Even though it's inevitable, death and dying is just as mysterious and elusive a subject in the modern world as it was in prehistoric times. Professional people who work with the dying seem to us both heroic and saintly. Yet the hospice or oncology department staff see nothing unusual about their work. "We do what has to be done," they say matter-of-factly.

Bris Bird is a nurse in a palliative care unit. She has vast experience working with terminal patients, both in the hospital setting and through home care service. She also lectures extensively on her down-to-earth, humane approach to the dying. "It's less difficult to die at home than in a medical setting," she states categorically.

"We're not certain what the sequence of events are in the dying patient," says Ms. Bird. For instance it's very difficult to predict when a terminal patient will die. Some appear to be on their last lap, but then improve and die just when they seem to be getting better. "Then there are those patients who just can't seem to let go," says Bird. "They suffer. They are obviously very weak, yet they hang on. Sometimes it's because they have some unfinished business to attend to, or their conscience is not free."

She recalls a woman who couldn't die, even though it was obvious that she was ready to do so. Ms. Bird sat by her bedside and just let the woman talk. It seems she had tolerated a husband who had strange sex habits, which she felt were "bad." Now she was afraid to move on. The nurse reassured her, saying what a good and supportive wife she had been, absolving her of her guilt feelings. Greatly relieved, the woman was able to die shortly thereafter.

"Some people manage their dying. They predict when they'll die, and it's uncanny, but it never fails to happen as they foresaw it," continues Ms. Bird. "One man tried to protect his wife, even in his terminal state. She was constantly at his side looking after him, and he lingered on long after the doctors predicted he would die. He passed away only when she stepped out one afternoon to answer a phone call." Although there's no research to bear out her hypothesis, Ms. Bird strongly feels that some people seem also able to control this aspect of their life. There was a Hassidic rabbi who said good-bye (not good night) to his wife before they retired one night. On the eve of his death, one of his followers had come to ask him what to name his newborn son. The Rabbi answered, "Wait until tomorrow and you'll have a name." And indeed, the next day, he named the child after the rabbi who had died.

"There is a time to be born, and a time to die," says Ms. Bird quoting Ecclesiastes, "and we can be more effective if we accept this maxim and realize we can't always prevent a patient's death. What we can do, as professional workers, is to determine how comfortably, with how much dignity, a person dies." Ms. Bird gives many examples how little things in the care of the dying can have a big influence on their welfare. "In palliative care the direction of care changes," she states. The focus is on symptomatic care and the staff takes its cue from the patient and what he/she wants."

Many patients are afraid of pain. "Even if they don't discuss it, they feel it." A dying patient might lie quietly but rigidly in his bed, afraid to move, afraid to ask for help. With just a little medication his quality of life can be improved many-fold. Even though some doctors are reluctant to give increasing dosages of painkillers, she finds their arguments (that they may become addicted or their breathing will be reduced) ridiculous. "There's no excuse for suffering," is her motto.

Ms. Bird is also alert to emotional and spiritual pain in her patients. She believes that it's very important to be aware of this aspect of the dying process. A sensitive worker can help her charges discuss what's on their mind and find some relief. Family members are important partners in this and should be encouraged to speak openly with their dying relative at this crucial state of life. "Lies to protect the dying only lead to isolating the patient from his dear ones. I try to tell families,

The nurse believes terminal people realize that they're dying, even though families like to fool themselves. "There are ludicrous situations where the daughter doesn't want her father to know he's dying to protect him and so can't tell him how much she loves him and how wonderful he was to her as a father. He, on the other hand, wants to protect her from the knowledge that his days are numbered, so he can't tell her how he wants his possessions distributed, how proud he is of her accomplishments and that he's not afraid to die. How sad and how unnecessary such very common situations are," she declares.

"Food and drink are big problems for the dying patient," says Ms. Bird, "especially for the families." Eating means life, love and care, so when their loved one doesn't eat, the spouse or children get very frustrated. The nurse cautions that dying patients should be allowed to eat when they want. She does not believe in forced feeding (even by intravenous tubes), and as far as water is concerned, she makes the radical declaration, "Patients die better a little dry." Dying patients cannot absorb fluids well, and will have less nausea, pulmonary secretion, and need less suction if given water only to keep their mouth comfortably hydrated.

As to breathing, oxygen is given in their hospital only if the patient is in distress, not if the breathing is slow or labored. "Patients with cancer of the lungs are often afraid of dying of suffocation or choking, and need to be reassured -- either by having an open window, a fan or best of all, a reassuring person next to them to allay their fears," she states.

"Good nursing of the most basic type really comes into its own with terminal patients," Ms. Bird says. Here again she expresses her matter-of-fact, practical approach, laced with a gentle and caring manner. "Washing the dying patient should be done only to make him/her more comfortable, not as a routine procedure to clean for cleaning's sake." She favors sitting the patient up, and even taking him out into the garden or day room when possible.

Patients who are bed-ridden, even in the last stages, should be moved to avoid stiffness and bed sores. If pressure sores do develop, they should be covered and left alone, unless infected, as dressing them is a futile and unnecessary hassle for the dying patient in her opinion. Toileting is important as is keeping the terminally ill dry, even if this means using a catheter. "There's nothing dignified about a wet bed," claims Ms. Bird.

Dying patients often have a poor self-image. "They hate their bodies, so brushing their hair, cutting nails, shaving or even applying cosmetics counteracts this negative sense of self," says Bird. "It also helps us focus on something we can do for them," says the nurse. She recalls one terminal patient who she convinced to put on some face cream and try a new hairdo. When the woman looked into the mirror and was pleased with what she saw, she winked at Ms. Bird and said, "Once a woman, always a woman, eh?" "That made my day!" says Bris Bird, a living legend in her own right and an inspiration to professional people who are privileged to gain from her guidance.

What have you done to make them emotionally, physically and spiritually more comfortable?