I didn't know what a death rattle was the first time I saw it. It didn't sound like a rattle at all, more like a sustained attempt to breathe and spit at the same time, khhkhhkhhkhhkhhkhh. Tony Pastorini's eyes were wide open, looking vacantly at the empty hole filled with hallway that was his doorway. He'd been facing that doorway for weeks now, even though his doctors had wanted to move him to a hospice long before. They needed his bed for someone who still had a chance. Though I'd known that his death was imminent, I still wasn't quite prepared to see him this way, hovering quietly and helplessly between life and death. He looked weary and emaciated, with a few lonely strands of hair jutting out of his otherwise bald pate. Tony's esophageal cancer had metastasized to his bones, and he had been bedridden for over a month. He appeared decades older than his fifty-three years and was now in the end stage. My feeling of shock was itself a surprise to me, as he already had been quite sick on the day of my first session with him months earlier. I didn't need to look at his chart to know he was going to die very soon.

I had been in such a good mood only moments before. I'd just been named the Chief Clinical Fellow in the Psychiatry Service, despite the fact that I was a Psychologist and not a medical doctor. I felt proud and honored and a little full of myself even though my schedule was so difficult. In addition to full-time hours, I was also on call some evenings and weekends and I had a two-year old son at home. But I loved my work, and I had strong hopes of a future there after my fellowship ended. I'll never know whether I was right, because things changed dramatically soon after this brief visit.

I had been seeing Tony regularly since his admission to the hospital. He loved to talk about his life, and our sessions often consisted of long monologues by him, occasionally interspersed with comments or questions by me. He spoke always in a slow, quiet voice, sometimes looking at me and sometimes looking off into space. And when I asked about subjects he didn't want to discuss, like his doctor's suggestion that he start looking into hospice care, he just looked at me and waited a few seconds. "You know," he would start while I'd wait for an answer, "did I ever tell you about my favorite Madame Butterflys?" Tony was very much an avoider, and, like many people in desperate situations, he held on to the coping style he knew best. He preferred to stay in the hospital rather than move anywhere, and simply avoided the question of why hospice might be more appropriate. And Tony was perfectly happy to coast in his bed, blithely reminiscing with familiar faces about the old days, whether those faces seemed to want him there or not. If he'd paid attention, he might have noticed that many of them didn't. They wanted to save their beds for the fighters, and with the unused Ensure cans piling up on his side table and his ever decreasing weight, he wasn't fighting anymore.

Tony's style was very different from my own, as I tend to go far in the other direction, looking for trouble before it starts and taking a proactive role in trying to hold it at bay or meet it head on. It could be hard sometimes to relate to Tony, for me and for the rest of his medical team. We were all so busy doing, it could be hard to understand someone who seemed content just to be. But I couldn't help noticing how Tony's voice would come alive when he was reconstructing his life outside the hospital, even when the subject was painful. Or how his face would brighten when telling stories of his overprotective brothers, or recalling his great lost love, a fiancée who had died in a car crash twenty years before, or describing his favorite paintings and operas. Besides, my style took its toll too. It takes a lot of mental energy to be always conscious of the things that can go wrong in a day, the things you need to do to feel like you're accomplishing something.

Tony's room was low enough that he could hear the bustle of the noisy narrow street beneath his window, and he liked to fantasize about the people below, imagining them walking down the block blissfully unaware of how quickly their time was passing. I imagined they probably were more aware than Tony thought, since many of them were the doctors, nurses and families of people like him. On the other hand, some of those people weren't walking at all, but instead were leaning against the hospital wall getting in a quick ironic smoke before putting on their white coats and scrubs and getting back to work.

It felt odd now suddenly to encounter Tony without words. Instead, all I could hear was the heavy sound of his breathing over the whir of the machines connected to him. As this was likely the last time I'd see him, I chose to stay awhile on the off chance that he might be comforted by my presence. I spoke to him a little, but mostly I sat by his side, feeling somewhat awed by the encounter. At least there was one battle he'd won; he clearly wouldn't be going into any hospice program. Although I'd worked with many terminally ill patients, I rarely had the chance to say good-bye at the end like this. A quote came to mind, by Samuel Beckett. "Astride of a grave and a difficult birth." And Tony certainly looked astride of a grave at that moment. Then, I thought of all the people trying to live their lives while fighting to survive their ordeal, and I envisioned a day when I would be the one lying in a bed just like theirs. What would I be reminiscing about?

I wondered if Tony sensed my presence, and, if he did, whether he considered it a comfort or an intrusion. I got up to leave, when I had a sudden insight that was as powerful as it was ordinary. Beckett wasn't referring only to people in Tony's situation. He was describing how we all live our lives, with our mortality hanging over our heads from the moment we're born. I caught a glimpse of myself through Tony's envying eyes — one of those healthy people walking down the street, oblivious to the real facts of life; that it's short and precious and you'd better know what matters to you now. I suddenly knew where I wanted to be in my life, but it wasn't the course I'd set for myself.

I thought of the previous weekend when I'd been on call, seeing to a delirious patient in the hospital in the middle of the night. Soon after I'd arrived at the hospital, my husband called to tell me our son was sick. His temperature would soon climb to one hundred and six. I stayed with my patient until his delirium stabilized, but spent the next sixty hours shuttling back and forth between the hospital and our apartment, juggling phone calls to my husband, our pediatrician and the hospital's team, trying to give my all to both people in my care. Both ended up feeling fine. I was less so.

Sitting now beside Tony, I knew that what I wanted most was to spend more time with my son before his toddlerhood completely passed me by. I wanted moments that I could reconstruct from my own deathbed one day, a lot of them. And I also wanted the time to digest the unarticulated impact my work was having on me. More than that, I wanted to write about it. Ever since I'd been a child, I'd wanted to write, but it had been a vague and unfulfilled desire. I knew I was now having an experience worth sharing, but was unsure what I had to say about it. I wanted the time to find out what it was I wanted to express.

I turned my attention back to Tony. He was lying there just as he had when I first had walked into the room, breathing loudly, eyes wide open but looking vacant. I leaned over him and touched his arm slightly as I said good-bye. He never regained consciousness and died quietly in the middle of the night.

At first, I tried to ignore my inconvenient epiphany. It was clear what the consequences would be for my status at the hospital if I tried to cut back my hours. One senior Psychiatrist suggested that if I couldn't give the three hundred per cent expected of me, perhaps I ought not to be working there at all. But the vividness of my experience stayed with me; I cut back at the end of my fellowship year anyway, and made a connection with a Psychiatrist at the hospital who wanted to start a new kind of group therapy for cancer patients. I studied the work of existentialists and scientific researchers, ultimately designing an existential group therapy and writing the manual for future research. It was and remains one of the most fulfilling experiences of my entire career.

But I also reveled in the time I got to spend with my son. I had to smile when a member of our therapy group told us about how illness had changed his priorities. "You're not going to find yourself on your deathbed saying, 'Oh shit, what about that meeting I missed.' No, you're going to think of all the times you missed being with the people you love."

I ultimately had a second son, and decided to stay home with my children for a while, consulting when I had the time. Then I began writing a book about my experiences at both ends of the life cycle. And the final catalyst for this sea change was a man whom I was supposed to be helping, a man who could not even speak and who was totally unaware of the effect he was having on me.

The famous Psychiatrist Viktor Frankl described the desire for meaning as a basic biological need, a craving for a sense of belonging in the world and of having a personal impact on it. He thought there were three avenues open to us in our search for meaning. The first is the most common, our work or our art. Not only our jobs, but what we do, the causes we fight for, the things we make. For Tony, this avenue had been closed off long before I'd met him. But all wasn't lost. Another path to meaning in Frankl's view was through our experiences, how we relate to other people or to beautiful things in the world; our ability to appreciate what Beckett once called, "the beauty of the way and the goodness of the wayfarers." Even in the bowels of a concentration camp, Frankl could appreciate a luminous sunset over the mountains of Salzburg, and he felt more whole simply for knowing he could. Just as Tony could still appreciate his favorite sopranos and the people he loved. And as I could appreciate his appreciating them, even when he could no longer tell me himself. And when that ability is also lost to us, Frankl suggested we could still experience meaning through nothing more than our attitudes toward the unavoidable things that happen to us. Just being alive, just being, meant you had an impact.

I especially thought of Tony when I walked my older son to his pre-school class each day. Before, taking him to school had been a source of nothing but tension, as we would struggle to make it out on time, yet another stress-filled chore. I am not a morning person, and, in addition to getting both of us dressed and out the door, I had to make sure I had whatever papers, articles, phone numbers, etc., that I would need afterward at work. Invariably, I would forget something on the way and would start calculating— whether I had enough time to go back, whether I could substitute one thing for another, how long separation would take at pre-school.

After I cut back at work, the walk to school became the most treasured part of my day. I was aware on one level that there were many aspects of my career that were going to suffer in addition to the financial burden. I couldn't put these walks on my vitae, I wouldn't publish articles about them (except perhaps now), wouldn't get promoted for conducting them well. And those were things that mattered to me, and still do. I had a particularly vivid taste of the conflict between my personal and professional lives when I received a call from a therapist. He had read my journal articles and wanted to discuss the therapy group he was starting. While we were busy discussing existential issues like death, hope and meaning, he heard a tiny voice call out from my end, "Oops! Sorry about your bedspread, Mom. I forgot to wipe! Could you help?"

But my feelings about my lost status paled in comparison to the new feeling I had walking arm-in-arm with my boy. To my surprise, my favorite moments were completely uneventful, the more mundane the better, like talking about what he'd have for snack or what color play-doh he'd be making in school that day. We talked about the different colors of the trees, found shapes in the clouds, and ate steaming H&H bagels with no yucky stuff in them. Just walking with him on Broadway made me feel alive. Even when I tried to kiss him in public and he recoiled in quasi-disgust. Even when he stumped me by asking if I would ever get dead, and followed it up by asking if he would get dead too. I answered briefly and almost honestly. Yes, I told him, one day, like his frog Eric, we would both get dead. But, I added, I didn't expect that to happen for a long, long time. "That'll be a bummer," he responded casually. I wasn't satisfied with my answer though it was the best I could do on the spot.

But I hope to do better than that one day, for both my children. I hope I can convey to them what I've learned from the people with whom I've worked. Frankl believed that we could find meaning no matter what the circumstances, even in Auschwitz, even unto our last breath. Even lying in our deathbed unaware of life going on around us, we can make an unexpected difference in someone else's life. Whether it's through our work, or our art, or the children we raise, or the example we set simply by living our lives and working with the cards we're dealt, we make our mark. It's hard to deny Beckett's point that from the time we're born, every moment of our living brings us that much closer to our death. But the converse is also true–every moment we're dying is also a moment we're still alive.