important to them? What do they want for a final resting place: burial or cremation?
I always ask my patients what their goal is while on hospice, and their answers vary greatly. Sometimes it’s as simple as slightly reduced pain, and others want to be able to get out of the house one last time and check something off their bucket list.
When it comes to asking personal questions, I tend to go with the flow, as every patient is different. If a patient is naturally reviewing their life and telling me stories, I will ask them if they have any regrets. The answers people have are fascinating. I not only like to listen to their stories, but I like to think about why that instance in particular stands out to them. I had a patient recently who told me multiple times about missing his daughter’s dance recital when she was younger because he had to work. I imagine that he probably missed many family functions due to his job, but for some reason that one really stood out to him. One day, I asked him why he thought that was. He said that he missed the recital because he had picked up an overtime shift after buying a car that was priced above his means. “That car is probably just rusty parts in a junkyard now,” he said, which really stood out to me.
What can we all do to support the caregivers in our lives, especially for those who are coping with a terminally ill loved one?
If you live near someone, offer specific help. Oftentimes, I see people saying, “Let me know what I can do for you.” While this is well-intentioned, many caregivers feel burdened by it. They don’t know what that includes. Are you willing to come stay with their loved one for an afternoon? Or are you just offering a phone call? Instead, offer specific help. Try: “I’m dropping off dinner this week. Does Tuesday work for you?” Or “I’d love to stay with [their loved one’s name] for a few hours so you can do anything you need to. Does Sunday afternoon work?”
If you’re further away, my go-to is sending a Doordash (or another delivery service) gift card with a heartfelt text. I do this both for my friends who are caregivers and my friends who are grieving.
How did your experience as a young, single mom shape your career as a caregiver?
It taught me a lot of empathy. It taught me that we’re all just doing the best we can and that the best someone can do is going to look different for everyone. I learned that casting judgment on someone, as so many people did to me, isn’t going to change their circumstances. It’s just going to make someone feel bad about their circumstances. If we have the choice to make someone feel worse or better about themselves, why wouldn’t we choose the latter?
You’ve spoken on TikTok about raising your three kids in a “death-positive household.” What does that mean and look like?
For me, it’s about not avoiding the topic. I was raised in a death-positive household as well—my grandparents are funeral directors, and I think that normalizing the topic of death is very important. If someone dies I say that they died. If my kids have questions I answer them honestly in an age-appropriate way. I don’t ever change the subject to avoid feeling uncomfortable.
How early did you start having those conversations with your kids?
As soon as they could talk and understand. A simple way to incorporate this is with bugs and flowers. When your child notices that a bug or a flower has died, you can say that it died. I don’t make a big deal about it, but I do use those words—dead, died, and dying—in my day-to-day language. If I’m talking about my day and a patient died, I will tell my children that they died. My 10-year-old sometimes has questions and I answer them honestly. I recently explained to him what the process of a death visit is like for me, including calling time of death, talking to the family, and assisting the funeral home. He listened intently, then went back to eating his dinner.
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