In the Midst of Life

by Jennifer Worth

  Perhaps I should qualify this statement. The last ten to thirty hours before death are very much the same; a semi-awareness of space and time and people takes over, leading into a different level of existence, accompanied by peace and tranquillity. If left undisturbed, death is not an agony. It is the earlier period, the weeks or months, or even years of illness or ageing that are so different.

  Mr Anderson was consultant to a firm of international financiers. He was a very successful man, confident, self-contained, a person who needed very little amusement or even warmth – his work was enough, and filled most of his time and his thoughts. For relaxation he liked to go long-distance trekking in mountain ranges, sleeping in wooden huts and scrambling over rocks and riverbeds. It was a total change from his business life, and kept him fit. His private life was less successful. He had married a pretty girl whom he thought he loved, mainly because it seemed the right thing to do, but he had no idea how to handle women, and his wife soon left him for another man. He was not particularly upset, and enjoyed the freedom of a bachelor’s life.

  He had never had a day’s illness, and prided himself on keeping fit through his walking, a sensible diet, no smoking and moderate alcohol intake. He had no time for some of his business colleagues who ate and drank too much, smoked like chimneys, went everywhere by car or taxi and then complained about feeling out of shape. ‘What do they expect?’ he said to himself.

  When he developed stomach pains and felt sick, he was slightly offended – it shouldn’t be happening, he thought, so for a week he cut out rich meats and fats from his diet and ate only salads. Things seemed to improve, and he was satisfied that he had nipped the problem in the bud. But a week or two later the nausea returned, along with heartburn. He had heard of something called a hiatus hernia, but lots of people get hernias of one sort or another, so he was not particularly worried. He felt well in other ways, work was busy and he was planning his first trek in the foothills of the Himalayas. Life was too full and too interesting to bother about a little heartburn.

  But things did not improve, and so, a month later, he went to see his doctor, who examined him, and found an unexplained lump in the upper abdomen. He said that another medical opinion should be obtained, and advised a gastro-enterologist at the Royal Free Hospital.

  Mr Anderson was indignant.

  ‘But I’m busy! There’s a lot of work on, and I’m going to the Himalayas trekking in ten weeks’ time.’

  The doctor replied that they must get him into good shape for the trip, and wrote his referral letter.

  At the Royal Free, Mr Anderson was taken to theatre for a routine laparotomy with exploration, and possibly a partial gastrectomy (there were no electronic scans in those days). In theatre, the surgeon opened him up, took one horrified look at an intractable growth of carcinogenic material, involving the stomach and duodenum, and stitched him up again. He looked despairingly at the theatre staff.’ ‘How can one tell a man of forty-five that he has inoperable cancer and has only a few weeks to live?’

  No one answered. Everyone knew how great was the responsibility of telling – if they decided to tell at all. Sometimes, it is better to maintain the illusion of recovery; sometimes, it is better to tell the truth. But how is one to know what is best for a particular patient? The strong-minded person who says ‘I want the absolute truth,’ can be the one who goes to pieces when told. But the truth can be received by another calmly, and in unexpected ways may bring resolution to life. One can never be sure, and usually it is better to let the patient take the lead. Only then can you get an inkling of what he or she wants to hear. Even so, you can be wrong, because people deceive themselves. A dying man rarely looks death in the face until the end. In the early stages of terminal illness, he might have a shrewd idea of what is going on, but usually, at that point, he doesn’t want to know.

  Mr Anderson was not told directly that he had cancer so advanced that it was inoperable. He was simply told that six weeks of radium therapy would be beneficial. He entered the Marie Curie feeling well, and was by far the most active and alert of our patients. He appeared scornful of the other men, and complained about not having a private room.

  ‘It is bad enough that I have no privacy. But it is intolerable that I do not have the use of a telephone.’

  I said that we had a pay phone for patients’ use.

  ‘Pay phone!’ he spat out in disgust. ‘You mean I will have to put pennies in every time I need to make a phone call?’

  I said I would discuss the matter with Matron. At Marie Curie we had a policy of keeping our patients happy, as far as possible, especially if we knew their days were numbered. Matron frequently went to great lengths to oblige, and she discussed the matter fully with Mr Anderson. It transpired that what he really wanted was the use of an office from which he could continue to manage his business enterprises with the help of his secretary.

  Matron swallowed hard. This was something quite new to her experience. A hospital is a hospital, not an office block, she might have said – but she didn’t. He was a dying man, and who could refuse such a request? There was a broom cupboard on the first floor that was little used, would he care to look at it? Together they examined it, and Mr Anderson said it would suit him if it could be cleaned out, and a desk found. Matron did not think a spare desk was available, so he said he would have one supplied, and would also pay for a telephone to be installed. It was surprising how quickly the broom cupboard was converted into a small but adequate office. The secretary, a smart young man, immaculately suited, arrived with a car load of files and folders, and within two days Mr Anderson was at work. We never knew what business he was engaged in, but it was most unusual and the nursing staff was very impressed.

  Matron’s arrangement was highly beneficial to Mr Anderson, because it kept his mind occupied and his energies engaged. Sickness usually dominates the thoughts of a patient with cancer, but too much preoccupation with illness can have a destructive effect on the mind, and knowing what can happen frequently becomes self-fulfilling. Today, people who are ill will spend hours surfing the internet to find out all they can about their illness – but this isn’t always a good thing.

  Although Mr Anderson had not been told of his condition, he was an intelligent and thoughtful man, and he must have known that radium was given for cancer. We anticipated that he would start asking questions. One day, during a routine ward round, he said to the Chief: ‘I am due to go trekking in the Himalayas in six weeks’ time. Do you think I will be fit by then?’

  The Chief hedged. ‘That sounds pretty strenuous.’

  ‘Yes, it will be. But it will do me good. I need a bit of fresh air and exercise.’

  ‘I think you should find something less demanding – walking in the Wye Valley or the Cotswolds, for example.’

  ‘I see. I will think about it,’ he replied. He picked up his book again and appeared to be reading; but I knew that he was watching us as we continued the ward round.

  It was not the first time I had had the feeling of being watched. Several times I had seen him observing the nurses as they went about their work, and wondered if he fancied one of them.

  One day, he said abruptly: ‘I have been watching you and your nurses.’

  ‘Yes, I know, and I have wondered why.’

  ‘You don’t miss much.’

  ‘Nor do you, it seems. But why?’

  ‘Because I can’t understand how you, any of you, can do it.’

  ‘Because we are trained to.’

  ‘But why start the training in the first place? From what I can see, nursing is such a filthy, disgusting job. Why should anyone want to do it, especially a pretty young girl – and some of your nurses are very young and very pretty.’

  Such a statement gave me a bit of a jolt. I had never thought of nursing the sick as filthy or disgusting.

  ‘I can’t agree with you. Admittedly we deal with the clinical indignities and intimacies that sickness entails but—’

  �
��That’s what I mean. Some of these old men …’ he glanced around him fastidiously ‘… are in such a revolting state that I wonder how anyone can go near them, let alone do the work that you girls have to do.’

  I tried to explain that each man was a person with a life, loves, dreams, hopes and beliefs, and that the illness imposed on them did not alter that in any way; in fact, illness intensified it.

  ‘I’ve never seen anything like it,’ he said thoughtfully.

  ‘No. Few people even think of what illness can lead to.’

  As soon as I had said the words, I wished I had not done so. I did not want him to identify himself with the ‘revolting state’, as he had put it, of some of the men around him. People never see themselves reaching the terminal stage of illness.

  ‘I’m damned sure I couldn’t do it,’ Mr Anderson said emphatically.

  An incident occurred in the hospital, and, for a while, everyone in our small, enclosed world was talking about it. Matron was a sweet, trusting soul who saw no harm in anyone. When a gentleman called at the hospital and announced that he was a representative of the British Patients’ Benevolent Fund and that the society wanted to offer the Marie Curie Hospital a television for the benefit of the patients, she fell for it. A charming conversation over coffee and biscuits followed and the gentleman was shown around the hospital, which he assured her was a most heart-warming experience. A suitable location for the television was selected, and the gentleman said that the cost of installation would be ten pounds – a very large sum of money in those days, far more than an average week’s pay.

  Matron wrote out a cheque to the Patients’ Benevolent Fund, but the gentleman requested cash, because he said he would have to pay the electricians in cash. She swallowed that one also, and went to her petty cash box and handed over ten pound notes. They parted with great goodwill on both sides, and the television and electricians were promised to arrive that same afternoon. One need say no more. Matron had many fine qualities, but spotting a con man at three paces was not one of them.

  The patients had all been told of the kind offer and those that were well enough were very excited. Televisions were expensive items in the 1960s, and few of our patients had even seen one. The afternoon wore on. Several patients and nurses eagerly looked out of the front windows, and Matron was a-twitter with expectation. But the minutes ticked by, then the hours, and no electricians or television set arrived. Five o’clock came, then five thirty, and still nothing.

  ‘Perhaps they will come tomorrow,’ said a hopeful voice.

  ‘Not a chance. He’s got his ten pounds. We won’t be seeing him again,’ said a realist.

  ‘It is disgusting,’ said Mr Anderson, ‘I despise such a man. Tell Matron that I will buy a television for the hospital, and pay for the aerial to be installed. I can enjoy it for a while, and when I am gone it will remain for the enjoyment of others.’

  This was a very unexpected and generous offer, but I wondered about his use of the words ‘when I am gone’. It sounded as though he knew he was going to die.

  Cancer can overwhelm the body with frightening speed. Although the radium treatment was probably reducing the growth in the abdomen, we could not tell to what extent without performing another laparotomy exploration. Mr Anderson was losing weight rapidly. He was a spare man, with strong musculature, but within a few weeks he became pathetically thin. He found swallowing more difficult, and waves of nausea frequently beset him after a meal. We gave him anti-emetics, which helped a little, but one day, as he drank the mixture, he said to the nurse, ‘This is not going to improve me, is it?’

  ‘Oh yes,’ she said brightly, ‘we wouldn’t give it to you if it wasn’t.’

  ‘There is only one thing that is going to help me,’ he said, ‘and that is work. My secretary is coming at two o’clock and I must go to my broom cupboard.’ He grinned at the girl.

  Mr Anderson always dressed in a suit to go to his office. We thought at first it was an affectation to assert his superiority over the other patients, who usually wore dressing gowns, but as time went on we realised that it was to preserve his self-respect and sense of dignity. As he lost weight, the jacket hung loosely on his thin shoulders, and he had to make new holes in his belt to keep his trousers up.

  Excepting the days when he had radium therapy, Mr Anderson went to work. He even went on the day following treatment, when we usually advised patients to stay in bed because they often felt very ill. He would struggle out of bed, and one could see him trying to control the nausea and dizziness flooding his head, as he shaved and dressed. He usually returned to the ward about lunch-time, looking somewhat better. Obviously, the work was doing him good.

  Pain is associated with cancer, and as the growth encroached further into the stomach and duodenum, Mr Anderson’s discomfort increased. Pain is something we cannot measure. No one can tell when the level passes from inconvenient to severe, to unbearable, and we all have different pain thresholds. Mr Anderson’s was probably getting to the severe stage – we could tell by the look in his eye, by the intake of breath and biting of his lip, by a slight moan that escaped as he bent over to try to ease the abdomen. But he would not take any painkillers. He had tried the Brompton Cocktail on a couple of occasions, but it had made him so sick he would not take it again, and he adamantly refused any injections.

  Putting on his suit was such a struggle that particular morning.

  I could see the effort it was costing him and he gave a little gasp as he leaned over to tie his shoelaces. He remained bent in that position for some time, and when he sat up, his face was grey.

  ‘You really must have some analgesics,’ I said to him.

  ‘No, I can’t. I’ve got to keep my head clear.’

  ‘Then why not stay in bed for the day?’

  ‘I am expecting some important telephone calls this morning.’

  ‘Your secretary will be coming. Can’t he take them?’

  ‘No. I have to make crucial decisions. No one else can do it. And then there will be a lot of follow-up work.’

  ‘Surely it cannot be so important that it can’t wait until tomorrow?’

  ‘It cannot wait. A great deal of money is at stake.’

  I gasped, almost unable to believe what I had heard. Money, of all things! What on earth would he do with more money on the brink of eternity? A man obsessed with money has never appealed to me, but because I saw him wince in pain I said gently: ‘You might be feeling better tomorrow.’

  ‘I will not be feeling better tomorrow, Sister, and you know that as well as I do.’

  Our eyes met, and, for the first time, I knew that he knew he was dying. The game of ‘let’s pretend’ was over. I was greatly relieved.

  ‘So you know, then?’

  ‘Of course I know!’ he said savagely. ‘Radium is given for cancer. Do you think I’m a fool?’

  ‘Do you want to talk about it?’

  ‘Yes, but not now. I have work to do. We can talk later. The only question I really want answered is, how long have I got?’

  ‘That is impossible to answer. Accuracy can never be assured.’

  ‘Weeks or months?’

  ‘No one can say. It depends on so many things.’

  ‘Then I will continue to act as though it is weeks, and I have work to do. You could oblige me by helping me to my feet, Sister.’

  I helped him to stand up, and watched with sorrow and admiration as he straightened his back, gritting his teeth as he did so.

  People with abdominal pain find it eases them to bend over slightly. But not Mr Anderson – he was determined to stand straight, and he walked firmly to the door and along the corridor towards his broom cupboard.

  It is generally assumed that doctors know all there is to know about death, and that, if a patient is to be told that his condition is incurable, it is the doctor’s prerogative. In my experience, this idea is overstated, because most of the time doctors are not on the wards, whereas nurses and carers are.

/>   During the time when I was a probationer student nurse in Reading, I was working on a male medical ward. I carried out simple duties such as washing the locker tops, and was at the bedside of a man who was very ill. He grabbed my wrist, and with fierce intensity barked: ‘Have I got a growth, Nurse?’

  Startled I said, ‘Yes.’

  ‘Thank you,’ he croaked. ‘No one would tell me. Am I going to die?’

  ‘I don’t know,’ I said truthfully.

  ‘But what do you think?’

  ‘I honestly don’t know. No one knows.’

  ‘Thank you, Nurse.’

  He sank back on the pillows and sighed. It might have been a sigh of relief or despair. One could not tell.

  I did not dwell on the incident, and it certainly did not occur to me that I had done anything wrong, until a few days later when Sister called me to her office.

  ‘Did you tell Mr S that he has a growth?’

  I probably looked blank, but said, ‘Well, he asked me, so I said yes.’

  ‘Nurse, you are still in your probationary period. I must report this to Matron.’

  The same morning I was called to Matron Aldwinkle’s office. The conversation I had had with the ward sister was repeated, but I added, ‘Well, what could I say if he asked me? I couldn’t say “no, you haven’t got a growth” when I knew that he had.’

  ‘You should have told him to speak to the doctor.’

  ‘But he had seen the consultant and the other doctors that morning. It was just after the ward round.’

  ‘Nurse, we do not tell a patient directly that he has a malignancy. Most patients cannot accept it.’

  ‘But what are we to do if we are asked?’

  Matron struggled to find the right words.

  ‘I know it can be very difficult, but you have to think quickly. Something like “I don’t know” or “it has not yet been diagnosed” would be suitable.’

  ‘But it had been diagnosed. And I did know.’

  ‘You have to understand, Nurse, that we cannot simply blurt out the truth.’