Love, Death and Spaghetti

“Theresa, you gonna sit, you gonna eat.” My orientation for hospice nursing didn’t cover this — an Italian grandmother who was clearly not going to talk to me about her dying husband unless I sat at the dinner table with her family and ate. Well, when in Rome, I decided, and obediently pulled up a chair.

The emotional connection between food, love and survival runs deep, and it comes up again and again at the end of people’s lives. “I can’t just let her starve,” family members will say about a loved one near death with little ability to talk, much less eat, and certainly no desire for food.

It was the same for this struggling wife. She wanted to feed her husband, in part because food was how she connected with people. Her husband was beyond any hope of cure. Giving him food was the last concrete gift she had to offer, and the one most associated in her mind with a lifetime of caring.

Her children, all grown, thought their mother was in denial, that she couldn’t accept her husband’s imminent death. They wanted her to stop trying to feed him, because he could no longer chew and swallow. They were concerned that he could choke, that any food he managed to get down was likely to make him feel worse, not better, because that’s how it goes when the body starts to permanently shut down. And they were right.

So, I talked to her about it while we both ate, twirling spaghetti around the tines of a fork, smoothing butter over a piece of bread. I reviewed the history of her husband’s illness and the signs that he was in a terminal decline: worsening respiratory status, an escalation in pain and a quickly diminishing ability to recognize or respond to anyone, including her. I gently told her that not only could her husband not eat anymore, he didn’t need to — that when people get very close to death they lose interest in food. She nodded while looking down at her lap, tears pooling at the edges of her eyes.

Her husband’s hospital bed was next to the kitchen, and I had watched her get dinner together while doing my initial assessment of him. As she drained the pasta and briskly directed the setting of the table, she looked like an artist at work in her own studio. The kitchen was big and light; clearly, the life of the extended family was centered there.

When a sick person refuses food and water, it makes his dying real. Family members may know intellectually that a loved one’s tumor is spreading and can’t be stopped, or that a heart is losing its ability to pump blood, but not eating is so fundamentally at odds with living that it can be very hard to accept.

I learned this lesson at the start of my nursing career. The family of a hospice patient in the hospital brought her dinner, including tater tots, from the diner across the street. “It’s her favorite meal!” the daughter told me mournfully, holding bites of food near her mother’s mouth, even though her mother, sadly, was long past noticing.

In hospice we talk about “eating for comfort.” Let the dying eat, or drink, whatever they want, whether a salami sandwich or an ice-cold martini. However, I hadn’t thought much about “feeding for comfort” — that the living have a strong urge to feed the dying because it creates the illusion that they aren’t dying after all.

When family members of hospice patients protest against “letting” a no-longer-eating patient “starve,” whose need is being served by the food being offered: the patient or his loved ones? I have to remember that spouses and children see life slipping through their fingers in the form of uncleaned plates and beloved foods refused. Any calories consumed are signs of life.

We clinicians could also better empathize with the food-love-survival connection by acknowledging the difficulty of seeing someone not eat. We can suggest concrete actions that don’t involve food, but still make a difference for the dying: sit and quietly hold a hand, control the patient’s pain, read from a favorite book, use medication to relieve shortness of breath. We can also recommend ice chips and the use of small moistened sponges to keep patients’ empty mouths from becoming uncomfortably dry.

The process of leaving the earth can be protracted and painful, as is accepting that someone you love will soon live no more. Those final proffered morsels of sustenance may be a way for survivors to salve their growing grief. At some point the dying no longer want food, but the living still want them to survive.

So it was with the Italian grandmother. At the end of my visit that day I felt pretty sure she would no longer try to feed her husband, but as a result she would feel the coming loss of him even more.

 

Theresa Brown is a hospice nurse and the author of “Critical Care: A New Nurse Faces Death, Life, and Everything in Between.”