Review: “The In-Between”

| October 22, 2023

Hadley Vlahos entered college with an aspiration of becoming a writer, yet nursing was a career choice that she made to provide a stable income as a single mother. Early on in reading her book The In-Between, it’s clear that she is both a gifted writer and a skilled hospice nurse.

Each of the book’s 12 short chapters features her nursing a different hospice patient. Throughout each striking patient narrative, she adeptly weaves together an overarching message about cultural views on death and dying with key aspects of her personal development. In reflecting on the process of cultivating close connections with hospice patients as they journey through death, Hadley bravely reveals her personal struggles with faith, childhood abuse, disordered eating, suicide, and an evolving understanding of intrinsic worth.

In nursing school, an emergency medicine internship led to Hadley’s first nursing job in emergency nursing. In her experience, emergency nursing and medicine often focuses on saving patients’ lives with little to no emotional intelligence. In nursing school, she aspired to be like her ER preceptor who was cool, calm, and collected under pressure. It wasn’t until she witnessed a loved one require emergency services that she realized the inhumane rudeness that permeated some ER professionals’ steely demeanors. Still, when she first transitioned from emergency medicine to hospice nursing, the nature of the work seemed foreign. Hadley felt like she was “doing nothing for patients.”

With the support of her hospice colleagues, she began to embrace the value of quality-of-life measures of care for patients. While administering analgesic medications was a top priority, sometimes the most effective care for a patient included making their favorite sandwich and playing beloved music. Hadley embraced a caring demeanor and demonstrated genuine interest in patients who had very little time left to live. By treating patients as worthy of growth, and as interesting people with stories worthy to share, Hadley worked to potentiate the end of life as equally valuable as any other time.

Hospice care, much like palliative care nursing, works to improve quality of life wherever possible. With these two medical specialties, life may be extended but it has a diagnosed end point. As a hospice nurse, Hadley doesn’t only extend her emotional warmth and comfort measures to patients but also to their family and friends where appropriate. The quality of her nursing care is a direct result of her emotional connection with patients and their families. While she strived to maintain appropriate professional boundaries, those lines were sometimes slightly crossed, driven by her ethical compass.

How do you feel about how our society treats those who are sick and dying, and what message is most often conveyed to gravely ill people about their worthiness? One highlight of the book is the chapter about Edith, an Alzheimer’s patient, and her husband, who cares for her. Hadley not only gives an intimate perspective on the tortuous diagnosis of Alzheimer’s on patients and families, she also discusses the realities of family caregiving.

Family caregiving is often full-time exhausting work. Burnout is frequent, and most families in America can’t afford outside support. While hospice is covered by Medicare, caregiving is not. In her area, Hadley reported nursing home costs averaging $10,000 a month, and most people must be very rich or very poor to get help.

Throughout the book, Hadley presents incidents of strange coincidence after coincidence, reviving her views of connection and faith after childhood religious disillusionment. After so many eerie striking occurrences with patients, she increasingly mulls about the possibility of an afterlife. While her medical training at first caused her to reject the spiritual nature of her observations, the repeated occurrences of unexplainable phenomena accumulate into a network of unforgettable data. Hadley, as she advanced in her hospice nursing role, became more comfortable with uncertainty while simultaneously feeling connected to larger cycles of life.

Of particular interest might be how Hadley writes about an extraordinary phenomenon that repeatedly occurs to dying patients despite differing religious backgrounds: it is common for dying patients to see, hear, and interact with deceased loved ones. Hadley was encouraged by her hospice colleagues to accept that this as the reality of their patients, and that it often gives them comfort. She learns that those patients are not crazy and do not need antipsychotics; in fact, they still might otherwise be completely oriented to time, place, and person.

The In-Between is captivating, emotionally touching, and illuminating. Hadley crafted a text that is both a raw view into hospice nursing and an alchemic personal journey.

As healthcare workers we are united by caring for others, yet healthcare worker burnout and turnover has reached catastrophic levels. While the reasons for burnout or needing to break from the profession vary, our motivation and internal fortitude can be bolstered by the inspiring viewpoints of nurses such as Hadley.