The body of Jesus was usually a wafer, but every so often it was a soft, warm loaf. I never knew who made the call behind the scenes, though I do remember being enlisted to knead dough one Saturday in the home of a Sunday school classmate. I knew that transubstantiation—the belief that the bread and wine becomes the body and blood of Christ—is what distinguished our Catholic Mass from its Protestant counterparts. And if that were true, if Christ were really in the bread, it seemed that the bread should be warm. Those were the Sundays I almost believed.

My father spent Sunday mornings at home, and so I understood that church attendance would one day be optional. Indeed, the Catholicism of my childhood presented itself as purely ritual: we said grace before dinner every night at a pace so rapid that, to this day, I can only issue the words in a single stream of sound, blessusohlordandthesethygifts. If called upon by a visiting relative to lead us in grace before dinner, I could dodge by simply saying my name, Grace, and everyone would chuckle and dig in. 

It is also possible that I heard rumors of mutual exclusivity between science and religion and assumed my father fell into the former camp. He was a physician, a birdwatcher, a tracker of constellations. He hated television but loved Winged Migration. He relished conducting blind taste tests when my siblings and I complained that Giant brand granola bars were not as good as Quaker. He viewed health in terms as simple as arithmetic, declaring his intention to “run an extra mile tomorrow” as he switched out his sugar cone for a waffle cone at the ice cream shop. He ran every morning until his knees insisted he bike instead. Hespent his days with patients at the ends of their lives, and he was the person everyone—from his siblings and my mother’s siblings to former neighbors and college friends—called when someone was dying.

I remember the conversation that finally clarified why my father did not attend Mass. We were crossing the Chesapeake Bay Bridge on a Sunday night, westbound for Baltimore. It was only the two of us in the car, not unusual in my high school years, after all my siblings had gone. The radio was, as ever, tuned to the classical music station, and someone was playing on the low end of the piano.

Our talk had turned to my father’s mother, Grace Vanderpoel, who died when he was fourteen. Beyond passing comments on her likeness to my oldest sister, I did not have a cohesive sense of the woman for whom I was named. I knew my grandmother was an obstetrician and one of the first women to attend her medical school. I knew she was taller than most, a physical manifestation of her Dutch last name, which she kept when she married my grandfather. And I knew that she was pregnant or postpartum for nearly the entirety of their twenty-three-year marriage, resulting in five daughters and six sons, my father precisely in the middle. 

One of Grace’s nieces, a second cousin I had never met, had died over the weekend, and my father was planning a trip to Philadelphia for his cousin’s funeral. He mused that the room would be filled with relatives he barely knew and that he’d likely have to endure a fire and brimstone sermon from the local minister.

These predictions surprised me. 

“Wait, your mom’s family are born-again, or evangelical, or whatever it’s called?”

“Oh, yeah,” he said, looking over, surprised that I didn’t know this. Youngest children, it seems to me, are often skipped in the passing down of family lore, always too young to know and then suddenly too old not to. “That’s why Grace was disowned when she married a Catholic.”

“She was disowned?” 

He nodded slowly.

“Oh, yeah, yeah. There’s no halfway, maybe you’re OK, with these people. It’s you’re with us or hope you like burning in hell. A heathen at least they could have talked sense into—but a Catholic? Forget it.” 

My father began tapping a beat on the steering wheel as traffic slowed to a crawl on the bridge.

“I mean, they’ve totally lost sight of whatever it was originally about. All of them have—Catholics, Protestants, all these other crazy branches. A belief system that makes you abandon your daughter? Who decided that was a good idea?”

“No room for grace,” I offered.

“Exactly right,” he said.

From what I have pieced together in the years since, it seems the rest of Grace’s family—her four siblings, and now many of their grown children—lived as Southern Baptist missionaries in South America. Her younger sister, May, spent much of her adult life traveling between Philadelphia and Asunción, spreading the word of God and raising her six children on both sides of the equator. 

Grace, in her early thirties, living in south Brooklyn with her husband and growing brood, wanted to join the family tradition. Of course, she had converted to Catholicism after marrying my grandfather and no longer belonged to the church of her family, but she did have a medical education and thought she might save bodies rather than souls. She applied through the Catholic Church to travel abroad on a service mission, but they told her she had too many kids to travel—four or five, at that point—so she adapted her plans and traveled instead to the small upstate town of Delhi (pronounced del-high, not like the city in India). There, she ran an obstetrics clinic out of the family home, welcoming the town’s newest residents into the world by means of her living room. 

Her own children, meanwhile, made their way through the Catholic rites of passage, the town’s Protestant majority notwithstanding. My aunt Sheila sang in the church choir, and my father and his brothers were altar boys. I laughed when I saw this photograph—my father, age eleven or so, dressed in a long white robe with a black collar, his dark hair neatly parted, facing the camera with a look of piety I had never seen on his adult face.

When I was twenty-three, nearly a decade after I was confirmed at Corpus Christi and my family stopped attending on days that weren’t Christmas, I spent a summer working in the same hospital as my father. My job was to interview patients with terminal diagnoses and their families about their priorities and concerns and to help determine whether or not their medical treatment aligned with those priorities. I quickly found that, more often than not, patients wanted to spend their last days free from pain and with their loved ones, even if that meant fewer days alive. 

Central to end-of-life care is the family meeting, when the palliative care team gathers the patient’s loved ones to explain their prognosis, answer questions, and make decisions about how to proceed. These are often precarious conversations, when one poorly chosen word from a doctor can rupture whatever fragile trust has been built over the course of a hospital stay. Given how easily the news and its messenger are conflated, even the most experienced clinicians sometimes falter when they tell a family they have no cure to offer. 

One morning early in August, I sat in on a family meeting that included the patient’s sister, brother, daughter, physician, nurse, social worker, and my father as the presiding doctor. I had not yet seen my father in this role, and I did not know the patient personally, but I knew the man was hooked to a breathing machine down the hall, and I could guess where this conversation was headed.

“Are you saying there’s no chance he’s going to wake up?” the daughter was asking.

“Well, I always leave room for miracles,” said my father, to my surprise. “But that is what we would need at this point.”

The conversation made its way to compassionate extubation, which means taking patients off a ventilator when it becomes clear they will never breathe on their own.

“How long will he live once we . . . unplug him?” asked the sister. Across the table, her brother cringed at the word.

“That varies from patient to patient,” my father explained. “It could be minutes. It could even be a whole day. Once he’s free to go, it’s up to God when he leaves us.” 

His words were delivered with the measured calm of a preacher, and they seemed to serve as a balm. The patient’s family members spoke in low voices to each other. At the end of the meeting, they walked down the hall to say their goodbyes.

There was no time to debrief in the bustle of the intensive care unit, but I made a mental note to ask my father about the meeting later. As I drove home that evening, it occurred to me to wonder if he still believed in God. 

The next time I visited my parents’ house for dinner, I broached the subject. While my mother washed dishes in the kitchen, I asked my father what he meant when he told that woman it was “up to God” how long her brother would breathe. 

He told me about the hospital where he spent the first two decades of his career: Bon Secours Hospital was built by Catholic nuns in the early twentieth century to serve as a both a convent and a free health care center. The hospital, its name French for “good help,” remains open in what is now one of the poorest sections of West Baltimore. There, my father said, the majority of his patients had more faith in God than in the medical profession, and usually with good reason. 

“By the time I saw patients,” he told me, “God, cancer, it came down to the same thing. We did what we could to keep them comfortable, to get them out of the hospital and back home, but there’s no cure when every one of your organs is failing. As you know.”

I nodded. This was the foundation of palliative care, something we’d talked about a hundred times.

“And the patients know that. I can’t tell you how many patients have told me in the end, ‘I just want to go home.’ And they’re not talking about their house, they’re thinking beyond that.” He pointed upward. 

“It’s the families who need help letting go. They need to understand they’re not making the decision to end their loved one’s life by pulling the plug, and neither are we. Death is out of all of our hands. So in that sense, it might as well be up to God.”

“Right,” I said. That accorded with what I’d seen that summer, the families needing the most help. For some reason, I was nervous to ask what was really on my mind. 

“But, I guess,” I started. “I mean, when you say that, do you really believein God?”

My father seemed taken aback.

“I did,” he said at last. “I was an altar boy, you know, and I wasn’t just going through the motions with the bread and wine.” He paused. “But to be honest, Gracie, I stopped believing in a benevolent God when I was fourteen. When my mother died.”

Somehow, it was not until that conversation that I saw the parallels between my father and his mother. Both had abandoned the churches of their upbringing. Both had pursued careers in medicine instead. Both brought to their work something of the missionary spirit, though certainly one more closely aligned with noblesse oblige than with the evangelism of the Vanderpoels. And between obstetrics and palliative care there is a common element of spirituality, as both met with bodies in a liminal space, my grandmother ushering people into this world and my father seeing them onto the next.

Not long after the family meeting that left room for miracles, I asked the palliative care chaplain if I could shadow her on her rounds in the intensive care unit. Contrary to popular belief, she did not only visit patients on their deathbed. In keeping with the palliative team’s goal of promoting comfort, it often made sense for the chaplain to visit a patient right after they’d received a terminal diagnosis, lost a critical function, or endured some other acute crisis. She was necessarily nondenominational in her ministry, and had been trained specifically for the hospital environment. I was curious to see what she did.

The first patient we saw could not speak, at least not right away. He fixed his gaze intently on the chaplain. He seemed to hear and understand when she asked, “How are you doing?” But he only continued to stare in response. It didn’t take long for the chaplain to switch gears, moving into deep breathing and what she called “mind-body” exercises, which involved the patient focusing his awareness on different parts of the body in succession. By the time we left, he was visibly more relaxed. He even offered a “Thank you, Linda” as the chaplain stood to go. 

I watched her in half a dozen rooms that day. Some patients wanted specific words said; she was not averse to prayer, of course. Some needed to talk about test results, family conflicts, money troubles; she let these worries air. I noticed there wasn’t a patient she didn’t touch, with their consent, or breathe with. I watched her dissolve the layers under which each patient was buried, doing the work of doctor, nurse, pharmacist, and social worker all at once. In the patients’ charts, where the spirit is irrelevant and the truth of symptoms absolute, she wrote with authority.

In the hallway, she explained to me the levels of somatic, emotional, and existential distress she observed in patients and sought to work her way through: the tight chest and shallow breathing, the silence and the tears, the terror and dread. I appreciated how this model connected physical sensations to their meaning, the literal to the abstract.

It is nothing new to find abstraction rooted in the body. An autopsy leaves little doubt: slice a person open and there will be no person there. Everything is at last contained within our cells. I had always thought that this dealt a devastating blow to any spiritual impulse a doctor might have, earthbound as it leaves us. I thought my father and grandmother had chosen bodies over souls. 

But the chaplain’s model challenged this dichotomy, collapsed the barrier between body and soul. Both, she maintained, can be true: Shortness of breath can be symptomatic of terror, and it can be terror itself. The body can be material and no less sacred for it. The communion bread is symbolic, yes, but you cannot eat a symbol.

It was not until the end of that summer that I found out how Grace Vanderpoel died. Two decades of pregnancy, miscarriage, and childbirth wreaked havoc on her body. The Catholic Church forbade the use of contraceptives, but after the birth of her eleventh child, my aunt Deirdre, Grace sought them out. This was in 1966, only six years after the first birth control pill was approved by the Food and Drug Administration. Its safety was understudied, and its long-term effects had not been studied at all. She died on a Sunday in February within months of her first dose from a blood clot induced by extreme levels of estrogen. Three years later, the FDA mandated a change in the pill’s formula.

It is easy to mythologize the woman who dies from having children. She is Christlike in her giving of self. It is easy to forget that this is still death, and there is still blood. 

I can see my father now as a profoundly spiritual person, despite his aversion to organized religion but not despite his work. His fascination with birds and stars and the human body is scientific but not without awe; his attempt to relieve the physical pain of dying is his way of helping families let go. We want to separate organ failure from what follows, as if life were not a bodily function and a transcendence, both. But I was raised in the Catholic faith, and they have a word for this. The fusion of the real with the symbolic—this is transubstantiation.