Questions.

Early morning questions around my sister’s death are constant.

I keep wondering, did I miss something?

What you might not understand about my sister is that she was always almost dying. She had a host of mental illnesses, one of which was Munchausen’s. If you don’t know what that means, here is how the NHS of the UK defines it (source):

Munchausen syndrome is a psychological condition where someone pretends to be ill or deliberately produces symptoms of illness in themselves. Their main intention is to assume the “sick role” so that people care for them and they are the centre of attention. Any practical benefit in pretending to be sick – for example, claiming incapacity benefit – is not the reason for their behaviour.

I could go on about how this affected her life and the lives of those around her, but the point is, I heard my sister say “I almost died” so many times that it became a catch phrase associated with her in the family. It also meant that I was skeptical of many of her medical claims.

Did I dismiss something important?

Her cancer was an incontrovertible fact. I was there for her appointments, surgeries, follow-ups. She was impossible during the entire process, because her Munchausen’s desire to be ill hit right up against her desire to live, which was incredibly strong. The war between the two played out in a lot of bizarre conversations, in which good medical news was greeted with anger and disdain, as if she’d been deprived of something. I endured this strangeness, teeth gritted, because she was my sister and she needed me. And because she was ill.

But was there something I disregarded?

She was on an estrogen blocker after her breast cancer, and those are associated with heart failure. Estrogen is such a miraculous substance. It bathes every tissue of a woman’s body to prepare her to pass human beings out of her body and into the world. When menopause starts, women’s heart health goes down. An estrogen blocker takes away what little estrogen a post-menopausal woman has. She hated her estrogen blocker and what it did to her, but she was afraid of getting cancer again so she stayed on it.

Is that what did it?

She was weak. I knew that. She’d had COVID more times than I can count—like five or six. She masked continuously, diligently, but she rode public transit with a lot of people who did not mask, and who were often sick, and sometimes would cough on her face because they were also mentally ill and she’d get angry and offer them a mask and you can only guess how that went. Besides, masks can only do so much.

COVID is hard on your heart. Was that what did it?

I want to believe that she woke up, stood up, fell to the floor and died sitting beside her bed. I want it to have been instantaneous and hopefully painless. But her wallet was on the floor, and her Medicare card and ID were on the counter by her front door. Now, as often as my sister took an ambulance to the hospital, this might just have been something she did on the regular. I have been transported in an ambulance once in my life. My sister took one at least once a month, sometimes more. But that time, did she wake up, think something was wrong, put her cards by the door and drop her wallet on her way back to the bed?

Was she afraid?

My nephew and I were so hopeful that she would move into assisted living. There is a place near me, only four minutes away from my front door. Brother Steve’s person lives there now. I’ve visited her and it seems fine and she says it’s fine. They’d have gotten along great, two intelligent, sarcastic women with significant health problems and sharp senses of humor. But my sis loved her apartment, her things, her friends. She wasn’t ready to downsize and give up her more independent ways.

But if she had, would help have been easier to get? Would she still be here?

I think about so many painful things in the earliest hours of the morning. I think most about my sister. I ask questions that will never be answered. The medical examiner declined to autopsy. That’s fine, because whether it was a stroke or a heart attack, my sister is still gone. The name for what took her would be one answer. But it wouldn’t be the answer to even one of the questions I ask myself when I wake up in the dark and start to cry.