In the Midst of Life

A FAMILY DIVIDED

The geriatrician came to assess Mrs Doherty and advised a rehabilitation centre. Miss Jenner said that the patient could not remain for long on the acute ward, and asked if a bed could be found on the geriatric ward until rehabilitation. It was not easy – there were too many patients and too few beds available. The consultants both knew the difficulties. ‘We’ll ask the medics. They have more of a turnover than we do.’ The medical registrar came to see Mrs Doherty and said that a patient with colitis would be discharged at the end of the week and a bed could be available.

Miss Jenner saw Priscilla and told her that two specialist opinions had been sought and that her mother would be transferred to a medical ward for treatment for the aftermath of a stroke. Following on from this, her mother would go to a rehabilitation centre. The woman seemed satisfied with this and said, ‘I will reside in London until next week, and then I must return to Durham.’ Then she said, very formally: ‘On behalf of my family I would like to thank you, Miss Jenner, for saving my mother’s life. You obviously acted with great skill.’

She turned to leave and had to pass her mother’s door. She put her hand on the handle, and paused. One could almost feel the indecision going on in her mind, her sense of duty telling her she should go in, yet opposing that, her fear of seeing her mother, of not knowing what to do or say. She half turned the handle, then released it, and started to walk away. At that moment Maggie came round the corner with an armful of flowers.

‘Priscilla! You old stick! You didn’t tell us you were coming in this morning. How is she?’

Priscilla hesitated before answering. She looked exceedingly discomfited, and then said truthfully, ‘There is no change.’

‘But is she awake? Was she glad to see you?’

Priscilla could not answer. Her nostrils closed to narrow slits and her shoulders tensed.

‘Priscilla!’ Maggie was furious. ‘You are impossible. You came here to see the doctor, not to see Mummy. How could you?’

‘Don’t make a scene here in the corridor, with everyone listening.’

‘I don’t care if the whole world can hear me! Dear Mummy, lying there ill, and you don’t want to see her.’

‘Stop this behaviour. We will go in together.’

She opened the door, and they entered. The staff nurse and I looked at each other.

‘Wow, that was a near thing!’ she said. ‘We don’t want them fighting here in the corridor. You see it all in this life, don’t you, Sister?’

I could only agree.

We had a busy morning. There were five cases for theatre. That meant preps and pre-meds, calling the porters, arranging for nurses to escort patients to theatre and, afterwards, back to the ward, post-ops to be received and cared for, and student nurses to be taught the details of post-operative nursing. I was thankful to have a very good staff nurse, who was highly experienced and loved the drama and excitement of an acute surgical ward. She was indispensable on such a morning.

We had almost forgotten about Mrs Doherty when suddenly Maggie came screaming out of the side ward. ‘Sister, Sister, come quickly. Something’s happened.’

The staff nurse was there before me. She said, as I entered, ‘I think it’s another stroke. I’ve called the doctor, but of course our team is in theatre. One of the medics will come.’

One look was enough to confirm Staffs assessment. Mrs Doherty had slithered from her chair, and was slumped on the floor. Her eyes were wide open, but her pupils had receded upwards, and only the whites were showing. Her mouth, hanging to the right side, was open, and copious frothy fluid poured from it.

Maggie was sobbing and holding her mother in her arms. Priscilla was leaning against the wall, her face as white as a sheet. She was struggling to control her breathing, and her eyes were staring horrified at her mother.

‘My God, we are going to have two strokes on our hands, if we are not careful,’ I thought, and went over to her.

‘Would you please go to the office and ring your brother, Jamie? Tell him to come, because this looks serious.’ Giving someone in a state of shock a job to do is usually the best way of dealing with the situation.

I whispered to a nurse, ‘Go and ask the ward maid to make some strong coffee for that lady. She’s going to need it. Then prepare a lumbar puncture trolley.’

Two porters were just entering the ward to take the next patient to theatre. It was fortuitous. I called them in to help us lift Mrs Doherty on to the bed and shortly afterwards the medical registrar arrived. She said, ‘We must sedate to stop these muscular spasms, then I will do a lumbar puncture.’ I said that the trolley was ready. We turned the patient, and doctor inserted the long needle between the third and fourth lumbar vertebrae. The fluid draining out was heavily bloodstained. ‘We can assume another haemorrhage. This patient belongs to your team, not ours. She must be seen by Miss Jenner.’

Maggie was in the room – she refused to leave her mother – and asked how long that would be. I said that Miss Jenner was in theatre and the list was due to finish at 1 p.m. It was then 12 noon. Mrs Doherty was deeply unconscious, breathing noisily and very slowly. Her pulse and blood pressure were very low. I thought, This is it. She won’t survive this one, and said to Maggie, ‘We must keep your mother very quiet. I am sure you will want to stay with her.’ She nodded tearfully.

In the office, Priscilla was looking a bit better. She said that her brother Jamie was on his way and that they would see Miss Jenner together.

Jamie arrived at about 12.30. Theatre closed slightly ahead of time, and Miss Jenner came straight to the ward, still in her theatre clothes. I accompanied her into Mrs Doherty’s room and Jamie and Priscilla joined us.

Miss Jenner examined her patient and said exactly what the registrar had said: ‘A second cerebral haemorrhage has occurred.’ She said no more. Maggie sat by the window, crying quietly. Priscilla stood by the door, looking tense. Jamie stared at them both, and said:

‘I don’t think any further treatment should be attempted.’

Maggie sobbed quietly. ‘But she will die, Jamie,’ she said in a tiny voice.

‘She will, and it will be for the best.’

‘How can you say that? For the best! What a wicked thing to say. Our darling Mummy!’ Her voice was rising.

The accusation stung. ‘I’m not wicked. I’m being realistic.’

‘I hate you. Realistic! At such a time!’

‘Don’t create another scene, Maggie,’ interrupted Priscilla.

‘You cold fish,’ she shouted. ‘I suppose you want Mummy to die also – then you won’t have to come and see her. Is that it?’

‘I decline to answer. You are getting hysterical again.’

‘I’d rather be hysterical than cold and heartless like you two.’

Miss Jenner and I looked at one another. This was not the time or the place for a family row. Miss Jenner turned to Maggie and said gently: ‘Your brother is probably right. The time has come to let go, and allow your mother to die in peace.’

Maggie looked up with unspeakable anguish.

‘Let go? She is all I have. She was getting on so well – almost talking to me. I was beginning to understand what she was saying, and she understood every word I said.’

Maggie sobbed quietly into a wet handkerchief, and Jamie gave her his, and put his arm around her. No one spoke for a moment, and between sobs she continued, ‘I’ve been getting the downstairs room ready for her – it’s all so pretty, just as she would want it.’ She looked up at Miss Jenner. ‘Is there nothing you can do?’

Miss Jenner did not answer. The silence in the room was tense. The sound of stertorous breathing from Mrs Doherty seemed unusually loud.

Then Priscilla spoke. ‘Is there anything you can do to relieve my mother’s condition, Miss Jenner?’ Her voice was precise, and demanded an answer.

‘I could do another cranial exploration,’ she said quietly.

‘Then it must be done.’

‘No,’ said Jamie, ‘I won’t allow it. She has gone through enough already.’

‘It must be done,’ Priscilla retorted.

‘Why? In God’s name, why?’

‘Because it can be done,’ Priscilla said.

‘I do not advise it,’ said Miss Jenner. ‘I cannot be confident that she will survive a second operation.’

‘There you are, Priscilla,’ Jamie said, ‘Medical advice is against operation.’

Priscilla ignored him, and spoke to Miss Jenner.

‘Will she survive without operation?’

‘It is unlikely. In fact, I must answer no, she will not.’

‘When is her demise likely to occur?’

‘That is more difficult to predict.’

‘Days? Weeks?’

‘Oh no, not weeks. Maybe later today, or during the night.’

Maggie screamed, ‘No, oh no, no, please!’

‘So the balance in favour of survival is to operate?’

‘Yes, it is.’

‘Then it must be done.’

Jamie confronted his elder sister. ‘I don’t agree, and I will not give my consent to operation.’

‘Your consent will not be necessary. I will give mine.’

Maggie jumped up, her tears stopped, her face hopeful.

‘Oh Priscilla, you’re wonderful. Can it be done, Miss Jenner? Can you save Mummy?’

‘I cannot guarantee it.’

‘But you can try, can’t you? And I will look after her when she leaves hospital. I want to look after her.’

Jamie was exasperated. ‘You just want something to fill your empty life.’

‘Don’t be so beastly. You just want her out of the way.’

Miss Jenner interrupted. ‘Please. You can settle your differences elsewhere.’

Jamie looked furious. ‘I don’t want her “out of the way”, as you put it. I just want what is best for her.’

‘And you think it’s best for her to die? You … you

She turned to Miss Jenner. ‘Please, oh please try’

‘I cannot guarantee a successful outcome, and therefore I am reluctant to operate,’ the surgeon said.

‘What is the balance in favour?’ asked Priscilla.

‘I would say about fifty-fifty Not more.’

‘Then it must be attempted.’

‘No,’ said Jamie, ‘It would be going too far. Why are you so keen on a second operation, Priscilla, when it is against medical advice?’

‘I am not “keen”, as you put it. I merely say that if an operation can relieve the pressure on her brain and save our mother’s life, then it must be done. To do nothing, and allow her to die, would show indifference or negligence, which I cannot allow.’

‘Priscilla, you are so sensible. We must do all we can for Mummy.’ Maggie turned to Miss Jenner. ‘Don’t listen to Jamie. He doesn’t understand. We can’t just allow Mummy to die.’

Miss Jenner replied, ‘Your mother is going to die anyway. An operation will only delay death.’

‘That’s what I’ve been trying to say, Maggie, only you won’t listen. And it’s the reason why I don’t think it should be attempted. We must do what’s best for her. I appeal to you, Miss Jenner.’

‘Be quiet, Jamie. Don’t listen to him, Miss Jenner.’ Maggie was sobbing again. ‘Mummy could get better. It’s quite possible. She has been improving every day this week. I have seen it. She can nearly talk – at least, I can understand her, even if you can’t. We must do all we can for her.’

Priscilla spoke again. ‘If a second operation holds any chance of survival, then it must be done. I cannot have it on my conscience that, when my mother was seriously ill, I stood by and did nothing. I am not even sure about the legal rectitude of non-intervention.’

Jamie, tight-lipped, said, ‘I think you are wrong, both of you. It will only impose more suffering on her.’

Priscilla said, stiffly. ‘I am confident the hospital staff will be able to reduce any suffering to the minimum. It is a simple matter: if a life can be saved, it must be saved, and a fifty per cent chance of survival is worth taking. She has been a good mother to us all, and we owe it to her.’

She turned to Miss Jenner and me.

‘I want it recorded that I request a second operation on my mother, to relieve the congestion on her brain. If you will get a consent for operation form, I will sign it now.’

I glanced at Miss Jenner and she nodded her head. I went to the office and returned with the necessary form and filled it in, ready for signature. Miss Jenner did not say a word, but left the room. Priscilla and Maggie signed, Jamie refused to do so.

When I returned to the office, Miss Jenner was sitting with her head in her hands. Poor woman – she had had a full morning in theatre, had another clinic in the afternoon – endless responsibilities – and now this. She looked drained.

‘There is something formidable about that woman. She is relentless in her logic, but she is wrong, in my opinion. Logic is a bad master. She may be right legally, but she is wrong morally and ethically. I’m sure of that.’

‘Her last words sounded like a threat,’ I said.

‘They were.’

‘Can anyone threaten a consultant? Surely a consultant’s opinion must be respected?’

She laughed, pulled off her theatre cap, and ran her fingers through her hair.

‘Not any more. Medicine is changing fast. Professional expertise and experience are no longer enough. Now we have the law breathing down our necks.’

‘That doesn’t sound too promising for medicine.’

‘No it is not. But you heard her words – “if it can be done, it must be done”. I don’t agree – I think it is a question of balance and restraint, but if it came to a court of law, my professional opinion would count for very little.’

‘A court of law?’ I exclaimed in alarm.

‘Perhaps not a civil court, but the BMA have their own tribunals, and they have unlimited power to make or break a doctor’s career.’

‘Surely you don’t think Priscilla would sue you, or anything like that?’

‘No, I don’t, it would be out of character. But her sister might. She is a very emotional woman who is clinging to her mother and won’t let her go. She wouldn’t listen to her brother Jamie, nor to me, because we would not say what she wanted to hear. If her mother dies today or tomorrow, which is possible, Maggie will blame me, and say that the death could have been prevented, but that I refused to operate. It would only require a letter to the BMA suggesting that I have been negligent in my professional duties Her voice trailed off.

And what then?’ I ventured after a minute. I could see she was deep in thought.

‘What then? Suspension on full pay whilst enquiries are made. Endless statements, investigations into my professional competence.’

‘That can’t be in doubt.’

‘I’m not so sure. Past record may count for something, but it is no defence. At a BMA tribunal, how could I stand up and say, “I thought we should let the old lady die”?’

Put like that, it sounded both callous and unprofessional. Miss Jenner laughed bitterly.

And even if I didn’t use those words exactly, you can be sure the press would.’ She heard my exclamation of surprise and indignation. ‘Oh yes! The press would be there all right. The tabloids love that sort of thing. They would drag me through the gutter, given half a chance. I can just see the headlines, “Consultant Surgeon says let the old people die”. I, and the hospital, would be named and shamed.’

Miss Jenner let out a long shuddering sigh.

‘My local paper would make it front-page headlines. They’ve got nothing much else to report – apart from the occasional “flasher” on the common! It would really be big news for them. And that’s where I live, and do my shopping, and take my dog for a walk.’

Her voice was nearly breaking.

‘I hate to think of it all. Even if my decision was vindicated by the BMA, the damage would have been done.’

She looked up, and her face looked ten years older.

‘Against my better judgement, I will have to operate. I have no choice. Instruct Theatre Sister to prepare for a trephine, will you please? And I will speak to the anaesthetist.’

She stood up, looking more resolute.

‘I must go and speak to the relatives first.’

‘What about lunch?’ I said ‘You have had nothing.’

‘There’s no time. I’ll eat later.’

‘You’ll need something inside you. I’ll get the ward maid to prepare a sandwich and coffee for you.’

‘Thanks. That sounds nice. I’ll go and see them now, then have a bite.’

The operation was successful. The bleed was less serious than before, and had been attended to more quickly than the first stroke. A small bleeding point was located and tied off. Free blood and serum were sucked from the cranium, a clot removed, and the patient returned to the ward. Nursing procedures were as before, and Mrs Doherty regained consciousness within three days.

Maggie was overjoyed and spent most of each day with her mother. Before returning to Durham, Priscilla called at the hospital a couple of times and expressed her satisfaction. Jamie also came to see his mother each day. He looked at her paralysed limbs, and listened to her gurgling attempts at speech, and murmured ‘I hope to God this never happens to me.’

Mrs Doherty remained on the ward for three weeks, and then was transferred directly to a rehabilitation centre. For a month she received physiotherapy, ultrasound, passive movement of the limbs, swimming sessions, and many of the exercises that attempt to restore strength to wasted muscle. A speech therapist helped her with jaw and tongue movements, vowel sounds and consonants.

It had been ten weeks since the first stroke and a measure of improvement was undoubtedly seen, so Mrs Doherty returned home with Maggie to care for her.

All went well to begin with. The old lady was obviously pleased to be home, and Maggie was full of enthusiasm and happiness. The children came in to see their Granny, expecting her to be the same, or very nearly. But when they saw an old, old woman, who looked nothing like the grandmother they remembered, slumped in a chair, her face fallen to one side, one eye closed, saliva trickling out of the corner of her drooping mouth, they backed off, afraid. She saw their alarm, and tried to smile and hold out a hand in greeting. But when she tried to say, ‘Hello darlings, I’ve come home,’ it sounded like ‘Ga ga wa wa ga’. The youngest one ran away in terror, and the eldest girl murmured to herself, ‘Oh, how dreadful.’

People paralysed from a stroke are usually fully aware of what is said, and what is going on around them, and Mrs Doherty wept, great tears that she could not wipe away running down her face.

Maggie did her best. But she had completely underestimated the difficulties involved, which, even for a professional nurse, can be daunting. A district nurse came in for four hours a week, but Mrs Doherty required twenty-four-hour nursing every day, and the only person to do it was Maggie. Feeding, drinking, washing, bathing, help with dressing – all had to be attended to. Soiled underwear and bed linen had to be changed frequently, and even though a bathroom and lavatory, specially designed for invalid use, had been built on to the ground floor room, Maggie found that getting her mother on and off the lavatory was a monstrous task. Mrs Doherty tried desperately to help herself, but early one morning, when she’d managed to get out of bed, her Zimmer frame was just a little too far away, and, in trying to reach it, she slipped and fell, and lay on the floor, wet and cold, for several hours.

Another thing Maggie had not expected was the boredom. Each day was the same – a struggle with physical necessities, until Maggie felt she could scream. Although Mrs Doherty’s speech had improved to the point where she could say a few words, she could not carry on a conversation, and her attempts to do so frequently led to tears of frustration. In the end Maggie gave up trying to speak to her mother. In the winter, when the days grew dark and wet, Maggie wondered how much more she could take.

Mrs Doherty made heroic efforts to do things on her own. She was not a woman who wanted to be a burden to her daughter. She did the exercises advised by the physiotherapist, but progress towards mobility was minimal. Had she been twenty years younger, it might have been different, but she was simply too old to build up new muscular strengths. Every little thing was a labour for her to achieve; frequently, she wept uncontrollably.

Jamie came to see his mother each day, but did not stay for long. It was difficult to communicate and conversation was confined to banalities. He could see the strain imposed on Maggie, and though they both thought often of the scene in the hospital, and Miss Jenner’s rejected advice, neither of them ever mentioned it.

One day Jamie said to his sister, ‘You need a holiday. You can’t carry on like this. You’ll crack up.’

Maggie burst into tears. ‘If only I could. But I don’t see how I can leave her.’

‘Tessa and I could take over.’

‘I don’t think you could. She needs someone with her all the time. You have to go to work, and I doubt if Tessa would do all that I do.’

‘Then she’ll have to go into a nursing home for a while. I will make enquiries and arrange something. You must have a break.’

‘That would be wonderful. Thank you, Jamie.’

He could see her depression and was concerned. Everything about her, her clothes, her hair, her face, her nails, was neglected. Even her body language was so unlike the Maggie they had always known.

‘Do you think you’ll ever go back to writing?’

‘Oh, I don’t know. Can’t see it, somehow. I had a letter from one of my magazines today, telling me that they were taking me off their books. That’s bad news.’

Jamie didn’t say anything but arranged for a nursing home to take his mother. It was not easy. because of his mother’s incapacity. Most nursing homes wanted old people who needed no nursing, he discovered. He found one, eventually, who said they would take her for two weeks, providing she was not incontinent. Jamie assured them that she was not, but would require help in getting to a lavatory, or a bedpan. The expense was colossal, but Priscilla agreed to help pay.

Mrs Doherty was terrified when she was told that she was going to a nursing home for a fortnight. She couldn’t express herself but kept saying ‘No, no, no,’ and shaking her head and crying. She managed to formulate the words ‘Let me stay here’, and then added, ‘Please, please, oh please,’ but no one took any notice. When two men came with a special recumbent chair in which to carry her, she resisted with all the puny strength she could muster – but they took her anyway.

The stress of being moved, and the mental agitation, the new surroundings, strangers taking care of her – it was all too much for the old lady, and she went rapidly downhill in the nursing home. She would not eat or drink, she made no effort to move, but lay inert in her bed. Her time, at long last, had come, and Mrs Doherty died five days later.

A man

half bent over on the sofa, eyes down, asleep or awake.

An assistant puts a mug of tea in his hand

but he can’t hold it or isn’t ready, she puts it gently

on the sideboard next to him, With the cup shakily

in his hand now (I am watching) he raises it slowly

to his .. . But where to go? The cup goes to his glasses,

almost touches them, then slowly down again, up again,

this time halfway to his mouth. The cup (I am watching)

is on the sideboard again. A biscuit has been put

into his hand. Using both hands shaking, and with

tiny movements he tries (I am watching) to break

the biscuit. With a small piece of it he tries to find

his mouth. He fails and lowers his hand again

very slowly. His left hand holds the biscuit half away.

His right hand has gone right down past his knees.

It comes up again. He achieves breaking the biscuit

again and with his right hand reaches his mouth

with a tiny piece (I am watching) and gets it in.

Now he has found the cup of tea on the sideboard

and holding it in his right hand he is drinking from it

very slowly, all the while his head down .. .

He tries to stand

and very slowly turns and is soon

heaped about the end

of the sofa, his weight greater than his power to shift it.

Two assistants help him up and sit him back on the sofa.

One says ‘Stay there’. But he wants to move, so they

help him up and he walks or is walked across the room

and into an armchair. One of the assistants pulls out

the footrest which tips the chair back. (I find myself

swaying). She puts the stool under the footrest

to support it. She adjusts the head rest, pats his chest

and says, ‘There,

have a rest.

He closes his eyes

and is still.

— David Hart

This poem and that on page 145 by David Hart were written when he was Poet in Residence at the South Birmingham Mental Health Trust, 2000—01. A man half bent over was originally written in an Older Adults Assessment Ward as it occurred, very very slowly, the version here being newly made. At the annual conference of the Royal College of Psychiatrists at the Queen Elizabeth II Conference Centre, a Van Gogh self-portrait reproduced as a poster for PR purposes by a drug company led to the writing of Poor Van Gogh. The whole sequence of residency poems with commentary was included in David Hart’s Running Out (Five Seasons Press, 2006).