Abstract
The In-Between is a narrative book describing the stories of 12 patients at the end of their life, as cared for by the author Hadley Vlahos, a hospice nurse. It interweaves the patients' stories chronologically with the author's life and explores how those patient encounters imparted wisdom and personal insight along the way. The patients' disease processes range from cancer to chronic diseases such as dementia and chronic lung disease.
The content of the book explores several themes, including the generally challenging and misunderstood topic of hospice, as well as the systemic limitations of health care and a phenomenon the author calls, “end of life visitations.” Overall, the text is written in an approachable way for a broad audience. The vulnerability of both the patients and the author allows for the text to touch the hearts of readers whether they have professional or personal familiarity with end of life, or not.
The introduction of the book discloses Vlahos's transition to nursing as a means of necessity to care for her young son as a single mother. She shares her personal journey, as someone who lived in a death-positive household during childhood, being a child of embalmers. She also reveals how the death of a close friend during her school years ignited existential questions about life and death at an early age. Each subsequent chapter focuses on a single patient, opening with Glenda—the first patient death Vlahos experiences as a primary hospice nurse.
Within Glenda's story, Vlahos describes her personal beginnings in hospice, including encountering the common question of how someone can provide end-of-life care as their primary occupation. She contrasts hospice with her hospital training environment from nursing school, as she begins to learn that not all treatment lies in administering medications. Sometimes, physical presence and connection is what someone truly needs, particularly nearing life's final moments. As Glenda's prognosis continues to shorten, Vlahos expresses her shock and confusion when Glenda shares that she can see and interact with her deceased sister in the room with her.
This story sets the framework for each subsequent one—all with unexplainable events in the final moments of life. These incidents range from premonitions to sensing a presence or noting flickering lights. Each subsequent patient, and chapter, explores additional imprints on Vlahos as a person and as a clinician—ranging from advice to give others a piece of your heart (Carl), to share love (Sandra), to maintain perspective (Elizabeth), to challenge hindsight (Reggie), and to accept genuine friendship (Lily).
The underlying themes of the book seek to highlight the gray areas in life—the moments without a clear answer, acceptance of the unknown, and everything in-between. Among these themes, there are two calls to action that stand out within the text. The first is a need to maintain humanity—as a person, a patient, a clinician, and a loved one. The second is to live a life that makes you happy and brings you peace. In other words, “Eat the cake,” as recommended by one of Vlahos' patients, Elizabeth. Two of the most pivotal transitions in the book occur with the death of her mother-in-law, Babette, followed by the story of Adam.
Initially, Vlahos avoids patients and diagnoses that mirrored the experience she shared with her husband and family as Babette died from glioblastoma. In the book's final patient-led chapter, Vlahos cares for a young man who mirrors her husband in age as he dies from the same condition her mother-in-law died from. She learns that her experience, although fraught with grief, gives her greater understanding, strength, and empathy to care for those who are walking down a similar path.
All in all, Vlahos unveils moments of awe, deep love, and understanding throughout the entirety of the book. She reveals her own struggles, navigating feelings of failure that are likely to resonate with many. With this book, Vlahos exemplifies the interweb of our own stories with those we care for and how the path to finding closure for ourselves can open us to learning from those around us. She encourages the population at large to be open minded and walk into the in-between with open hearts and minds.