The final days leading up to my sixth birth have become a humbling, initially unwelcome reminder of how much we want to control time, and how rarely time agrees to be controlled.

I should know. This is what I do and write about for a living. Well, turns out I’m a human just like you, and I too want to know exactly when I am going to give birth and under what circumstances: who the nurse and doctor will be, how long it will last, and which interventions I will and will not receive. And when I felt like I was starting to lose control and clarity, I started feeling anxious and disappointed.

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I intellectually know that labor isn’t a cinematic rush that ends seconds after the amniotic sac breaks; it’s slow, grueling, and uncertain. The due date simply marks 40 weeks pregnant. Only a small percentage of women go into labor on this actual date.

Typically, you can go into labor anytime from 2 weeks before to 2 weeks after your due date, so that’s a month-long window. A month of contingency planning. Not being too far from the hospital or your support people. Having backup childcare and a work plan. Getting texts from family and friends asking if it’s happened yet. Going to sleep each night wondering, is this going to be it?

The hardest parts of my six pregnancies have always been what is called prodromal labor, where you experience contractions that ultimately don’t increase in intensity or frequency. But you don’t know that until later. So every time you think, this is labor. This happens to me for days to weeks, throughout the day and the night. The outcome is total sleep deprivation.

I used to go to the hospital for my earlier pregnancies, only to be sent home after being monitored and the contractions fizzled out. Now, I just wait it out at home, but it’s still hard to fully internalize. These are not turning into labor. There is still the wonder, and the hope.

Death, too, is often lengthy and unpredictable; it is not the peaceful, swift passing surrounded by loved ones gathered at the bedside, a person dying quietly in their sleep. I typically counsel patients and their loved ones that once someone stops eating and drinking, and is spending most of the day sleeping and confused, this process can still take longer than anyone imagined, sometimes even close to a month.

This is shocking for most people to hear. The classic question is, how can you survive without food or water for that long?! The answer is that it’s not about the food or water in the way we usually imagine. A body that is actively dying is not using hydration and nutrition the way a healthy body does. The organs have already begun the process of shutting down.

For some people, that happens quickly and for others it can be prolonged. And it can be full of false alarms. Someone may stop eating and drinking and begin breathing slowly, and you think it’s time. You cancel work. You fly out. You pull an all-nighter at the bedside. Only to see your loved one rally and have a few more good days. I’m putting the term prodromal dying out into the universe as an explanation for this phenomenon.

With more kids and more job responsibilities, I have completely caved on my views about embracing pure spontaneous labor. I have nightmares of going into labor at home while watching all five kids and not getting to the hospital 20 minutes away in time while simultaneously finding emergency childcare. Who wants to take on the responsibility of watching five kids under nine, which really makes me wonder how wild it is to have five kids under nine.

I have had to keep reminding myself that birth doesn’t follow calendars. Neither does dying. I’ll never forget Tom. He was admitted to our inpatient hospice unit with metastatic stomach cancer. When I walked into his room, I was startled by how alert he was. He greeted me like a host, then gave me precise instructions for dissolving his cannabis gummies in hot water. Based on his appearance, I told him I thought he would likely live for weeks—maybe even a short few months—and that he might have to pay a room-and-board fee to stay at our facility. The next morning, I arrived to learn he had died overnight.

And yet I’ve had the hardest time reminding myself of this as I lead up to my own labor. When I recently met with the obstetrician and he told me I didn’t seem dilated enough to have my water broken in a few days with confidence that labor would begin without additional interventions, I could have reminded myself that things can change and evolve. I could have remembered all the times I have told families that bodies do not owe us a schedule. But instead I feel frustrated with myself for all the planning and logistics I had been so sure would certainly work out.

So here I go today, returning to the hospital to see what will happen. Still pretending, a lot, that I might get to control the story. And still trying to surrender to what birth and death keep teaching me: the body keeps its own time.

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My husband has a sweet habit of asking, “What were you thinking about?” when I have a rare moment alone after he takes his evening shower and the kids are already asleep.

“I was imagining you were dead.”

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It was painful to visualize. For thirty minutes, my heart rate rose and my muscles tensed. I imagined the emptying of my body and mind. I asked myself how I could go on for another millisecond without the love of my life, the person I have loved more with every passing day since I was eighteen years old. I realized, perhaps naively, that caring for dying people professionally is very different from living through the worst day of your own life.

I imagined how I would tell our five children, using the same guidance I have given thousands of families: Be direct. Be strong. Be present. Don’t use euphemisms. And all the while, I would want to collapse under the weight. I would wish I were the one dead instead.

I would write a beautiful eulogy, though I wasn’t sure I would be able to deliver it through the paralysis. I would spend the rest of my life finding concrete ways to honor and celebrate him. I would reenact his nineteenth birthday party, when we staged the Swedish Battle of Brunkeberg. I would fulfill his dream of opening a smoothie shop called Tart for Two, where you buy two smoothies and give one to a stranger. I would finally put my shoes in the shoe rack and eat my food from an actual plate, the small things he has always wanted me to do.

Thankfully, he has a running document on his computer filled with his favorite ideas and quotations, along with a spreadsheet tracking every movie and television show we have watched together and his observations. I would also be grateful for my Raffi document, where I keep track of all the romantic things he says to me. I imagined clinging to those records through the blur, the fog, and the impossibility of trying to fall asleep alone.

To my husband’s credit, he has fully embraced being married to a hospice doctor. He responded, “That’s what the Stoic philosophers recommend doing. Visualizing tragedy so you prepare your body and mind. It’s called premeditatio malorum, the premeditation of adversity. I literally just wrote about it in the novel I’m writing!”

I find myself doing this from time to time now, not only with my husband, but with each of my children. My parents. My friends. I imagine getting the phone call. Hearing the words. Maybe even being the one to find them dead. Trying to respond. Would I scream? Would I be silent? Who would I call next? I picture myself holding something they loved and breathing in its familiar smell. Looking through photographs. Asking why devastating things happen.

It is always painful in the moment, but each time, I feel surprisingly calmer afterward.

I first learned about the power of visualization not from the Stoics (or from the draft of my husband’s novel, which I love), but from the childbirth education movement. Preparing for childbirth often involves imagining the sensations of labor: the contraction beginning, building, cresting, and finally releasing. We practice breathing through it. We picture the room. We repeat the words we hope will steady us when ordinary language becomes difficult.

With my sixth child due in the next few weeks, I have been doing this more often. I imagine the first contraction I cannot ignore. I rehearse meeting each wave rather than resisting it. In previous labors, I have screamed that I couldn’t do it, that I didn’t want to do it, that I just wanted it to be over. This time, I am trying to imagine fully surrendering to the pain. Maybe I will even manage to say, only half-jokingly, “This is amazing. I love this.”

Of course, visualization can easily cross into anxiety. There is a difference between deliberately entering a feared possibility and becoming trapped inside it. Catastrophizing makes the imagined future feel inevitable and leaves us more frightened of the present. Purposeful visualization brings us back.

Birth and death feel both unfamiliar and intensely emotional. There is a great deal of uncertainty, which I do not believe we can, or should, fully eliminate. The real moment will always exceed the imagined one.

You need not imagine every detail; simply notice the physical changes in your body and the words that come to mind. Then notice what it feels like to return to the present, to the person still here.

For today, all I know is this: my husband is alive, and I am unbelievably grateful.

I was concerned that when I no longer practiced frequently as a childbirth doula, and when I transitioned from full-time hospice work into primary care, I would no longer interact as intimately with the bookends of life. I worried I would lose the daily grounding I had found in being close to birth and death; that life is fragile, temporary, embodied, and astonishing.

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And yet, every day in my primary care office, I hear about birth and I hear about death. I never had this awareness in medical training. Not once did a physician educator I spent the day with say: your patients will tell you about their births and the deaths of their loved ones, and these stories will shape how they care for themselves and what keeps them up at night. We were taught to ask about family history, but not always family meaning.

I find that my patients are often more motivated than ever after the birth of a child. A baby arrives, and suddenly the future is no longer abstract. A patient who has not seen a doctor in years comes in wanting to understand their cholesterol and blood pressure. A mother who has ignored her own symptoms for too long finally says, “I need to be healthy for my kids.”

All at once, they are living not just for themselves, but to care for another person. The body is no longer only theirs; it is now part of the infrastructure of someone else’s existence and future. They have purpose, responsibility, and urgency. It is about the long game.

But birth is not only simple inspiration. Pregnancy and birth often take a significant physical toll, and the baseline can be pushed back dramatically. Weight gain that feels impossible to lose. Pelvic floor injuries no one fully explained. Breastfeeding struggles. Hormonal shifts. Chaotic, frightening, or disappointing experiences with the health care system. A body that no longer feels recognizable at the exact moment the person living inside it is expected to become more selfless than ever.

Then there is the sleep deprivation. Exhaustion that wears down patience, appetite, memory, metabolism, and mood. There is the looming sense of not having enough time. The routines that once made someone feel grounded disappear almost overnight.

The desire to do better has never been stronger, and the capacity to do better has never felt more limited. The generic advice to eat healthy, exercise more, sleep more, and manage stress may be true, but truth delivered without context can feel incredibly unhelpful. The work is to acknowledge these stressors and this duality.

Death opens people in the office in a different but equally profound way. The death of a spouse, a child, a sibling, a friend, or a parent is never just an event that happened in the past. Each story is heartbreakingly unique and life-altering. People inherit identities they never asked for: widow, widower, orphan, solo parent, caregiver, griever. They become the person who has to make all the decisions alone.

Sometimes death brings clarity the way birth does. A patient loses a father to a heart attack and suddenly wants to know every number. A daughter watches her mother disappear slowly from dementia and wants to talk about advance directives and preventive measures. A husband cares for his wife through cancer and realizes, after the funeral, that he has not slept well in two years. Death of a loved one can make people want to live differently. It can make them want to stop drinking, take medication, schedule the colonoscopy, walk outside, or say the thing they have been waiting to say.

The death of someone loved also exhausts people. Grief changes sleep, appetite, alcohol use, blood pressure, blood sugar, pain, inflammation, memory, and energy. The body often begins speaking the language of loss before the person has words for it. These moments frequently show up in the exam room as abnormal labs or new symptoms. The patient comes in worried that their body is betraying them, when often the body is telling the truth about what the person has survived.

Of course, sometimes there is something biological that needs to be treated, and it is my job to take that seriously. But it is also my job to help decipher what is biological and what is psychological, not in the dismissive sense of “this is all in your head,” but in the deeper and more reverent sense that your psychology is influencing your biology. Your grief is not imaginary. Your stress is not separate from your body.

This is why primary care, at its best, is not “small medicine.” It is not only refills and screening tests and reminders. It is the place where biology and biography meet. It is the place where someone says, often without saying it directly: help me live inside this new version of my life.

Back to regular programming: The Bookends of Life is a collection of reflections about witnessing and experiencing birth and death to be grounded in life’s finitude and meaning.

When I hosted a “Let’s Talk About Death Over Dinner” at the inpatient hospice where I work, I described how many patients arrive in our care: in severe pain, agitated, vomiting, struggling to breathe. There is often yelling. Comfort medications like opioids and anxiolytics are needed immediately, and frequently around the clock through an IV.

I think I unintentionally scared the dinner participants. Someone asked, “Is this what dying is—so many symptoms? So much suffering?”

The hospice nurse with me, who was much older and wiser, responded that she hadn’t seen deaths like this when she worked in Ethiopia. There were fewer medical interventions. The endings were gentler. People died in their sleep, simply of old age, their bodies less battered by prior procedures.

There were, of course, losses there she would never wish on anyone: treatable infections, hemorrhages without blood available, cancers discovered too late. Gentler endings sometimes came at the cost of options we would consider basic medical care. But her point stayed with me: when we have more tools, we don’t always use them wisely, and they aren’t without downsides.

In modern medicine, many people arrive at dying after months or years of interventions that keep the body alive while also leaving them much more fragile. I’ve come to see that greater frailty often means more symptoms at the end. Sometimes the body doesn’t only die of disease; it dies of accumulation.

I see a related emotional dynamic all the time with patients: a desire for more time on earth, and then anger at what that time actually looks like.

A kind of psychological delay sets in. Many deaths I’ve seen are made harder by fear and the fierce fight to keep going. The most driven personalities often have more symptomatic deaths. Control has been their lifelong language, and surrender is unfamiliar. The will to live is incredible, and it sometimes pulls us toward treatments that increase suffering without meaningfully changing the end.

We do with endings in modern life what we often do with beginnings: we delay. Our culture has come to treat limits as negotiable, as though enough technology or willpower can always buy us more time.

More and more people are having kids later in life. Waiting for the right partner, the right savings, the right job title. We see other people waiting so we wait too. But we then mourn the waiting: that we didn’t start sooner, and that it became more complicated and painful than we imagined.

The reality is that our biology keeps its own quiet calendar. When pregnancy is postponed, the road can more often wind through miscarriages, medications, intensive monitoring, sometimes a premature birth. I’ve seen this a lot in my female physician colleagues for whom, because of the training and culture of medicine, fertility is commonly delayed. We’re told, implicitly, that we can delay without consequence—and then we’re shocked when the body does not agree.

Through being a hospice physician, a mom, and a childbirth doula, I have come to accept that we cannot defer nature and then demand that it obey. We suffer when we mistake postponement for mastery. It’s a reminder that bodies keep their own seasons, often kinder when met sooner rather than managed late. We are simply not above nature.

The Bookends of Life is a collection of reflections about witnessing and experiencing birth and death to be grounded in life’s finitude and meaning.

I see a woman in her seventies on the preparation table in the funeral home. She is wearing a bright blue floral nightdress, which tells me she probably died at home. She was well cared for. Perfectly done wound care, probably as recently as that morning. Nails painted bright pink. She could have been my loving mother-in-law. Same age, same physique. Life feels impossibly fragile.

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As part of a sacred society that ritually prepares bodies for burial, I stand beside three other women. We keep our voices quiet. I imagine this woman’s soul still nearby, hovering at the edge of the room, held by the people who loved her and are waiting in the world to come.

In the funeral home, we pull on our gowns and gloves and fill large buckets with water. We listen as the blessings begin. First we do a gentle washing, and then a continuous pour of water so the body is cleansed with dignity and respect. We dress the body in white shrouds before gently lifting her into the coffin. We then place our hands on top of the pine wood as we ask for final forgiveness if we did anything wrong.

I realize I’m caring for babies, the dying, and the dead in similar ways: with washing, bathing, toileting, and dressing. The tasks are ordinary, but the meaning is not. I think of this washing as love in its simplest form. Every movement—how we lift, how we pour—is taught and deliberate. The rituals give us presence and purpose. They give our hands something to do when words are not enough. Ritual says: this mattered. This still matters.

When I come home from the funeral home, or from a day at the inpatient hospice facility, I always take a shower. Under the water, just standing there, I feel so grateful. I’m on the verge of tears. To squeeze soap. To lift my arms. To lather my hair. To turn the water on—and then off. To feel warmth without pain. To be alive and to feel for at least one more day.

I think back to the anatomy lab in my early medical training: the formaldehyde, the bright lights, the strange intimacy with a cadaver. Afterward I would go straight to the pool. Postpartum, I showered immediately, covered in blood and amniotic fluid, watching the water run over a body that had just performed a miracle. Even now, I look down at my softened belly and marvel at what my body has survived.

I’ve always found water purifying and grounding. It isn’t just cleanliness. It’s returning. Reentering.

Water gathers at the thresholds of birth and death. A baby buoyed in fluid months before birth. The bag of waters that breaks. The first bath, one careful cupful at a time. The warm washcloth on a fevered forehead. The sponge swab in a mouth that can’t swallow. These are the moments when care becomes intensely physical. The gestures repeat across time—across diagnoses, across families, across beginnings and endings.

So the next time you drink a cup of water, go for a swim, take a shower, or lower your child into the bath, pause. Feel how often love arrives as something simple. Water is part of life and is present at death. Most importantly, let it remind you that your body is here, still, and for today, that is truly incredible.

In medicine, transition is a clinical term used both in birth and death.

In birth, transition is the shortest, most intense phase of labor: the cervix moves from roughly eight to ten centimeters; contractions last about sixty seconds and come every two to three minutes. The body trembles from teeth to toes. Nausea won’t let up. You’re hot and cold at once. Pain narrows into a fierce downward pressure: the ring of fire.

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I’ve labored through that passage five times. Minutes from meeting a new life I created, I questioned, more than at any other time, whether I could do it. I’ve never felt or voiced greater doubt. It’s common then to cry out, as I did: “I can’t do this anymore. I don’t want to do this anymore. Please make it stop.” Pure, overwhelming fear. You simply want to quit—to step out of the experience and go back to before. And still, if you stay, something opens, and a baby arrives.

In dying, transition is when the body begins to shut down. Sleep deepens. Appetite fades. Words thin. Breathing stretches, pause, then breath, until even the pauses feel like part of the letting go. Like birth, there can be pain and nausea: the body doing what bodies do when they release.

Transition looks like intensity, doubt, and a narrowing of focus—right before the next stage announces itself. It is a threshold: when a baby crowns, or when breath begins to space itself apart.

Transitions teach us the body’s purpose. In labor, the body rehearses opening, over and over, until the opening holds. At the end of life, the body rehearses letting go, over and over, until the letting go holds.

These transitions, like all transitions, ask one thing of us: stay. There is no other way through but through. Breathe. Do the next small thing, then the next. Resistance loosens. You do cross over—and you are not the same person you were before.

I love this parable about two twins in the womb. One twin insists this small, fluid world, food from a cord, constant darkness, is all there is. The other believes in more: light, voices, a place to stretch, stand, and walk. Labor begins. “It’s ending,” says the first. “Maybe it’s beginning,” says the second. A rush, a cry, what sounds like panic inside is cheering on the other side. One twin thinks it’s over; the other opens eyes and finds arms waiting.

We know, because the research is clear, that how we show up in this first hour of life matters. The way a baby is welcomed into the world—dim lights, quiet voices, warm bodies instead of cold surfaces—can set the tone for the hours that follow, and in subtle ways, the beginning of a family’s story.

In the birthing world, we call this the “golden hour:” immediate, uninterrupted skin-to-skin contact between parent and baby. It helps stabilize temperature, heart rate, breathing, and blood sugar. It supports oxytocin release, which promotes bonding. Early breastfeeding, ideally within that first hour, improves the chances of exclusive breastfeeding later. Even how we handle vernix (the waxy white coating on a newborn’s skin) matters; avoiding unnecessary early bathing supports the skin barrier and microbiome.

The ethos of the golden hour is simple: delay anything that can wait. Weights. Measurements. Visitors. Photos. “Just a quick exam.” We protect that brief window when the newborn’s instincts to crawl, root, and latch are strongest, and when the birthing parent’s hormones are primed for calm, safety, and connection.

I missed the golden hour with the birth of my first son. After days of labor and four hours of pushing, a cesarean became necessary. He was sunny-side up, spiked a fever, and was rushed off for blood cultures and antibiotics.

Later, I had a golden hour with the births of my four other children, and I still remember the felt-sense of it: the steadiness. When a baby is placed on a parent’s chest—it’s hard not to feel the cycle. Someone has left; someone has arrived. The world keeps exchanging bodies and souls.

It’s made me wonder: what if we talked about and treated the last hours of life the way we treat the first? An end-of-life golden hour: a guarded window where the goal is comfort, dignity, and connection? While the exact timing is harder to predict, this approach could still add meaning.

Fewer tasks, softer light, less noise, more presence. A hand held. Lips moistened and lotion on dry skin. A warm blanket tucked in with care. A familiar playlist turned on low. The steady presence of someone who isn’t trying to fix the unfixable. And we speak to the person as if they can hear—because sometimes they can, and because love doesn’t require proof. Simple words can settle a room: “It’s okay to let go. We’re here. You’re not alone.”

A man with dementia recognizes his adult kids for the first time in decades as his breathing becomes more shallow. Or he reaches out to his deceased wife and physically feels her hand reaching out to him. A lamp clicks off at the moment breathing stops. A favorite song turns on unexpectedly. A door that’s been shut all afternoon eases open as if someone has just entered. A picture slips from a wall.

When this happens, we actually make room to witness mysterious moments. Medicine often simply labels these moments as “hallucinations.” I’ve learned to hold them more gently—as meaningful, not-fully-understood experiences at the edge of consciousness. In my own imagination, I picture souls carried across a threshold by those they loved.

Whether you experience those moments as coincidence, mystery, or something holy, when we slow down enough, the moment can hold more than medicine. It can hold meaning. It can hold a kind of spirituality—a human recognition that something profound is happening here, and we are treating it as sacred.

In medical school, I looked forward to my obstetrics rotation. With my experience as a childbirth doula since I was 17, I expected to shine academically. I shouldn’t have been surprised—but I was—by the stigma toward doulas at the time. Residents, attendings, and labor-and-delivery nurses often made derogatory comments about doulas and midwives, and I found myself staying quiet.

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One day on the rotation, Angel’s cervix had stalled, and the team proceeded to a non-emergent cesarean. Music played; her boyfriend suited up. A healthy baby boy emerged. As we closed, her blood pressure crashed. The boyfriend Chris was ushered out, his face still lit with joy. Frantic pages, compressions, a rapid response, cardiothoracic surgery to the operating room. I decided to leave the OR and sit with Chris and Angel’s mother. “The teams are doing everything they can,” I said as they prayed. A nurse rolled in the baby. “Please get him out of here,” Chris said. “We need Angel.”

Angel was diagnosed with an amniotic fluid embolism and transferred to the ICU for extracorporeal membrane oxygenation. I stayed with her family, making calls on their behalf. She died an hour later, before ever holding her son. She was my first patient to die. She was also my age.

The next morning an intern said, “I can’t believe I missed all the excitement. Cases like that almost never happen—you’re so lucky.” The words caught in my throat. Medical training can make us look past the person; I didn’t want that to happen to me.

Soon after my obstetrics rotation, I became pregnant, and that pregnancy ended in a second-trimester miscarriage. Expecting to welcome life while confronting so much death challenged me. In that season I learned I could sit with hard conversations without rushing to fix, and that listening, naming what was happening, and aligning care with someone’s values felt like important and undervalued work. I wanted to be the kind of physician who meets people where they are. These two births and deaths during medical school changed and defined the trajectory of my life. When residency applications came around, I chose internal medicine with the plan to later specialize in end-of-life care. As I’ve later come to internalize, the births and deaths of our own lives are our greatest teachers, mirrors, and catalysts.

Now, a few years into full-time practice, I feel steady in the presence of death. I can stand with grief, pain, heartbreak, and loss without turning away. I can stay present even as a woman my age with metastatic cancer stroking her husband’s face in the hospital bed while their young children play on the floor. I’ve internalized that I could have been that woman. I could still be that woman. And that everyday is not something to take for granted. It’s not a matter of if we die, it’s a matter of when we die. Perhaps you are thinking about your grandparents who will die and then your parents and then your siblings. Death happens to everyone, and often not the way we imagine or expect it. Nature does not follow orders.

I live with the finality of my life at the forefront of my mind, and it has made ordinary, simple moments feel incandescent. The small moments are the big moments. Holding hands with my husband. Sitting around the dinner table with my kids. Going on a walk with my best friend. Even at the end, when life has never felt more finite, most wishes are simple: sit outside and watch the birds, feel fresh air, share a laugh with grandchildren, reconcile with a daughter, drink a glass of beer.

I’ve never felt more alive than after bearing witness to death. When I kiss my husband, especially after a day at the hospice facility, I sometimes think: this could be our last kiss. This might be our last night falling asleep wrapped warmly together. I’ve heard enough husbands sharing that no one expected their wives to be the one to get sick: she was always the healthy, positive, active one. I think this way with my children, too: maybe tonight is the last time I tuck them in; maybe tomorrow is the last time I’ll pack their lunchboxes or walk them to the bus.

These aren’t morbid thoughts, and they don’t come from fear. They’re acknowledgments of impermanence that pull me fully into the present. The kiss lasts longer. Waking up in his arms feels like a gift. I let go of frustration at the kids’ bedtime shenanigans and try to make room for as much laughter as possible. I tell people how I really feel and I want to repair rifts quickly. And at family gatherings I’ll say, gently, “We probably only have a handful of these left, all of us together.” It can overwhelm, but it recalibrates the room toward gratitude.

When we live with our beginnings and endings in view, life doesn’t shrink; it sharpens. May we notice—and keep noticing. We’re often so busy reaching for the next moment that we miss the one we’re living. Live in alignment with your values. Feel things that are raw and real. Keep one another company—through contractions and last breaths, through ordinary mornings and dishwasher repairs. Bless this brief, beautiful time by being fully here while we have it.

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