With medication, Thomas is able to live his life in relative peace and work at a coffee stand, yet occasionally has severe episodes of illness.

Dominick sees him through the decision not to reattach the hand, and makes efforts on his behalf to free him from the inadequate and depressing hospital for the dangerously mentally ill.

In the process, Dominick contemplates his own difficult life as Thomas's brother, his marriage to his ex-wife, their only child dying of SIDS, and his hostility toward their stepfather.

In the course of Thomas's treatment, Dominick is covertly informed of sexual abuse taking place in the hospital and helps to expose the perpetrators.

In October 2018, HBO announced they were planning a six-episode limited-series TV adaptation with Mark Ruffalo set to appear in the roles of both Dominick and Thomas Birdsey.