Our Long Marvelous Dying by Anna DeForest

One moment of Anna DeForest’s Our Long Marvelous Dying, just published by Little, Brown and Company, captures the immense grief at the root of their new novel:

 In the interval between giving a dose of intravenous opioids and seeing the peak effect, I will sometimes pass the time by catching up on the news. There is almost always a disaster imminent…You get used to it…

A sense of resignation and detachment pervades the story told by an unnamed narrator, who works as a palliative-care fellow in New York City after the peak of the early COVID-19 pandemic.  In the first chapters, she recounts aspects of her training as a specialist, who “serves as a sort of illness interpreter, bringing the jargon of clinical medicine into the life and language of the patient who is living the experience.” It’s a specialty also “trained to be comfortable with [prescribing] the stronger stuff: morphine, hydromorphone, fentanyl.” As the fellow learns these skills, an assessment of how her specialty serves the dying patient and her colleagues becomes clear:

The trouble that the other doctors have is not a lack of gentleness. Well, not only that. More often what they cannot do is tell the truth. They pack death up in so much misdirection, talk about the success or failure rate of this or that procedure or treatment, when the truth is the patient will be dead soon no matter what we come up with to do in the interim. That’s the part they need a specialist to say.

 We also get glimpses of the narrator’s personal life: her relationship with her husband Eli, the dark ground-floor apartment they rent, the chess games she plays with her young niece Sarah, who her brother has left with them. We learn about the death of her father. Throughout the novel, the narrator seeks ways to withstand suffering—the global and local, present and past—in her daily existence.

Anna DeForest (they/their) is the author of the novels A History of Present Illness and Our Long Marvelous Dying, and a palliative care physician in New York City.

Photo by Stephen Douglas

Our Long Marvelous Dying is DeForest’s second novel and in some ways narratively follows A History of Present Illness, published in 2022, which challenged the lore of medical education through the story of a student managing her own personal trauma and the wider trauma of American healthcare. Reviews of DeForest’s first novel linked the writer, who works as a palliative care physician at Memorial Sloan Kettering Cancer Center in New York City, to the narrator—and the same might apply to Our Long Marvelous Dying, as many moments seem pulled from the firsthand experience of a physician versed in hospice and palliative care.

In many of the novel’s settings, bereavement surrounds the narrator and often consumes her. But the grief that grounds the story and proves most unsettling for the narrator stems from the death of her absent and unkind father. DeForest structures the story to reflect the narrator’s apprehension towards him. We see him in pieces between scenes in the hospital, and can’t put him together as a whole until the very end. In managing the arrangements for his death, the narrator takes us through their fraught relationship. His favorite story to tell her romantic partners when meeting them for the first time is how whenever she cried as an infant, he said “I never liked you from the beginning.” But the cruelty of his abandonment is in its persistence—he is a “latent monster,” a “ghost” from whom she never stops craving acknowledgement.

Beyond her family, the narrator guides us through additional layers of grief in a way that we never stay long enough in one place to take up the devastation. The world offers constant tragedy—floods, destruction of coral reefs, extinction of thousands of species. And every day the COVID-19 pandemic rages. The reader hears about the refrigerated trucks lining New York City blocks, but what the reader sees in specific detail are the causalities for healthcare workers: their loneliness and coping mechanisms of alcohol use, disordered eating and SSRIs for suicidal ideation. During rounds, for example, an attending physician recounts the peak of the pandemic and says absently, “I am on an SSRI.” Meanwhile, the narrator notices the spring air coming through the window in his office that has “no bars, no screen. Fourteen floors up, with a view of the Empire State Building.” There is an omnipresent threat of self-harm, if not from one tragedy, then from the weight of so many others. 

But Our Long Marvelous Dying is not a trauma dump. It confronts the obvious truths we train ourselves to overlook: the truth of death in a hospital, the truth of our own progression to death. It forces the question of “what is the purpose of living?” and does not give a satisfying answer. In this way, the novel’s title does not allude to the hidden deaths in the hospice wings, it alludes to us. Without despair, the narrator states “that all of us will die…that all of us are dead already.” The narrator acts as a palliative-care physician for us all, interpreting the jargon and euphemisms that drown the simple truth of daily tragedy.  The sugar coating has dissolved, and she wants to communicate that “no one is coming to comfort you” and “nothing will help.”

 One of the most provocative aspects of DeForest’s work is their ability to situate the reader in the day-to-day clinical world. The narrator normalizes death, dying and the grim collapse of human bodies that happens, not because of dispassion, but because of routine. While contributing to the book’s undercurrent of grief, the hospice unit provides meaning on a quotidian basis. On a phone call, in response to a mother’s dismay that her daughter may die before they arrive, the narrator reflects: “of course she can and does die alone.” In another situation, she reflects that an aging actress “dies the same as anyone.” These are tragedies that are contained, expected and managed. 

Despite submission to muted sorrow, the narrator still attempts to manage her trauma. The palliative-care fellowship itself, in the view of its program director, draws those with personal layers of grief in addition to their professional interest. For the narrator, her work keeps the despair at bay and allows her to reflect on the minutiae of existence—for example, describing her underground commute as “the long stretch of track between where I live and everything that matters.” In revolving her life around the care of others, she does not have to generate her own will to continue living.

She also tries to endure by tempering her connections, especially to her husband Eli, a “well-adjusted” and handsome chaplain with a network of friends who adore him. The constant in their marriage is the restrained threat of its end, from “red flags” or laments that “it isn’t working.” This sense of detachment also manifests with her niece Sarah, who she describes as her “temporary daughter” while Sarah’s father is unable to care for her due to his substance use. We learn that an intergenerational dearth of attention and love has conditioned the narrator to the security of pain rather than love; the cycle of abuse contributes to her decision not to have children. The place where she seeks connection is a monastery out of the city, where she arrives and departs anonymous to her peers.  

While there is no neat resolution, the protagonist steadily approaches the grief that eludes her—the death of her father. We see this through the lengthening of the scenes themselves. Initially, we learn about her father in brief moments between scenes of her palliative-care fellowship; by the end, we are allowed to linger as she sorts through his belongings. For a person who asks uncomfortable questions (Are you happy?) and speaks revolutionary words in a hospital (death and dying), the narrator takes her time to confront his death. She asks a rabbi at the hospital what to do after death about the bad acts her father committed in his life. Just as she can cut through medical euphemisms and jargon, he cuts through her question: “The weight you feel, he says, is not a need to forgive anyone. Just call it grief. Call it trauma.”

In Our Long Marvelous Dying, DeForest challenges our discomfort with death and instead leads with loss and our search for meaning within it.—Margo Peyton

---

Margo A. Peyton is a resident physician in neurology at Massachusetts General Hospital and Brigham and Women's Hospital. Prior to medical school at Johns Hopkins, she worked in film and television story development for DreamWorks Animation. Her essays and book reviews have appeared in The New England Journal of Medicine, JAMA and the Boston Society of Neurology, Neurosurgery, and Psychiatry.

Aging as a Spiritual Practice – A Contemplative Guide to Growing Older and Wiser By Lewis Richmond

Western society does everything possible to convince us we can live forever. But death is inevitable. We all age and die. No one is exempt. How can we approach this stage of our lives with acceptance, wisdom, appreciation, and even joy? As a physician, I was not afraid of dying, but as I aged, I was unprepared for the suffering before I died – loss of hearing, chronic pain, a knee replacement, and more. Aging as a Spiritual Practice – A Contemplative Guide to Growing Older and Wiser profoundly impacted my approach to aging.

Buddhist priest and meditation teacher Lewis Richmond offers “an inner road map that reimagines aging not as a time of decline, but as a time of fulfillment that can, in spite of occasional indignities, be something to enjoy.”

Beginning with “Lightening Strikes” – the moment we awaken to the fact of our aging (mine was needing hearing aids), Richmond uses individual stories, including his own experience of encephalitis to present topics such as Chapter Four -"I Like Growing Old,"- in which his friend Stephanie says, “Let me tell you how getting older is for me. I’m fifty-three and I love being the age I am! I’m doing a job I really like, I can wear what I want, and I don’t have to worry what people think! I’m grateful for the life I have now.”

In Chapter 5 - “I Don’t Like Growing Old,” some of the comments were: “I have less energy, physical, sexual, and emotional.” “People I know are getting sick and dying.” “I’m stuck with what I’ve got.”

Lewis Richmond is the author of five books: the national bestseller Work as a Spiritual Practice; the award-winning Healing Lazarus (a memoir of his experience with and recovery from a rare neurological disease); and most recently, the highly praised A Whole Life’s Work, a sequel and companion to his first book, and the award-winning Aging as a Spiritual Practice.  

Richmond's writing is conversational, as when he writes, “Reframing” is a bit more difficult to define, but basically it means to shift your attitude about a situation from pessimistic to optimistic—in other words, the power of positive thinking. It really works!” He is a master storyteller. I could see the similarities between myself and the people he encountered. A feeling of compassion and understanding underlies his interactions with them.

Richmond explores what medicine and science know about healthy aging – and why women are more skilled at it. “Realistically, because they go through menopause. When it comes to realizing they’re aging,” one doctor said, “women drop off a cliff, so to speak, while men the same age either ignore the signs or notice them a lot more gradually.” “Another gender difference is that women tend to use humor more in dealing with aging, while men—once they get past their denial—prefer serious data and hard facts. Women form support groups around their emerging interests—a book group, a gardening group, a hiking or bird-watching group—that can also serve as a forum in which to discuss age-related issues and problems, physical and otherwise.”

The chapter with the most significant impact on me was "Conquering the Five Fears." Presenting Fear of Death, Fear of Illness, Fear of Losing One’s Mind, Fear of Loss of Livelihood, and Fear of Public Speaking. Yes, public speaking! He says, “These five fears are called “great” because each of them can cause panic and trigger the autonomic nervous system. The prospect of death, illness, losing one’s mind, losing one’s livelihood—and yes, even speaking in front of a crowd—can cause panic.” He presents some strategies for approaching these fears.

At the end of each chapter, Richmond invites the reader to try various contemplations related to the material. For example, identifying our emotions related to aging or taking a gratitude walk. Many include visualizations, a powerful tool, or guided explorations of thoughts and emotions.

Richmond touches very lightly on his Buddhist practice. The reader is not asked to believe anything, but see an offering of something to try as we live at this stage of constant change. He says, “To practice ahimsa (non-harming) is to follow Buddhist values, whether you call yourself a Buddhist or not. Meditation grows out of the ahimsa spirit and is a central expression of it. The application of Buddhist meditation to aging, as we are pursuing in this book, is another application of the ahimsa spirit. Our increasingly fragile and infirm bodies and minds are sacred and worthy of the greatest kindness and care. To respect our aging at every stage is the greatest kindness we can offer to ourselves and those we love.”

I use this brief meditation from the chapter “What Buddhism Teaches” daily: “As I grow older, may I be kind to myself; As I grow older, may I accept joy and sorrow; As I grow older, may I be happy and at peace.”

In the final section, Richmond offers "A Day Away." This daytime self-retreat is presented with straightforward hourly instructions for a journey of self-discovery. He concludes the book by saying,“Hold on to the underlying principle of all we have learned here: to remain aware and awake, regardless of what is going on. Many of our strengths and faculties decline as we age, but our ability to pay attention can be practiced through the contemplations in these pages, and can persevere and even grow. As the Buddha said so long ago, “Don’t believe it because you have read it or because I say it. Believe only because you have tried it and found out for yourself that it is true.”

This is a book to read slowly and savor. Repeated investigations of the contemplations reveal new insights and bring comfort to the aging process.

It happens. There is nothing to fear here. - Maureen Hirthler

---

Maureen Hirthler is the Managing Editor of the Intima. She holds an M.F.A. in Creative Writing from UMKC and studies Buddhism.

Some Kind of Happiness by Claire Legrand

In her 2017 YA novel Some Kind of Happiness, Claire Legrand paints a poignant picture of mental illness and the difficulties of navigating family relationships. It is a fictional account of teenager Finley Hart as she spends a summer with grandparents and cousins she has never met while her parents resolve their relationship issues. Interspersed in the chapters is a magical story of a place called “Everwood,” a fantasy realm that serves as a coping mechanism for the young girl, who uses it to journey through dangers, meeting friends and foes both without and within. Fantasy and reality bleed into each other as Finley struggles with what she sees as “a darkness” within her, a darkness that threatens to destroy the Everwood.

Claire Legrand used to be a musician until she realized she couldn’t stop thinking about the stories in her head. Now Ms. Legrand is a full-time writer living in New Jersey. She has written two middle grade novels—The Cavendish Home for Boys and Girls, one of the New York Public Library’s 100 Titles for Reading and Sharing in 2012, and The Year of Shadows—as well as the young adult novel Winterspell. Her newest book A Crown of Ivy and Glass Book One of the Middlemist Trilogy will be published by Sourcebooks Casablanca in May 2023. Visit her at Claire-Legrand.com and on Twitter @ClaireLegrand.

Some Kind of Happiness is an insightful tool that can be used to teach teenage and adult audiences the difficulty in confronting and naming mental illness in one's life. The book starts off with Finley being dropped off for the summer at her grandparents' house. For reasons not yet known Finley’s father is estranged from his parents, so until this point Finley has never met them or her aunts and uncles. Her parents need the summer alone to “work on things” and it is implied they are approaching divorce but not explicitly stated.

This refusal to give a name to problems is a recurring theme that’s true of the teenagers and adults alike in this insightful narrative. Like Finley many teenagers may be unable or unwilling to articulate what they are feeling. They are suddenly dealing with complex emotions and adult situations they’ve never encountered before. Finley’s journey through this symbolic forest of emotional struggles—and how much her viewpoint as a teenager differs from the adults around her—is a reminder of the confusion adolescents experience and the real benefits that come from confronting and giving voice to their struggles.

While the story is geared towards a Young Adult audience, Legrand’s skillful and engaging prose creates a useful depiction of working through these emotions and figuring out what they mean. It also helps to combat the stigma of mental illness, normalizing it as a part of life. Adult readers can glean a lot of insights as well. I found myself reflecting on how I try to recognize struggles in children and youth around in my life, and how I approach difficult and sensitive topics with them.

As the story progresses Finley tells her cousins about the Everwood and the children play fantasy games in the nearby forest together. Her cousins are knights, squires and princesses, and Finley plays the orphan turned queen. Against the warnings of their grandparents, they make friends with the neighbor boys and create a world full of lore and magic. The tone and story of the book made me think of Bridge to Terabithia by Katherine Peterson.

Though she plays with her cousins the Everwood isn’t a game to Finley; it is something more, a place where she escapes from her problems. One day the young girl realizes the Everwood is changing and decaying and as she investigates, she meets a snake. The snake warns that something within her is destroying the Everwood and helps extract a portion of oily darkness from her. Unfortunately, the snake isn't powerful enough to remove all of the darkness, but warns that it must be removed to save the Everwood, as seen in this passage:

“Whatever we carry within our hearts, the Everwood’s power makes it real. And soon what you carry will destroy not only you but everything you touch. The Everwood is not as strong as it once was; your darkness will bring out its own. To save the forest you must face this thing inside you.”

The orphan girl held back tears of shame. Her great secret, the one she had worked so hard to conceal, lodged in her heart, “But how?”

“First you must give it a name,” said the snake. “Naming a thing takes away some of its power and gives it to you instead.”

But Finley refuses, finding it too hard. This reminded me a lot of when a patient I worked with told me that being diagnosed with depression was almost as hard as suffering from it. To have their sadness given a name made it real and was painful, in part, because they couldn’t hide from it anymore. This is what Finley feels, and later, when she is confronted with a fox, she still refuses to name the darkness. It is unclear whether Finley is just afraid to name her condition and admit what is going on, or if she truly doesn’t understand what is happening and is unable to name it.

Legrand uses Finley’s internal dialog to adeptly describe the struggles of mental illness. Her young protagonist often has “blue days” and “episodes” that seem to be panic attacks. Finley, who feels incredible guilt about these attacks, recognizes her life is better than others and feels she has no reason to feel the way she does. When her cousins and friends discover a burned-down house with three graves in the front, they name it “Bone House” and learn about a young family that died in a fire. As the revelation comes to light, Finley begins to have a panic attack:

“...not even fresh air can get rid of this fear living like bugs underneath my skin.
This fear that I have no reason to feel.
There is no reason for the heaviness I can feel pressing down on me. Like when you step outside before a storm and the air feels heavy and damp, like you’re drinking it instead of breathing.
Like that, but worse.
It seems wrong to feel these things while standing in front of this poor, broken Bone House.
I ought to be able to get rid of these feelings—right?
Shouldn’t I be able to live in my beautiful, clean house (which is not burned) with my family (who are still alive) and be happy about it?
I ought to be able to get rid of these feelings.”

Eventually, as she explores the Everwood and receives help from her parents and family, Finley is able to name her darkness when she goes to see a therapist:

“I breathe in. I breath out.
(Its ok, Finley.)
(Let her see.)
Dad squeezes my hand.
“I think I have depression.” I hesitate, “And anxiety, too.”
When I say it, the words float away from me and leave nothing behind.
They are only words. They are only part of me, and I am still here.
I do not need to be afraid of them.”

With an understanding of what is going on within herself and a realization that things aren’t as perfect as they appear on the outside, Finley is able to accept who she is, and as she does the darkness of the Everwood recedes. Things are right again and she becomes more than “the orphan,” she becomes Queen of the Everwood.

I was impressed with the honest way mental illness was portrayed. I’ve read many clinical books that describe mental illness, but Claire Legrand was able to portray it in an emotional way that strikes one's heart. Some Kind of Happiness does what Finley struggles to do: It adeptly names and beautifully describes the struggles of depression and anxiety in a way that connects with readers. While Legrand doesn’t have an academic background in mental health, she has spoken on the struggles of living with mental illness. Her personal experiences shine through in the way she describes these struggles, making it an insightful one for those who are confronting their own difficult emotional landscape. Using both real world examples and allegory Some Kind of Happiness is a useful story for younger readers as well as clinicians in understanding mental illness. It gives voice to those who feel like outsiders in their own families or feel inadequate compared to everyone around them. It teaches us we don’t have to be afraid of what's inside us. We can face it, and when we do, we don’t need to face it alone. —M.T. Bennett

M.T. Bennett is a student at Trinity School of Medicine. He enjoys writing and spending time with his wife and two sons. Bennett is the author of “Dark and Bright: Poetry and Prose.” His writing has appeared in various publications from the Harvard Medical Student Review, to the Journal of Supernatural Studies, World Medical & Health Policy, Graphic Medicine, HEAL, America Media and MedPage Today.

---