John Beale, Post-Gazette Six-year-old Daniel Mankamyer shows off after reading for his mother, Laura, who tried to keep the family's routine as normal as possible throughout a 3 1/2-year battle with cancer. Click photo for larger image. Photo journal Share Laura Mankamyer's last days with family and friends in a gallery of pictures by Post-Gazette photographer John Beale: A remarkable life

Everyone had a hand on Laura Mankamyer last Monday evening.

Her closest friends and relatives gathered around her bed in the living room, stroked an arm, massaged a foot, caressed her forehead as they read scripture, told her they loved her, sang hymns. Her husband and best friend, both proud ex-Marines like her, joined in the corps anthem: "From the halls of Montezuma ..."

The group ran out of songs at one point. They prayed. Some wept. The Mankamyers' modern South Fayette townhouse fell silent as they wondered what to do next, but only for a moment.

Eyes closed, Laura twirled her index finger, a conductor's gesture to keep going. She was a 30-year-old woman minutes from dying from cancer, but she was still in charge. Nothing had changed for this marathoner who rebounded from multiple rounds of chemotherapy by running, drawing, kayaking, quilting and selling homes, among the many things she did that outpaced most healthy people.

So the parents and siblings and siblings-in-law and friends and husband and 6-year-old son sang some more:

Matt Mankamyer, the husband Laura fell for in 1990 when she was 16 and he was a new military policeman headed off to guard Iraqi prisoners in Operation Desert Storm, upped the doses of morphine and oxygen running through tubes to her. He hoped to comfort her. Soon, she seemed unconscious.

Young Daniel, her only child, the only one she could ever have after her disease robbed her of her uterus, asked if Momma was dying.

"Yes, she is," Matt said.

"Is she OK?"

Before Matt could answer, Laura took over with the family's common signal. It was the same one she flashed at her energetic son when he did well in his gymnastics routines. She turned a thumb upward.

Yeah, Momma was OK. She was gone within a few more minutes, but Momma was OK.

Not everyone gets to die like Laura Mankamyer -- surrounded by love in her own home, at peace with the plans made, the care received and whatever lies ahead.

	John Beale, Post-Gazette Matt and Laura share a light moment as they reminisce about their marriage. They tried to stay as positive as possible throughout her illness. Click photo for larger image.

On her last day, she still heard stories about herself, smiled and ribbed others in a whisper. Her room with the big bay window looking out on the back yard in the Hunting Ridge development was still a living room, not a dying room.

From some combination of personal determination, family bonds, religious faith, Marine training, hospice care and a medical support team that helped her let go, she died the way virtually any rational person would want.

But then, death is so rarely rational.

More than 2.4 million people die each year in the United States. Nearly 600,000, like Laura, die from cancer, though most are far older than she.

Many -- encouraged by their doctors and family members -- fight disease to the bitter end. They die in institutions, hooked up to machines, undergoing pain and probing, unable to communicate clearly with loved ones, cared for by changing shifts of staff who barely know them. If alert, they may be angry or depressed.

"The data that we have suggest that too many patients die in hospitals and nursing homes despite their wishes to die at home," said Dr. Robert Arnold, a University of Pittsburgh professor of medicine and president of the American Academy of Hospice and Palliative Medicine.

"Too many patients die with pain or shortness of breath despite data that show we can do better," he said. "Too many families go bankrupt or are financially devastated by the loved one's life-limiting illness ... and too many families receive little or no support in the bereavement process."

No one fought cancer harder than Laura Mankamyer did for 3 1/2 years. It was about twice as long as the normal remaining life span for someone diagnosed with her rare illness: extra-pulmonary small-cell carcinoma. But she was younger, tougher, fitter than most people when they realize a devastating cause for that cough or chest pain or fatigue that sent them to the doctor in the first place.

The initial diagnosis came in April 2001. A cough had bothered her since December, just before discharge from the Marines as a captain and adjutant running a general's office at Camp Pendleton in California.

The hacking grew worse. It seemed as if it might be whooping cough or pneumonia. She was distracted from addressing it because she was visiting a brother and sister-in-law to help care for a nephew who had just been diagnosed with leukemia. By the time she was X-rayed in one medical facility and scoped in another, the truth was awful.

Her first doctor at the VA Medical Center in Oakland told her in May 2001: "It doesn't look good. You've got cancer of the esophagus, and you should start getting your affairs in order."

She was a 26-year-old mother and graduate of Carnegie Mellon University with commendations as a military officer. Having just completed her service commitment, she and Matt were starting to plan the path ahead in terms of career and family. Now an oncologist was telling her that death was part of the not-distant future.

There was no "Why me?" from this nonsmoking, seldom-drinking fitness nut, nor would there ever be.

She scoured the Internet for information about her type of unrelenting cancer. It spreads rapidly and always reappears elsewhere in the body after chemo has treated it in one section. She read that 80 percent of people die within three years, maybe 2 percent make it to five.

Laura made it her goal to last five, then she carried her family, friends and medical professionals along on her inspirational, anguishing journey as far as she could go.

Laura's photo albums are full of her smiles, either with her normal, shoulder-length red hair or while bald from treatment. There's plenty of those carefully captioned and well-designed scrapbooks, as she was one of the most organized, creative, artistic individuals anyone who knows her has met.

	John Beale, Post-Gazette Laura holds a scrapbook turned to a page that celebrates her participation in the New York City Marathon in 2002, the year after her cancer diagnosis. The photo is being taken by Ellen Douglas, a hospice employee who was putting together a presentation for Laura's memorial service. Click photo for larger image.

The photos show her smiling whether hiking on a hilltop, sitting in a hospital room or completing the Marine "Mud Run." That's a 10-kilometer jog through a messy obstacle course after getting sprayed with a fire hose at the outset.

That was fun, or her idea of it. Everything had to be a challenge, the more unconventional the better.

She and best friend Rachel Graham felt a need to run on subzero days as college ROTC Marine Corps midshipmen when the 20 or so males in their group stayed inside. That level of dedication won her appointment as her unit's battalion commander during her senior year of 1995-96.

Her unconventional side came from her parents, Larry and Vicki Rempel. Larry was a conscientious objector of Mennonite background during the Vietnam War. Vicki was something of a counter-culture hippie.

Together, the parents developed a deep Christian faith and worked as missionaries and educators while living simply in various parts of the world. Laura was born in Zaire, Africa, and spent part of her high school years in China, where her parents adopted a daughter, now 15. Her military interest skipped a generation and came from her maternal grandfather, a World War II veteran and career Navy mechanic who's buried in Arlington National Cemetery.

For much of Laura's youth, the family lived on a farm in Lower Turkeyfoot, Somerset County, where her parents now operate a bed and breakfast. They had no television when she grew up. Her parents told Laura and three younger brothers to go outside and play and "don't come back until you hear the dinner bell."

Matt's family, the Mankamyers, is a large one that goes back generations in Somerset County. His uncle is a county commissioner. His father is a storyteller and former state trooper who runs a firm that installs security alarms.

Matt's and Laura's parents became friends before their children did. The Rempels lived in California temporarily after their China stint. They housed Matt for a few days when he was a 19-year-old Marine reservist, just activated in 1990 to be sent to Saudi Arabia. Matt and Laura, who was three years younger, were inseparable during those days.

That brief relationship led to letter-writing during his months in a sweltering, foreign land without showers or hot meals. The letter-writing led to love. The love led to marriage in 1994, when Laura was at Carnegie Mellon and Matt was a Collier police officer. He's an investigator today for the Mt. Lebanon Police Department.

Matt, who has gentle brown eyes and a boyish face, is described by various family members as "a rock,'' cool and steady in his approach to everything.

He was accustomed to the more intellectual, energetic Laura coming up with ideas for projects, household or community or otherwise, many of which he was expected to carry out.

He'd been an enlisted man in the Marines, after all. She was an officer. At 5 feet 7 inches, she also was a half-inch taller.

"I was the ox, and she was the fly buzzing around me -- bzzzzzz -- with a ton of energy and ideas," he explains. "She'd push people to go further than they would on their own," and not just him.

One of the things on Laura's checklist after her cancer diagnosis was making out a living will and do-not-resuscitate order, which she did. Another was to run in the New York City Marathon, which she also did.

	John Beale, Post-Gazette As evening settles in, Laura rests while husband Matt and their son, Daniel, mix it up on the couch nearby. It was four days before she died. Click photo for larger image.

She ran it in four hours, 19 minutes and 44 seconds on Nov. 3, 2002, with Matt and then-4-year-old Daniel using subway rides to get to locations ahead of her on the route, handing her water and shouting encouragement. The year before her diagnosis, she had run the Marine Corps Marathon in Washington, D.C., slower than that.

From the end of her first chemotherapy, she had two good years from August 2001 to October 2003. She became a stay-at-home mom while getting her real estate license and selling homes on commission for Howard Hanna. She illustrated children's books written by her father-in-law and a family friend. She volunteered for a Christian-oriented adoption agency.

With her youngest brother Erich, a mountain climber, she began making plans to scale Alaska's Mount McKinley, North America's highest peak. But then she felt a pain in the abdomen. The cancer had returned. She required a November 2003 hysterectomy to remove the uterine organs where it had spread. More chemotherapy followed.

Laura had another healthy half-year, even going on a 26-mile, three-day backpacking hike last September on the Olympic Peninsula in Washington as part of a Rempel family reunion. Her hand hurt during the trip. The cancer had returned, this time to the bone, about as painful as the disease can be.

That meant more chemo, but then her doctors at the VA in Oakland also found more spots on her kidneys and lungs and lymph nodes. Initial treatments for all that in November accomplished little. Cancer cells build up resistance the more a patient goes through chemotherapy. Laura had been through plenty by then. The treatment was exhausting her without improving anything.

By Thanksgiving, she and Matt, in consultation with the medical team with whom they'd bonded over three years, started facing the inevitable. Her oncology nurse, Michaelene Kinser, who keeps a picture of the family on her desk, asked Laura what she wanted.

"She said, 'You know what? I'd really like to go on a cruise with my family and friends,'" Kinser recalled.

A lot of people were surprised: first, because the thought of a cruise would have been anathema to a healthy Laura, who Matt notes would have preferred something like trekking to a primitive hut in Nepal; second, she was weakening and in frequent pain worse than ever.

A rotation of family caregivers began spending days with her and helping with Daniel after school so Matt could keep working. Sharon Richards, a nurse from Family Hospice, began arriving to monitor her and offer relief with medication.

But for Daniel's sake, Laura scheduled a Disney Florida visit and Caribbean cruise from Jan. 11-22.

By the time they left, she needed a wheelchair to get everywhere. She couldn't hold down the sumptuous cruise meals and would frequently cry and vomit at night. She hid it from Daniel and spent the days sightseeing, swimming with dolphins, doing things Matt couldn't believe based on the nauseated woman he'd seen in the cabin the night before.

Some people endure pain better than others. Laura was off the charts, much to her caregivers' frustration. She frequently refused morphine and other painkillers because they dimmed her ability to interact with other people, especially her son.

"If you ask people what they're afraid of," Richards said, "it's not dying or death -- it's the process of getting there and the pain. More people are willing to take pain medication on a more timely basis than Laura was. She had certain goals she needed to meet, and part of those were being present for her son as much as possible, for as long as possible."

It was with Daniel in mind that Laura arrived in a wheelchair at the Family Hospice Quality of Life Center in Manchester on Feb. 1. Her voice was a whisper. Tumors in her lungs and on her vocal cords affected her ability both to talk and breathe. She coughed and wheezed.

	John Beale, Post-Gazette Erich Rempel, one of Laura's four siblings, comforts his sister as her friend Rachel Graham looks on. Laura was surrounded by friends and relatives in her final hours. Click photo for larger image.

But she wanted to take advantage of a special benefit from Family Hospice, the Mt. Lebanon-based agency that created the new center to pamper its clients and help them leave a legacy. Laura came to be videotaped telling her life story, so Daniel could always refer to it.

For about 40 minutes, she talked with a clear gaze and frequent smile about her family, her upbringing and Daniel. Curled into a big chair, her body was some 50 pounds lighter than it once was, but her clear gaze was undiminished. While whispering, she paused to cough frequently, each time apologizing before continuing.

After the taping, she took a pain pill and threw up in the bathroom. She apologized once more. She received 40 minutes of a massage-meditation combination and made plans to return the following Tuesday, and to come back as many weeks after that as possible.

She never returned to the North Side facility, or left her home again. Her ability to breathe on her own nose-dived and her pain worsened. She could feel herself slipping and Matt could sense it. He monitored her escalating heart rate and she began discussing the end openly with others, including her mother.

On Feb. 4, she told Vicki Rempel, "It's not going to be very long," but not in mournful fashion. "She was like, 'You know, I've never done this before, Mom, but I'm on my next great adventure.'"

By Saturday, she accepted the intravenous morphine and downstairs hospital bed she'd long resisted. Family members came in from around the country to say goodbye. Then she and Matt had the one honest talk they'd resisted until unavoidable, at a child psychiatrist's advice: They told Daniel that instead of Momma just being sick with cancer, soon she wouldn't be around at all.

		A Remarkable Life More photos from this story

By Monday morning, she was resting so much that Matt couldn't quite tell what her status was. He thought she might be slipping away for good, almost unnoticed. He called to her and threw at her one of the many well-wishing cards sitting on a windowsill. She reached a hand and snatched it out of the air, startling him, one-upping him as she often did.

"I was like, 'Wow, man, I bow down to you, grasshopper,'" he said, able to chuckle in reference to the Eastern mystical character of quiet strength from television's "Kung Fu."

And hours later, on her own terms, Laura was gone.

Laura Mankamyer's memorial service will be at 2:30 p.m. tomorrow at Somerset Alliance Church, 708 Stoystown Road, Somerset.