In the Midst of Life

by Jennifer Worth

  Her life force was incredible. She was absolutely determined to cope, and seemed to accept every difficulty as a challenge to be overcome – nothing was going to beat her. Nobody knew the mental and physical effort this cost her, no one saw the tears of frustration as muscular weakness took its toll, or the relief as she sank into bed at night. No one saw the effort it cost her to get up in the morning. She once said, ‘When I wake up, I can hardly move, my limbs feel so heavy and I ache all over. But I have to make the effort. Sometimes it takes me half an hour to get out of bed. Can you believe it? Half an hour just to get up!’ Then she would have a bath, which loosened her up, and, dressed, did her hair, creamed her face, and manoeuvred her Zimmer frame around several awkward corners to go to the kitchen for breakfast. It took her three hours. Many people twenty years younger would simply have stayed in bed and expected someone else to look after them. Not Leah – she would look after herself, thank you. Renewed pleas from her family to go to Israel were all rejected.

  It must have been early June when Sandy from next door had cooked a meal for Leah and she said, ‘I don’t really feel like eating.’

  ‘Try it, dear, it’s nice.’

  ‘Yes, of course I will. It looks lovely. You’re very kind.’ But Leah couldn’t eat it.

  Quite quickly after that, Leah suffered from nausea and vomiting, and became constipated. ‘If only I could open my bowels I would be all right,’ she said. ‘What I need is an enema and a good clear out.’

  I was sitting beside her. She didn’t look herself. I asked her if she would like a game of Scrabble. ‘I don’t think I could concentrate,’ she said. She moved a little and winced. ‘I can’t seem to get comfortable. This pain jabs at me, here and here.’ She pointed to her stomach. I felt the area. It was a mass of hard lumps.

  The district nurse came to give her an enema. I met her in the hallway as she was leaving.

  ‘I am going to get her doctor to come and see her as soon as possible,’ she said.

  ‘Are you thinking what I’m thinking?’

  ‘I don’t know what you are thinking.’

  ‘I think she has cancer of the stomach and abdominal organs.’

  ‘I am sure she has,’ replied the nurse.

  The doctor came a couple of days later, and arranged for a hospital scan, which showed a massive cancerous growth in the abdomen.

  Leah spent a few days in hospital at the time of the scan, then came home, then went back to hospital for more tests, then was sent home again. She was not eating, or at best she was taking only a tiny bit of food, and she lost weight rapidly. She began to look very ill. Her grandson came over from Israel and stayed with her for a week. He put pressure on her to go into a nursing home. ‘I will not return to Israel and leave you alone like this,’ he said, ‘and if I don’t go back I will probably lose my job.’

  He searched widely, and found a home he thought she would like. She moved in.

  I visited her there. It was a lovely day in June, and she was sitting in the garden in the sunshine – Leah always loved the sun. She seemed more relaxed, and therefore a little improved. This is often the way. The hospital or nursing home offers a feeling of security and freedom from the constant tension of struggling to cope with a battle one is going to lose. She was deeply engrossed in a crossword and saw my shadow on the grass before she saw me.

  She looked up with a lovely smile. ‘You can’t stay beyond three o’clock,’ she announced. ‘It’s the finals of Countdown on television. I’ve been following it all through and must see these finalists.’ Her passion for word games and mental gymnastics was undiminished. She told me that she liked the new place, though she couldn’t eat the food, which she blamed on the cook, not on her digestive system. She felt she ought to stay there, because it was a worry to her family if she was alone at home, though she missed her home terribly.

  I suggested again that she could have a live-in carer. Before the sentence was finished she butted in. ‘Never. I should hate having someone around me all the time.’ Most of us would think like that.

  She told me that the previous day she had been taken to the anti-coagulant clinic at the hospital. Whilst I was with her, a carer came and said that the results had come through, and that she must have an increased dose of Warfarin. She handed Leah about six or eight tablets to swallow along with a glass of water. Leah sighed. ‘These pills! I’m sure it’s all these pills that are making me feel so sick.’ But she swallowed them nonetheless.

  Suddenly she looked at her watch. ‘I’ve got to go. It’s time for Countdown.’ I tried to assist her indoors, but she resisted help, and in the end I gave up. I left her, paper and pencil in hand, eyes eager, sitting in front of the television, waiting for the first jumble of letters. On my way out I met another of her friends. ‘I’m just going to see Leah,’ she said brightly. I wondered what sort of dusty reception she would get!

  I was bothered by the higher dose of Warfarin, and made a point of seeing the matron to discuss this before leaving. She was very guarded at first, as though I was accusing her or the nursing home of some impropriety.

  ‘It has nothing to do with me. We can only do as we are instructed. You will have to talk to the doctor.’

  ‘I’m not trying to cause trouble, honestly. I am merely puzzled.’ We swapped details on our training and experience. She was a woman in her fifties and was obviously dedicated to the care of the elderly. When I mentioned that I had been sister-in-charge of a cancer ward, she realised we were probably having similar thoughts.

  ‘If you look at her medical record you will see that since January the dosage has been going up after every visit to the Warfarin clinic,’ she said.

  ‘On what assessment?’

  ‘On the blood sample analysis.’

  ‘But she’s a hundred and three! What do they expect?’

  ‘I’m not sure that age comes into it.’

  ‘Apart from Warfarin, what other drugs does she have?’

  ‘Statins, cardio-vascular drugs and stimulants, anti-coagulants and diuretics, as well as regular analgesics.’

  ‘But that’s crazy. She has advanced cancer. It is better to die of heart failure than cancer.’

  ‘I know that. You know that. The doctors know it. But we cannot discontinue the drugs.’

  ‘Why? I don’t understand.’

  ‘At the moment she is alive, alert and enjoying life.’

  I thought of Leah watching Countdown, beating the contestants at their own game.

  ‘You are right,’ I said thoughtfully, ‘she does enjoy life.’

  ‘If we stop the drugs someone might say that we were deliberately hastening her death.’

  ‘But is that likely? Would anyone say such a thing?’

  ‘It is quite possible.’

  ‘Have you discussed it with the relatives?’

  Yes, and they said they will leave the decision to us.’

  ‘Have you discussed it with Leah?’

  ‘No.’

  ‘Does she know she has cancer?’

  ‘No.’

  ‘No? Why will no one talk about death? That’s at the root of the trouble.’

  ‘I know. But I have to safeguard the good name of the nursing home. I can’t discuss philosophical issues.’

  At that moment a young man in a T-shirt and open-toed sandals breezed into the office.

  ‘Philosophy? Sounds a bit heavy! Is that how you spend your afternoons?’ He laughed good-naturedly.

  ‘We were talking about Leah, Doctor,’ said the matron.

  ‘Leah? She’s fine, going on nicely.’

  Encouraged by his obvious good nature I said, ‘I was wondering why she is still on cardio-vascular drugs and diuretics.’

  His smile vanished. ‘What’s the trouble? Have you any complaints?’ he said abruptly.

  ‘No, not at all. Quite the opposite, in fact.’

  ‘Are you a relative?’ he demanded.

  ‘No, a friend.’

  ‘I cannot
discuss a patient with friends,’ he said curtly, and walked out.

  I must have looked really put out, because Matron said, ‘You shouldn’t have said that. For all he knows you might be a journalist looking for a story about hospitals or care homes. The newspapers could probably do with something like that to boost circulation.’

  ‘I hadn’t thought of that,’ I said quietly.

  The strength of the media, with their seemingly insatiable desire to criticise the National Health Service, came home to me.

  ‘I see what you mean. It would require more courage than the average doctor possesses to say “no more”. He would probably have to face an internal enquiry to justify his position.’

  ‘Exactly. And in the meantime, Leah is as well as can be expected.’

  ‘Yes, she is. In fact, she’s better than I expected, for which you are to be thanked.’

  We shook hands and I left, but before leaving the building I poked my head around Leah’s door. She was deeply engrossed in Countdown, eagerly writing things down, crossing them out, looking up and thinking, then scribbling again with evident satisfaction. The friend who had arrived at three o’clock was nowhere to be seen. Presumably she had been sent packing by this doughty, irrepressible old lady.

  *

  Cycling encourages meditation. There is something about the gentle, rhythmic movement, the fresh air, the curve of the road, the passing hedgerows, that promotes thought. As I cycled home from the nursing home, I reflected that I had undoubtedly been in the wrong. Three times in the past twelve months I had thought that Leah would die, and in the back of my mind I had suspected that it would probably be the best thing for her. She would die quickly and peacefully, without suffering. When I had seen her in the hospital after the embolism I had really thought she would not survive the night. But she did survive – triumphantly. She had lived to enjoy six months at home, gaining strength, improving her walking ability, seeing her family and friends … in short, living life as fully as a lady of her age could expect. None of this would have been possible had it not been for modern medicine. The intervention of cancer was not really surprising. We all have potential cancer cells inside us, and a shock to the body, such as Leah’s broken leg, would be enough to trigger a growth. It is quite possible, as medicine advances, and death is pushed further and further into retreat, that many of us may die of some form of cancer. And yet … and yet … it nagged in my mind … isn’t it better to die of heart and circulatory failure, before you have to die of cancer? In the end, we are all in the hands of God, and nothing we do will alter our fate.

  I had gained a good impression of the nursing home. The matron was the only trained nurse on the staff, but she set a good example and the assistants and carers whom I met all seemed pleasant men and women, who looked after the residents with cheerful goodwill. I saw a lot of smiling faces the day I was there. Leah’s room was spacious and airy, with two windows facing south and west, both overlooking the gardens, and she had a large bathroom leading off the main room. I felt she would be comfortable and happy there in the last weeks and months of her life.

  However, an incident occurred that shattered the calm. Leah was barely digesting food, felt nauseous much of the time, and sometimes she was sick. Both constipation and diarrhoea plagued her. Most of these nasty emissions she could control, but not always. One night, shortly after I had seen her, she tried to get to the bathroom, but what with the struggle to get out of bed and manoeuvre her Zimmer frame, she could not quite make it, and vomited all over the bathroom floor.

  Leah called for a member of the night staff, to whom she explained what had happened, apologised, and asked if the woman would clear it up. The woman looked at the mess, looked at Leah, said, ‘Clear it up yourself,’ and walked out.

  Leah told me that she had struggled into the bathroom again, and managed, though she was fearful of falling, to detach the showerhead and spray water all over the vomit. Then she got hold of towels and spread them over the watery mess to soak it up. Finally, she returned to bed and got some sleep.

  But that did it for Leah. In the morning she demanded to see the matron, told her what had happened, and said she was leaving that day. Poor matron was profuse in her apologies. She said that the woman came from an agency and would never be employed there again. But nothing would change Leah’s mind. ‘Because of that woman I am leaving this morning,’ she said. A taxi came, and by ten o’clock she had left the nursing home, although she was in no way fit to do so.

  Matron was deeply ashamed and embarrassed. None of her staff were trained nurses, and ninety per cent of them came from agencies. Only ten per cent were employed full or part time because of the impossibility of getting rid of anyone who was unsatisfactory. If an agency care assistant did not work properly, the matron could say that she would not have the person back. The care assistants were always being shifted around, and some were trained, some not; some experienced, others not; some were very good, others poor or bad. It was always a lottery who was sent by the agency, and night duty was the hardest to cover satisfactorily.

  Poor Leah arrived home, and no one was expecting her. She was seriously ill, and had to climb the front steps to the house, open the front door, which is heavy, cross the hallway, and open the door to her flat, which had been double-locked and is even heavier due to fire regulations. She was cold, and the heating had been switched off. She had to go to the cupboard and pull down the main switch, which is stiff. I just cannot imagine how she managed to do all this in her condition, but she did. Later that day a driver brought a case with her things in it, and left it in the hallway. That was the first clue that anyone in the house had of her return.

  Steve went round to her flat and found her in a state of utter exhaustion, collapsed in her armchair. He telephoned the family in Israel to inform them. The doctor and community nurses had been informed by the matron, but visits could not be started straight away and Leah had to wait several days for a district nurse, carer, or home help. Sandy cooked meals for her, but she could not eat.

  Once again, though, Leah perked up. Perhaps being at home, which is where she had always wanted to be, stimulated her. Added to this was the knowledge that she had to cope, because she adamantly refused to return to the nursing home, and there was no alternative. So each morning she got up, bathed, dressed, and received her friends, with whom she talked intelligently and with humour. She played with Steve and Sandy’s baby, did her crossword puzzles and word games, and generally spread around her a love of life that was infectious.

  Yet all the time she was growing weaker and losing weight. The weight loss accentuated the growth in her abdomen, and now she looked as if she were seven or eight months pregnant. Her pain was increasing, and the prescribed analgesics no longer relieved it. One night it became so unbearable that she rang her GP, who arranged for hospital admission immediately.

  I visited her in hospital towards the end of July. When I walked in, I thought she was unconscious, but no, she smiled and took my hand.

  ‘They’ve given me something to relieve the pain,’ she said. ‘It feels easier. I wish they would give me an enema. I feel I need a good clear out.’ Her faith in enemas was touching. Had she still not been told, or had she, perhaps, guessed the truth?

  Apparently not, because her next remark was, ‘I’m wondering if I’ve got shingles. It can be very painful you know, my cousin had it.’

  She drifted off into sleep again and I sat stroking her hand. Then someone came round with a drinks trolley, and she had a little water. A nurse emerged with the evening drugs, but she passed Leah’s bed. ‘I’ve told them I’m not having any more pills,’ Leah said, ‘nothing.’ There was a pause, then, ‘I’m sure it was the pills that made me so sick. But no more, I’ve told them. And I don’t feel as sick, now. I feel better without them.’

  Did she know that it was the pills keeping her heart and circulation going that had sustained life in her through the months since the accident? She was a highly intel
ligent woman, and it seems unlikely that she did not know. Perhaps she had discussed it with her granddaughter, the Israeli trained nurse.

  Yet I had never discussed it with her, or the present fact of progressive cancer, or the inevitability of death. Mutual friends told me that she had never mentioned death to them, either, which is surprising because most old people – well short of one hundred and three – will say things like ‘I’ll be glad when it’s all over,’ or ‘I’ve had a good life. I’m tired now, and want it to end.’ My grandfather talked of the Angel of Death; others speak of going to meet their loved ones. The only time Leah had mentioned death was fourteen months earlier, when she had looked out of the hospital window at the blue sky and said, so wistfully, ‘I hope this is not the end. Life is so beautiful, so exciting, so interesting. I don’t want it to end.’

  Her passion for life had sustained and driven her through all the months of coping alone. Yet now I felt her life force was waning. She could struggle no more, and she knew it. Was that why she had announced she would have no more pills? Had she known all along that it was the pills that had kept her going and that rejecting them would mean the end? Was this Leah’s way of closing the door?

  A nurse came up to the bed and gave her an injection.

  ‘Is that morphine?’ I whispered. Our eyes met.

  ‘Yes,’ she said briefly.

  ‘I’m glad,’ I said softly. The nursed smiled and moved away.

  It was high summer – long bright evenings with no wind. But the sun sinks eventually, though it seems it never could, and when I left Leah that evening I felt her light was going out, and that I would not see her again.

  Leah died on 8th August, 2008. Her family were with her.

  Cancer can sometimes lead to a hard and difficult death. It was so for Leah, and her daughter and granddaughters told me of this. They couldn’t understand how her body managed to sustain life for so long. I think I can. Her love of life had been her strength and driving force. She had led a privileged life, with a happy childhood and a happy marriage – who could ask for more? She had also enjoyed good health until the age of a hundred and two when she broke her leg. Three times – the break itself, the embolism, the hospital infection – she had nearly died, and each time it would have been a relatively quick and easy death. But three times modern medicine had pulled her through and kept her alive until cancer intervened. I wondered how Leah would have reacted if she had been able to see ahead.