How many times since his cancer diagnosis and death have I had to bat away tears while working at the hospital? How many times has the shape of a patient's eyes, the cut of their jowls, the familiarity of their accent, the cadence of their speech, or the rhythm of their gait made me think: He was like that too. He would have wanted to leave the clinic out of frustration. He would have looked at his doctor like that. He would have shrugged his shoulders too at the impossibility of it all. Blink, blink, blink. Now is not the time. There are other patients to see, residents to supervise, and questions to answer. Now is not the time.

In pre-COVID times, my father spent the intervening months from his cancer diagnosis to his death, in and out of the hospital, for weeks at a time. From recurring bouts of heart failure, to COPD exacerbations, to febrile neutropenia, the hospital became like a second home. He was a fixture there. I can still picture myself pulling-up to the hospital's roundabout and seeing him, in a hospital gown and flannel pajama pants, smoking alongside others on the small patch of grass across the main entrance. This was his small reprieve from the tedium of the hospital routine. Sitting there, smoking his cigarettes, where the statue of the hospital's namesake saint held court over the wayward souls. Many times, the nurses would be looking for him to take his blood, to dispense a medication, and to check his vital signs and he would be gone. Ironically, it was a good sign when he would have the energy to go out for a smoke; it meant that he had a temporary pardon from what ailed him at the time, a fleeting improvement in a larger battle he would not ultimately win.

When I stayed at my parents’ house during my father's hospitalization, memories of growing-up there came rushing back. The click/squeak/creek of the basement door heralded my father's arrival from a day working on the construction site. The front balcony where a teenager coming home too late at night might find him, smoking outside, leaning back on a plastic chair with his right leg sticking out. The two lion sculptures, painted white with black eyes, would greet us when we returned home from school. The garden where he grappled with, and ultimately prevailed, in trying to grow a contraband fig tree from Italy in Canada's harsh climate. The basement cold room, or cantina as we called it, with rows of jarred tomato sauce. The fireplace in the basement where one of his kids threw his beloved cigarettes into the flames. Our futile attempt to incinerate them so he would not smoke anymore. We still argue about whether it was my brother or I who committed this simultaneously brave and stupid act. The avocado green kitchen appliances are now gone, but the memory of my brother dropping an open bottle of orange soda to the floor with an impressive spray has not faded. He always sat in the same seat at the head of the table. This was his unspoken and unmistakable spot for as long as I could remember. The wood-paneled basement with his precious hunting trophies from long ago days when he was well enough to head into the wilderness on weekends. The tiny garage where the spoils from those hunting trips would be hung and prepped for dinner. The driveway where a huge car from the late 70s gave way to a smaller, more manageable model over the decades. The fence that held his rusty bicycle he rode to the park. This was his small kingdom and sanctuary that he had built alongside my mother. The place that his myriad illnesses took him away from all too often in the months preceding his death.

I asked him during those months, what he thought about the multiple hospitalizations, often so close together, only home for days at a time. Did he mourn his previous quality of life? Did spending more days admitted to the hospital than at home bother him? As long as your mother can come to visit me, bring me some coffee and some homemade food, I am fine. As long as I can go out to smoke, then I can manage. This is enough for me. Shaken by his answer, and oblivious in that moment to my own biases and assumptions about what a good quality of life could possibly look like, I was chastised. Silent. This is often the unspoken curse of the healthcare provider. Thinking they know best. Thinking that their own personal, and ultimately theoretical, preferences for their end-of-life should be the objective truth for others too.

Only months after his diagnosis, my father died in the intensive care unit of their local hospital. An urgent tracheostomy and ICU admission seemingly other decisions I would not choose to make for myself. Weeks before his death, he began to lose his voice. Then he became progressively short of breath. One day, he had so much difficulty breathing that he went to the emergency room. He saw a specialist who told him and my family that his airway was critically obstructed and he would need a tracheostomy to survive. The doctor also offered him a comfort care approach, where they could palliate his symptoms and allow him to die with minimal suffering. Initially, he vehemently declined the tracheostomy. He did not want to live with a hole in his neck. But given the options, he eventually relented. He was hopeful the surgery would help prolong his life. Unfortunately, the promise of the intervention went unfulfilled. He died six days later in ICU after multiple complications, sedated, and was unable to communicate with us. He was never awake for more than a few seconds. I am not sure he even realized we were there. Although I was able to visit him in the days before he died, I was not there when he passed away. His big, bold presence was gone.

Only after he was gone did my mother tell me that he had actually been preparing for his death. He had never breathed a word of this to me. On good days, he could be found at the neighborhood park playing cards with his fellow paesani. Italian card games like Briscola or Scopa were usually the card games on tap. The stakes were low but pride rode high. Even in the midst of telling us that he was going to recover and travel to Italy for a visit soon, he gave away his usual pack of playing cards to a friend shortly before he died. He talked to my mother about selling his car. He could not picture driving it again. He discouraged my mother from wearing black after he died, even though it was their tradition. I know what you did for me while I was alive, it doesn't matter what other people think. You should wear whatever you want. My father, ever the protector and epitome of the strong silent type, never spoke to any of his grown children about this. For as long as I could remember, my mother would say “se tira avanti” which literally translates into "I am pulling myself forward." In the midst of grieving my father's loss, all of us are also grieving a way of life temporarily lost due to COVID-19. It seems we are all trying to find a way to pull ourselves forward, for better or for worse. We are attempting to both honor and mourn those people who are slipping away, enduring silent moments of recognition and tears that still need to be kept at bay.