In The In-Between: Unforgettable Encounters During Life’s Final Moments, Hadley Vlahos, a hospice nurse, explores her experience caring for dying patients as it influences her own life. She writes in first person as she weaves together her professional and personal lives, which at times become indistinguishable from one another. Discounting the Introduction and Conclusion, the book is split into 12 chapters, each named after a different patient.

This summary references the first edition of her memoir, published in June of 2023.

Content Warning: The source material features stories that revolve around death and dying, including descriptions of a healthcare system that at times fails patients as well as descriptions of ailments including cancer, liver disease, and Alzheimer’s. The author also touches on topics such as eating disorders, suicide, abortion, emotional abuse, and unhoused populations.

Summary

Vlahos begins with an introduction that presents an overview of hospice. Hospice refers to the point at which a patient who has been medically determined to be at the end of their life chooses to forgo treatment and instead pursue comfort for their remaining time, which could be days, months, or years. Vlahos introduces a paradox that threads the book together: that moments of devastation often coincide with moments of beauty. She also explains her purpose for writing, which is to share these stories of death and dying with those who do not get the chance to see into this world outside their own personal tragedies. She aims to debunk misconceptions and fears surrounding death, satisfy a universal curiosity surrounding the topic, and show the differences and similarities between the ways people die.

Vlahos recounts the journey that led her to become a hospice nurse. As a child, she was strictly Episcopalian. Her grandparents were funeral directors, so she was aware of death at a young age. In her early teenage years, she watched her friend get hurt in a football game and die later that night. This prompted her to think about death in the context of religion, and she wondered why, if God is all-powerful, he would let this happen. Asking these questions was taboo, and when she left for college three years later, her feelings remained unresolved. At college, she felt free for the first time but became pregnant the summer before her sophomore year. Her life was once again flipped on its head. After having an unexpected spiritual experience in a church, she chose to keep the baby and drop out of college to enroll in nursing school and become a mother.

The first patient Hadley introduces is her very first hospice patient, Glenda. Glenda’s death brings with it a scientifically unexplainable situation. A chandelier’s light goes out the minute Glenda dies—the same chandelier under which her dead sister appeared to her days prior. Vlahos, a new nurse, is shocked and scared, but several other nurses reassure her that dying patients regularly see their deceased loved ones before they pass.

Vlahos next recounts the story of Carl, whose deceased daughter seemingly comes to fetch him in the form of a bird. Vlahos connects with Carl and his wife deeply and mourns him when he passes. Next is Sue, a “difficult” patient who reminds Vlahos that hospice exists to provide comfort, not treatment, and that comfort is a worthy goal. The well-off Sandra prompts Vlahos to reflect on the fact that no amount of money can shield a person from death; what ultimately matters is human connection. Elizabeth, a 40-year-old patient, sees herself in Vlahos and confesses that she spent her life worrying too much about things that don’t matter, like her weight; this prompts Vlahos to confront her eating disorder.

Edith is an Alzheimer’s patient who transforms Vlahos’s understanding of the disease by remembering things she should not be able to (medically speaking) and even correctly predicting a fire that happens after her death. When Reggie dies of liver failure, his wife, Lisa, dies by suicide. This nearly break Vlahos, who blames herself and must go to therapy and face the fact that she cannot control most things. The bond between a young woman, Lily, and her friend reminds Vlahos of the importance of friendship. As a result, she reaches out to an old friend about being a bridesmaid in her wedding, having just gotten engaged to her boyfriend, Chris.

Chris’s mother, Babette, has brain cancer throughout much of the couple’s relationship but lives years longer than expected. However, by the time Chris and Vlahos marry, her health is clearly declining, and she soon enters the hospice Vlahos works for. Vlahos is close to her mother-in-law and determined to give her the most peaceful death possible, but a series of unpredictable events results in Babette dying in a chaotic hospital environment. This deepens the grief Vlahos experiences, as she blames herself.

When Vlahos treats an unhoused patient named Albert, she reevaluates her assumptions about people and defies company rules by bringing him and his friends groceries. Frank, a staunch atheist, pushes Vlahos to verbalize her spiritual beliefs and suggests that she write a book about her experiences. The final patient the book covers is Adam, a young man whose family mirrors hers. She returns home more grateful than ever for her family and takes comfort in the idea that, as Chris assures her, there is a greater purpose at work in their lives. In the brief conclusion that follows, Vlahos notes that while her experiences with death have persuaded her that an afterlife exists, she feels that one’s beliefs are less important than what one does with one’s life. What’s more, she has grown comfortable with the ambiguity of what is “in-between.”