a difficult climb

I haven’t been to this block before and I’m confused by the entrance. There’s no intercom anywhere I can see, and the door seems to be closed. It reminds me of another block on the other side of town. The only way in is to phone the resident and ask them to release the front door, or to knock on the window of the scheme manager’s office (an arrangement that always baffles me, because really – how difficult do you want to make life?)

So figuring this is another place like that, I phone the patient again.

‘Oh really?’ huffs Angela. She lowers the phone and shouts for her daughter to go down because the nurse is ‘outside and doesn’t know how to open a door.’

She says something else, too, but it’s muffled so I can only guess.

After a few minutes, Frances waves to me from the lobby as she approaches. She’s a cheerful, red-faced, middle-aged woman in a bulging tartan skirt and yellow cardigan, her hair so frizzy the hairdresser must stand on a ladder to prune it with shears. But then – I’m so busy remarking on her extraordinary look I don’t realise she’s miming for me to push the door. Which I do – and find it’s been open all along – just a little stiff. And just inside the lobby to the right is a second set of doors with an intercom to the side.
‘How embarrassing!’ I say. ‘Sorry to drag you all the way downstairs!’
She shrugs cheerily.
‘Salad!’ she says.

I know from the notes that Frances has a form of expressive dysphasia that means she struggles to speak in complete sentences and often uses the wrong word. I’d read that she’d come back to live with her mum after her stroke, but that Angela was struggling now, had fallen recently and needed a home assessment.

‘This is such an interesting building!’ I say, making conversation as we walk up the stairs.
Frances nods and smiles back at me, her eyes wide but her lips tightly pursed, as if there were a pressure of words wanting to come out but she couldn’t be sure which to use.

She shows me into the flat – a large, coolly shadowed place with dark parquet flooring, antique furniture, serious photographs in serious frames, and at the furthest end, a floor to ceiling window overlooking the park.

‘Hello Angela!’ I say, putting my bags down. ‘I’m Jim, the nursing assistant from the hospital, come to see how you are and what help you might need.’
‘Have a seat,’ she says, nodding to the scallop backed affair opposite her.
‘Thanks!’
I settle in. Frances climbs up on a stool at the little cocktail bar to the left, stuffs her hands under her thighs and starts gently swinging from side to side whilst Angela scrutinises me. Between the great bony arc of her mouth and her hooded eyes, it feels like I’ve been granted an audience with a giant, royal frog.

‘I can’t believe I had such a struggle getting in,’ I say, laughing drily. ‘I was standing there, pulling away…’
‘You push,’ says Angela.
‘Yes!’ I say, closing my eyes and shaking my head from side to side, like Stan Laurel. ‘I know that now!’
‘Hmm,’ says Angela.

It’s a struggle to make any progress after that. If Angela was resistant to the idea of help before I arrived, nothing I can say now improves the situation. My mouth dries. I become horribly self-conscious, feeling like an imposter who found all this equipment down in the lobby and tried it on for a laugh.

Frances beams at me from her stool, chipping in with non-sequiturs. The shadows in the room close in, take on more weight.

‘What a lovely view of the park!’ I say, finishing off her blood pressure. ‘Beautiful! All the … you know… trees.’
Angela nods.
‘My husband chose this place,’ she says. ‘Then he died.’
‘Oh. I’m sorry.’
‘He was a climber. He went to the Himalayas.’
‘Wow!’ I say, looping the stethoscope back round my neck, just exactly the kind of thing a fraudulent nurse would do. ‘The Himalayas!’ I say, making too much of it. ‘Even I’ve heard of the Himalayas.’

‘Sandwiches!’ says Frances.

Angela ignores us both.

‘He was a well-respected climber,’ she says. ‘He was so good, he used to train people in climbing. All over the world. There wasn’t a mountain he hadn’t climbed. And then, of course, he went to the Himalayas…’
She trails off, gravely rolling down the sleeve of her blouse, like a surgeon about to give bad news.
‘Oh…?’ I say.

She doesn’t react.

I’m desperate to ask if that’s how her husband died, plunging off Mount Everest or being buried alive in an avalanche (all of which I’d rather be doing right now). But that would be a difficult question at the best of times, and I feel about as ready to ask it as a Yeti would feel to knock on the door of a tent and ask if I could come in for tea.
‘So… what happened?’
Angela frowns up at me.
‘What do you mean – what happened?’ she says. ‘We bought this place! What do you think happened?’
I look over at Frances.
‘Christmas!’ she says.

Frankie & Rita

If you didn’t know better you’d think Frankie’s wheelchair was a time machine. A particularly down-at-heel version, ruined by food debris, bodily fluids, scorch marks. And if it is, you’d have to think he’d leant too hard on the joystick, because suddenly he’s found himself in a brilliant new flat – a futuristic development, all chrome, glass and sharp corners – without an abusive partner, but with a beautiful dog. And the dog is strangely quiet, with deeply golden eyes and a deeply golden manner. And Frankie is slumped in his chair, as if this last leap has wiped him out, and he needs a good long sleep to catch up.

‘Sorry I didn’t answer your call,’ he says, slowly rousing and raising his chin, hooking aside his great mass of hair, stroking his beard into some kind of shape, his great silver skull rings glinting dully in the overhead spots. ‘Only I was a bit distracted.’

It’s always impossible to know what to do with Frankie. It’s obvious to anyone who deals with him that his problem is drug addiction. Frankie is the kind of user whose entire life has been sacrificed on the altar of altered states. You couldn’t name a drug he hadn’t swallowed, snorted, pumped in his veins or shoved up his rectum. He’s something of an expert in the field, and his destroyed body is his CV.

‘Rita!’ he says, leaning so far out of the chair I can’t help putting a hand out. By some miracle of gravity he stays seated, though. Rita leans up to accept a stroke.

‘She’s a good girl!’ says Frankie, mussing her head a couple of times then flopping back into the chair. ‘She deserves better.’

Rita turns her golden eyes up to me as if to say: You see?

We chat about how our service can help – which isn’t much, it has to be said. The flat is as good and well-adapted as you could wish for. Certainly better than the certified Pit of Hell I saw him in just a couple of years ago. And whilst his drug use is gradually working its magic on the place, still there’s room to move, and you can breathe with a measure of confidence, and there’s light coming in at the window.

‘I want to kick this shit,’ says Frankie. ‘I really do. Ya know? It’s not good for you. But I had that guy from mental health come by the other day, and he sat there, and he said did I want to go on the methadone. And I said to him What? Substitute one drug for another? Why would I wanna do that? I wanna come off the shit completely, ya know? Start over. Get on with my life. So he said Suit yourself. Just like that. And then he sat there, looking round. He was really mean. A mean, horrible, uncaring kinda guy. What’s he doing, being in a job like that? He oughta be caring for people, not judging them and making dumb suggestions. I told him to get out and not come back. But I tell you what, though. I’d LIKE him to come back. ‘Cos if he did I’d put some gloves on. And I’d give HIM some gloves, because I’m a fair-minded kinda guy. And I’d say C’mon on, then! Let’s settle this, man to man! Because I’m not a violent person, y’know? I teach street kids Taekwondo and Jiu Jitsu – but only for self-defence, yeah? Not aggression. And there’s a big difference, my friend. A BIG difference.’

He strokes his beard thoughtfully for a while and seems to fall straight asleep. I can’t imagine how he’d teach martial arts having only one leg. But maybe that was some years ago, before the drugs took over and he lost not just the leg but everything else.

I fuss with Rita whilst the physiotherapist wakes Frankie up to talk about options. Rita is a staffie, solid as a pommel horse, with a fleshy mouth and nipples like tire valves. Her eyes really are the most incredibly warm, extravagantly deep caramel colour. I can’t help staring into them, and blinking slowly, whilst she pants with her big fleshy mouth, and widens her eyes, and draws me in.

It’s an effort to break free.

‘Rita’s lovely!’ I say, eventually standing up again, as the physio writes something in the folder, and Rita curls up by the wheelchair’s footplate. ‘Where did you get her?’

‘Rita?’ says Frankie, orienting himself to me in a blindly approximate way, much like a bear might look to the mouth of the cave in the middle of winter. ‘Dunno mate. She just kinda showed up.’

the sea captain

Alex reminds me of the sea captain in The Simpsons. If you rapped the TV with a wand, pulled the sea captain out of the screen by the shoulders of his great coat, gave him a shake to fill him out, swiped off his captain’s hat, pulled out his corn cob pipe and substituted it with a cheap Russian cigarette, took off one of his legs and sat him in a wheelchair – you’d have Alex. The orneriness you could leave.
‘No, no! Not there! THERE!’ he glares. I take a step back.
‘Okay. Off you go, Alex. I’ll stand here just in case.’

Alex has a routine for everything, which is fair enough of course, except it’s all so inappropriate and hazardous you have to bite your lip and cross your fingers and everything else and hope beyond hope he manages it. But the thing is – he invariably does. Which is half the secret with Alex.

‘How come he doesn’t bite your head off?’ says the coordinator. ‘Everyone else he tears a new one.’
I shrug.
‘Maybe he sees me as as pushover.’
‘Yeah?’ she says. ‘Or a kindred spirit. Still, at least he gets to see someone.’
I don’t like the way she says ‘someone’. There’s something of the dot dot dot about it.

Alex is what you might call a non-compliant patient. In fact. he gives non-compliance a bad rap. He’s forever self-discharging against advice, then throwing his hands up and calling for help. Then when the help comes, he puts so many demands on the various clinicians and therapists and carers he makes any meaningful intervention impossible. And to make the situation worse, he talks. And talks. And talks. Great rolling monologues that brook no interruption or question. Vast avalanches of discourse that will bury the novice unless they know the trick, which is to surf his words to a rapid and professional dismount on the beach, which, in this Alex-worthy, extended metaphor, would be the corridor outside his flat.

And breathe.

Which is, of course, the other thing about visiting Alex. Those Russian cigarettes.

I don’t know who supplies them, or who makes them. I’m guessing they’re secretly rolled out in Chernobyl or somewhere, a novel way of offloading waste. Because they stink. It’s the kind of spoiling, roiling, super-leafy stink you’d get if you took a flamethrower to a compost heap. With a splash of detergent to zip the whole thing up. I’d guess if I walked out of Alex’s flat and straight into an X-ray machine, you’d see noxious curls of the smoke wedged like bed springs in my bronchioles. Coughing doesn’t help. You need the respiratory equivalent of a douche.

Which is why I wasn’t keen to see Alex again.

‘I can’t believe he’s back on the books.’
‘Yeah. Well. Whaddya gonna do?’
‘What is it this time? It can’t be care. The carers hardly last a minute.’
‘I don’t know,’ sighs the coordinator. ‘He went into hospital with an AKI. They changed his meds and he self-discharged without anything. Refused to sign a non-concordance. And now he’s back home calling the ambulance every five minutes. So I think they figured they’d either refer him back to us or wheel him off the pier. And these days the pier’s fully booked.’

I have a nightmare vision of Alex as a figure on a carousel – one of those garishly painted wooden versions, all brightly coloured eyes and flaring nostrils, scattering equipment and pills and ambulance sheets as they go round and round and round.

‘Anyway, just go and see he’s okay, try to make sense of where we are now. Maybe get him to sign a non-concordance,’ says the coordinator. ‘And stamp his reward card.’

When I get there, it’s difficult to find anywhere to park. There’s a fire engine, a fire officer’s car, a rapid response ambulance car and an ambulance truck, and a small crowd of people on the pavement. I excuse my way through just as a throng of emergency officers lumber out through the lobby in hazmat suits. At first I wonder if it’s Alex, and the team are all suited up because they heard about his cigarettes. But weirdly, the patient on the stretcher is an elderly woman looking perfectly healthy, wearing a comedy, cliche-old person Astrakhan coat with a fur hat, her handbag clutched to her chest. She waves to the crowd as she emerges on the trolley. I’m surprised the crowd don’t burst into applause – but actually what they do is start moving away, somewhat disappointedly, as if what they really wanted was something more dreadful and entertaining.

It seems odd to go into the block, but there’s no reason not to and the warden is standing nodding and smiling at me.
‘Come for Alex?’ she says. ‘Good! You know where to go…’
And leaves me to it.

Alex is where he always is at the start of any visit, which is smoking one of his goddamn cigarettes over by the closed window.
‘Hello Alex!’ I say. ‘You wouldn’t mind putting your cigarette out, would you?’
‘I haven’t finished it.’
‘No, but I don’t smoke so I’d really appreciate it if you did.’
‘It’s my house.’
‘I know, but still. Thanks. That’s very kind…’ (hoping it’ll clinch the deal – which, miraculously, it does). He nips out the burning end as if he were dead-heading a rose, and rests it tenderly in the ashtray.
‘There were loads of emergency services down in the lobby,’ I say, to kickstart the meeting. ‘I was worried. I thought it might be you.’
‘Me?’ he says. ‘Why? I’m not the only person who lives here.’
‘No,’ I say. ‘That’s true. You’re not.’

And even though the next half an hour will be filled with Alex telling me everything about those lost weeks, where he’d been and what happened to him, who he talked to and how he put them right, what they wanted him to do and what he ended up doing – with much better results – and so on and so on. But instead, just for one moment, one, slender unexpected moment of silence, backgrounded by the sound of slamming ambulance doors outside, framed by the melancholic curls of smoke rising from the pinched cigarette in the ashtray next to him, Alex stares at me, and I stare back, and we don’t say a word.

I’m tempted to break the silence and say ‘Ahh! Squiddy!’ – affectionately, like the Simpsons Sea Captain when he meets his nemesis, the giant squid, again.
But I don’t.
I adjust my mask.
And the whole visit goes ahead as normal.

hovercrafts & game shows

One of those headlong, breathless mornings, where I’m furiously trying to fit too many visits into too few hours, with the hopeless intention of being back in time to relieve Mandy on the desk at one. Mandy only came in because she heard we were short. ‘One day they’ll put up a statue of you in the marketplace,’ I tell her, almost spilling the tea I’ve made as an extemporary thank you. ‘What – so the pigeons can shit on me?’ she says. ‘Thanks for the tea.’

It’s the kind of morning where I’m overly conscious of my heart. I feel it swinging on a piece of frayed string, side to side, side to side, the joke pocketwatch you might hang inside the ribcage of a medical skeleton. All my timings might work if everything clicks – here then here then here via there – tick tick tick. Back by one. Yeah, right.

And of course, not one thing goes to plan.

The first assessment turns out to be much worse than the breezy drive-by the GP promised in the referral. I’m met at the door by a carer so stressed you can see it trembling through her like a tractor on a pinking idle. She has her mask under her chin like it’s stopping her mouth falling open into a scream; even worse than that, she’s carrying a knife.
‘Can you pull your mask down, too?’ she says, gesturing with the knife. ‘My hearing’s not what it was.’
I tell her I’ll speak up, then, because I can’t really take the mask off. It’s more for the patient than my benefit.
‘She’s jabbed, though,’ says the carer, like she did it personally, with the blade. ‘Twice.’
Even so, I tell her, she can still get pretty sick with Covid. Especially given how frail she is. I say I’m sorry but I just can’t do it.’ This doesn’t go down well. I follow the carer into the kitchen. She rushes through a handover whilst she dices her fingers with the cucumber. ‘Can you at least help me change her?’ she says.
‘Of course!’
‘She’s stuck on the sofa.’

All in all I’m at the house for two hours, late for my next call.

But it’s fine. It’s okay. This next one should definitely be quick. I’ve been asked to drop in to an elderly patient just to check his obs, see how he is, weigh him and check his pressure areas, so we can discharge from our service. It’s a formality. I can make up time there.

I let myself into his flat with the keys from the keysafe. A Welsh dresser narrows the hallway and I have to turn sideways to get through. There’s a ribbed-glass door just ahead so fiercely illuminated it’s like stepping onto the deck of a spaceship orbiting the sun – except, a spaceship with a threadbare carpet and faecal footprints tracking from the soiled cot bed in the corner to the captain’s chair by the window. Before I go any further I put some shoe covers on. Check my fob watch. The air is thick and noisome.

‘Hello Mr Carpenter,’ I say, going over to him, lightly waking him up by resting a gloved hand lightly on his shoulder.
‘Wha-at?’ he says, with a start, wide-eyed at the rustling, white-gowned alien looming over him.

At first glance he seems immaculate. Like James T Kirk started modelling in his dotage for a geriatric gentlemen’s outfitters, smartly put together in a sharp check jacket, pink stripe shirt, belted trousers and some impressively elaborate leather boots that zip up right and left from the toe to the bend of the ankle. I can see a glob of faeces on the heel of his left shoe, and a slide mark emerging from the hem of his trousers.
‘My name’s Jim. I’m a nursing assistant. From the hospital. Come to see how you are!’
He bats the air, then linking his hands on his lap, rests his head back again.

He’s obviously been incontinent, but before I do anything else I run a set of obs to see if he’s acutely unwell or not. Everything seems fine, though, and his vagueness is probably due to his advanced dementia. I help him stand up, loosen his trousers, and peer into the horror below. His mobility is pretty poor, and I know I’m not going to be able to wash him on my own – especially given the tiny bathroom with no aids of any kind. I sit him down again whilst I ring his care company. He’s not due another call until the evening, they say – and no, they don’t have anyone they can send out to help me. ‘He needs more care,’ I say. ‘We’re in discussions about that,’ they say. So I phone the office. Mandy says the only person available to come out is Tim, a new carer still on induction. ‘It’ll be the Jim and Tim show!’ she says. I tell her I’m almost certainly going to be late back. ‘Don’t worry,’ she says. ‘I’ll just stay on a bit longer.’ I tell her the statue will be made of gold, with diamonds for eyes. ‘Oh yeah?’ she says. ‘Just make it in concrete and throw me the diamonds.’

Whilst I’m waiting I clean Mr Carpenter’s hands, then go into the little galley kitchen to make him a cup of tea. There are sandwiches laid out for him on the side – not that he’d have any idea they were there. When I give them to him he eats them hungrily, taking big toothless bites, craning forward at the neck like an ancient tortoise with a lettuce leaf. Whilst he’s tucking in I strip his bed down, clean it up and put on fresh linen. Use antiseptic wipes to get the worst of the mess from the carpet.

Tim arrives. Between us we help Mr Carpenter up, strip him down, walk him to the bathroom, clean him off. Tim is great, chatting to Mr Carpenter and teasing out little scraps of information. Apparently Mr Carpenter was a civil engineer. ‘How amazing!’ says Tim. ‘My brother’s an engineer. He makes hovercrafts.’
‘I’ve been on a hovercraft,’ I say.
‘Oh really?’ says Tim.
‘Yes,’ I say. ‘To the Isle of Wight.’
The Isle of Wight suddenly seems like a very strange name. The Isle of Wight? I really went there? On a hovercraft?

Meanwhile, Tim is saying how his brother was always interested in bridges.

We dress Mr Carpenter in a new set of clothes – sans jacket, unfortunately, which also has to be added to the small mountain of soiled clothes and bed things we leave for the carers to deal with later. Then we help him back to the armchair which we’ve cleaned and covered in a beach towel, and settle him in. He eats the other half of his sandwich whilst Tim pours some orange juice and puts the glass beside him. Mr Carpenter smiles and holds up the remaining crust from his sandwich – working the upright part of it like a hinge.
‘Come on Down!’ he says. ‘Come on Down!’
‘The Price is Right! Bruce Forsyth!’ I say.
Mr Carpenter stares at me, then drops the crust back on the plate.
‘Finished?’ says Tim. ‘Good!’ then takes the plate away.

here to help

It’s a cliche that dogs look like their owners. But whilst I wouldn’t say it was true, even someone as cynical as me would have to admit that Ralph the Shih Tzu is a dead spit for his owner, Robert. They have the same overhanging mullet, the same bug-eyes, the same extravagantly friendly, panting smile – to the extent that if I picked up this squeaky banana toy and threw it across the room, I’m not sure which one of them would get there first.

‘So what happens now?’ says Robert, sitting on the edge of his chair, whilst Ralph plumps himself down at my feet so I can scraggle his ears.

Robert’s mum is entering the final stages of her illness. The district nurses are organising the End of Life nursing care, and they’ve referred to us for additional care support and any extra equipment that might need providing at short notice.

I explain exactly what it is we can offer, how the system works, what’s going to happen next. Robert writes notes on the front page of the folder I’ve given him. There’s a lot to process – mostly how the teams come together, who does what and so on. It’s taken me a few years to figure it out, so I’m not surprised Robert struggles to understand. I try to simplify it to the basics – what time the carers will come in, what they’ll do.

‘I’m grateful for anything,’ says Robert. Ralph swipes at my leg with a paw. I scraggle his ears some more. His back leg begins to twitch.

‘He’s lovely,’ I say.
‘I rescued him,’ says Robert.
‘From the pound?’
‘From the neighbours next door but one. I think the kids wanted a dog, but then went off the idea. Poor thing. He never got a walk. They used to go out all the time and leave him behind a baby gate in the kitchen. I went round one day to help them with their fridge, and I felt sorry for him. So I said do you want me to take him for a stretch round the block? And they said if you like. So I did, and it became a regular thing. We just kind of clicked. He came and stayed with me for a week when they went on holiday. I didn’t hear from them when they got back, and when I went round and said what about Ralph then? And they said you may as well keep him. So I did.’
‘He landed on his paws.’
‘I think so. We both did. Didn’t we, Ralph? Eh?’
Ralph gives him a glance, then puts a paw out, taps my leg, and bows his head ready.

a perch in the square

The thunderstorms they promised have yet to materialise. Instead, a giant grey lid has drawn low over the city, holding down a pressurised heat that makes you long for clear skies and a clean breeze, the sea, and a rock to dive from.

I’m visiting Andrew, a patient whose history of alcohol abuse and mental health problems means he needs to be a double-up. I’ve arranged to meet Sandy, one of the nurses, at the address. As well as my obs bag and folder I’m carrying a perching stool, because the notes say Andrew injured himself recently and needs something to sit on when he washes. I’m so hot now I’m tempted to stop and sit on it myself, right here in the street, and just wave for people to go round.

Andrew lives on a new estate, somewhere I’ve been before but only to the outer houses. I’ve heard the private parking arrangements can be fraught, so I take the safest option of leaving my car out on the street and walking through. Rookie error. The estate turns out to be the architectural equivalent of a cavity – a small entrance roadside that quickly opens out into a wide, faux village green, red brick Lego houses on four sides and cul-de-sac arms windmilling off at the corners. Whether it’s the heat, my innate stupidity, the evil planners, or all three, but I cannot figure out the way the numbers run. I take the south side of the green; of course, the numbers are completely wrong. I cut across the green, but in the far corner they’re even lower. I have a sudden, terrible image of myself, discovered years later by maintenance staff when they strim around some overgrown bins, my skeleton sprawled on the rusty perching stool, a squawking crow gothically and ironically perched on me. The maintenance staff taking a picture, uploading it. People commenting yeah right how fake.

Eventually, though, more through luck than judgement, I find myself standing outside the entrance to Andrew’s place. There’s an intercom with half a dozen numbers, high numbers at the bottom, low numbers at the top. Andrew’s buzzer is at the bottom, which means, I’d guess, he lives on the top floor. Great. I put my stuff down, sit on the stool, and wait.

Sandy rings. She’s lost. The satnav has taken her somewhere else entirely. I try to give her directions but it’s only then I realise how little I understand the area myself. We spend five minutes trying to establish which way she’s facing, whether we’re talking about the same convenience store, the same school. I can’t remember whether the entrance to the estate is opposite a boarded-up pub or a church. I’ve walked too far into the estate to walk back onto the road and wave as she drives past. She says don’t worry she’ll drive around a bit and see what happens. I say fine, good luck, see you later.

Take a breath. Take stock.

A large white van enters the square from the far corner, drives round the opposite side and stops in the road facing me. It idles there a second, then a guy in a baseball cap and a face as red as his shirt leaps out, fluorescent tabard wings flapping behind him. He strides round the front of the van leaving his door wide open, throws open the side of the van, grabs out a parcel, hurdles a small flower border with his index finger already extended to press the intercom so forcefully he almost puts it through the wall. He stands there, breathing heavily, looking around. He sees me sitting there and seems to straighten. After a second he nods once, sharply, then spins the parcel in his hand like Billy the Kid. The door opens. Even before the woman has said hello the guy has chucked the parcel at her. She drops it and apologises, but he’s already vaulted back over the border, slammed the side door shut, slid arse-first across the bonnet, thrown himself into the driver’s seat and set off, only closing the driver’s door when he’s made ten yards. The woman slowly retreats back inside. The square falls silent again.

A woman further down on the left comes outside, carrying a folded camping chair in her left hand, a glass of drink in her right, a rolled magazine under the same arm. She drops the chair down onto the scrap of grass outside the main door, pulls the magazine from under her arm, sets the magazine and the drink down, then shakes out the chair, kicking the feet out securely with a crocked foot. When she sees me I wave. She nods back, but in a non-committal way, then carries on setting herself up – a little more self-consciously, it seems to me – occasionally glancing my way to try to figure out quite what I’m doing over here, perched on my perching stool. She must realise I’m an official visitor, though? Black trousers, black shoes, a white polo shirt (the hot weather allowance instead of a tunic), an ID badge hanging from my belt. But then – if I’m visiting, why am I sitting outside the house and not going in? There’s no way of miming that I’m waiting for a colleague, and I’m certainly not going over there to explain. Because what if she isn’t wondering what I’m doing? Maybe she’s just happy to see someone else sitting down in the square. You can overthink these things.

My phone rings. Sandy has found the entrance and wants to know whether to drive in or not. I tell her that I didn’t drive in but wished I had. I give her directions to follow once she’s reached the square.
‘This is exciting,’ she says. ‘It’s like in the films when the pilot has a heart attack and the control tower tells a passenger how to fly the plane.’
I agree with her, although when I hang up I try to remember a film where that happened and can’t think of one.

A few minutes pass, more than you’d need to drive round. I wonder whether to ring again.

I look across at the woman again. When she sees me she raises her glass in a cheers way. I smile and nod and mime how hot it is by wiping my forehead and flicking my hand off to the side. But then I wonder if she interprets that as me saying how hard I’m working when I’m patently not.

Sandy pulls up in her enormous car. Watching her drive front first into the parking space is like watching a tanker super-cautiously nudging into dock. After a while she struggles out, desperate to avoid dinking the neighbouring car with her door, which she only manages by using her knuckles as a cushion.

‘I forgot to get the air con gassed-up when it went in last week so basically I am fully cooked now!’ she says. ‘Anyway. Here I am. I made it.’

I fetch the key from the key safe and we struggle up the stairs to Andrew’s flat. We stand in the doorway, puffing and blowing and staring inside.

He’s lying prone on a low sofa, covered in a fleece. The room is unbearably hot, the radiators on, the windows closed. A tropical greenhouse would be several degrees cooler. Sandy looks at me, widening her eyes over the top of her mask, her forehead already glistening with sweat.
‘Andrew?’ she says. ‘Would you mind if we open a window please?’
‘I’d rather you didn’t,’ he says, slowly turning his jaundiced face to the side and giving us both a sad, heavy look. ‘I like it warm.’

hat

It’s so hot my shoes feel tacky, like I’m puddling footprints of molten plastic as I go. I’m visiting a patient in a bunkerish, red-brick block called The Apples. Quite why they called it The Apples is anyone’s guess. Maybe there was an orchard here once. Maybe they tried a lot of other names, nothing fit, so they asked a five year old. Maybe they misunderstood the architect, who actually said ‘Thermopylae’ over the phone. Whatever the reason, the block is just about as far away from apples as it’s possible to be. Unless you count supermarkets.

There’s an elderly woman dragging a wheeled shopping bag up the path ahead of me, her long white hair reflecting the sunlight so powerfully it’s like she’s wearing a bridal veil of spun silver.
‘Where’s your hat?’ I say to her as I gradually overtake her.
She stops, turns and frowns.
‘Don’t believe in ‘em,’ she says. Then carries on.
When we get to the main door I tell her I’ll buzz my patient to let me in, but her frown deepens so much it meets her chin. She swipes her fob in front of the pad.
‘Let me get that for you,’ I say, holding the door.
She drags her shopping bag into the shady hallway.
‘I’m using the lift,’ she says, and nods for me to take the stairs.

Luckily, Mr Felstrom is on the first floor. I wonder if he’ll be confused, me knocking on his flat door without having buzzed the intercom first. There’s no sound from within the flat, so I’m surprised when the door suddenly opens and he’s standing there, looking as if he’s been waiting for me there ever since I rang to arrange the visit a half hour ago. He looks extraordinary – comprehensively buttoned into a tartan shirt, his bristly hair sticking straight up, like he showered, then dried himself by standing over a vent.

Mr Felstrom’s flat is as small and ruthlessly organised as the cabin on a ship, everything aligned with everything else, even the piles of letters on the table in size order, the letter opener parallel, a list of medications surrounded by a display of equidistant pill packets. Even the fridge magnets are all in a grid. I begin to feel as if I’ve been uploaded into a photograph, just like the one on the calendar – a young woman standing next to him under a tree – blu-tacked to the kitchen door. The calendar is covered with carefully written dates and an array of post-its with important messages.

‘My daughter’s coming round later to take me to the park,’ he says, after I’ve finished the examination and I’m writing up the notes.
‘That’s nice! A lovely day for it. If you wear a hat. Which park are you going to?’
‘You know,’ he says.
‘Which?’
‘The long one.’
‘Like one of those stately home kinda parks?’
‘Lots of trees.’
‘Sounds amazing.’
I try naming a local park.
‘No,’ he says.
I try to think of a couple of big parks out of town.
He shakes his head.
‘How are you getting there?’ I say, hoping that might shed some light.
‘On the bus,’ he says.
‘Fantastic! Maybe you could sit on the top deck and get a great view.’
‘My daughter’s taking me.’
‘Lovely.’

He stares at me, blinking rapidly but otherwise completely still. And it’s something about the way he speaks and looks, combined with the stultifying heat in the room, the hectic geometry of the place, the grid of his shirt, that starts to make me feel a little dizzy.
Bus? Park? Daughter?
‘But don’t forget to wear a hat,’ I say.
Hat?

stressful deliveries

Ken has been sent home to die. It says so in the discharge summary, once you get past the medical terminology, acronyms and abbreviations. And if the End of Life description in the narrative isn’t clear enough, they’ve packed him a bag of ‘Just in Case’ medications, or JICs, the medicines the District Nurses will administer to ease the symptoms of Ken’s death. So really there’s no question about it.

It’s worrying that there doesn’t seem to be a ReSPECT form, though. (ReSPECT being yet another acronym, standing for: Recommended Summary Plan for Emergency Care and Treatment). The form clarifies the treatment expectations for a patient, including when they’re approaching end of life. The form gets filled in after a frank conversation with the patient and their family, exploring what they want to happen, what’s important to them, how and where they want to be treated, especially when things deteriorate. Without it, you’re left tiptoeing round the edges of an emotionally fraught subject, to no-one’s benefit, not least the patient. Good End of Life care needs clarity, honesty, stability and forward planning. Without these things it often deteriorates into last-minute fixes, stressful appeals, unnecessary hospital admissions.

In this case, not only is there no ReSPECT form, but neither Ken nor his son Simon seem to have the least clue what’s going on. And if they have been told, the best you could say was that it hadn’t sunk in.

‘What are these?’ says Simon, shuffling through the JIC boxes like a poker player with a bad hand. ‘What are they for, then?’
‘Those? They’re …erm… for a little bit further on. If things change. The District Nurses will talk to you about those. They’re the ones who’ll be giving them, so you don’t have to worry. I’d put them in a cupboard out of the way or something.’
‘Nah. I’ll put them up here,’ he says, stacking them up in the middle of the mantelpiece. A grim talking point. ‘So what d’you need to know? Only I’ve gotta get back…’

You’d know they were father and son without being told. It’s not just they’re both bald, with the same roughly-chiselled head, the same pinched nose and beak-like mouth. It’s something else they share, a startled watchfulness. But if they have the same essential character, Ken is the one you can see is mortally ill. His lips are dry, his eyes sunken, and there’s a dull, liverish pallor to his skin, like someone tried to sculpt a rough copy of the younger man in clay before it dried out.

Encouragingly, the house is roomy and clear, with plenty of space to make the necessary adaptations. There’s a large room immediately adjoining the living room that would be perfect for a hospital bed. All it needs is to clear away the card table and six chairs currently taking up the middle.
‘No. No way,’ says Simon, folding his arms. ‘He won’t want that. He’s got his own bed upstairs.’
‘The thing is, though, Simon, as your Dad’s illness progresses, he’s going to find it harder to use the stair lift. It’ll be much better and safer for him to stay on one level. Also, the hospital bed means he can be cared for more effectively than on his own bed. It goes up and down to the right height, so it’s easier for the carers to do what they need to do. And it’s got a pressure mattress to help stop him getting pressure ulcers.’
‘No,’ says Simon. ‘He won’t have it. He wants to have his friends round to play cards. How’re they going to do that with a bloody great bed in the way?’
‘They’ll think of something.’
‘No. It’s not going to happen. We’ll leave things as they are for the time being, thank you very much.’
He takes me upstairs to look at his Dad’s current bed. It’s a standard divan, standard height. Once Ken lands in it, the risk is he’ll be stuck there and then the carers will struggle to do personal care and change his pads in a safe way.

It’s a common problem. For each patient, of course, their situation is unique, a once in a lifetime event. They can only think about how it affects them; everything else is secondary. For the carers, though, it’s part of their working day. They see a lot of end of life patients. If the carers are to avoid a back injury, they need to be able to adjust the bed to a sensible working height – not to mention the facility to change the patient’s position, to sit them up or lie them flat as required. But it’s awkward to insist on this without making the conversation sound more about the carers than the patient. The trick is to have these discussions before the patient is discharged home.

As a nursing assistant I don’t feel I have the seniority to push the subject with Ken and Simon. Instead I make a mental note to escalate things when I get back to the office.

‘I can’t stay long,’ says Simon, showing me back downstairs. ‘I’ve got to get back to work.’
‘Oh? What do you do?’
‘I’m a delivery driver for a supermarket,’ he says.
‘How’s that going?’
‘Terrible!’ he says. ‘I thought it’d be a breeze but it isn’t.’
‘Why? What’s the problem?’
‘They know everything about you. They know exactly how fast you’re driving, how hard you step on the brakes. They know how fast you go round a roundabout. It’s all monitored by a computer, every second of the day. And if you make the slightest mistake they know about it. If you accelerate just a few miles an hour over the odds, ‘cos maybe someone’s coming up too fast, or maybe you’re overtaking and need to get past, or maybe you’re waiting for a gap to get out and you have to pull away a bit sharpish, because otherwise you’ll be waiting there till Christmas, and you’ve got all these jokers flashing their lights and leaning out of their windows calling you every name under the sun… I don’t know. I don’t think I’ll do it much longer. But the trouble is, there’s not much around. What else am I going to do?’
‘I don’t know. It’s difficult.’
‘Difficult? It’s impossible! The whole day you’re monitored. Like they’re sitting right there in the cab. With a clipboard. Saying Ah-hah!…TICK! …. Yep – Er Hmmm … TICK!… every time you do something they don’t like. And for what? Minimum wage? I don’t think so.’

He stares at me, unblinking, hyperattentive, a holographic version of the onboard computer.
‘Why can’t people just be reasonable?’ he says.
And I tell him I don’t know, but wouldn’t it be great if they were.

*

Later that week Ken deteriorates, and there’s the inevitable scramble to set up all those things it was obvious he needed from the start.
‘Where did they put the bed? I ask the carer.
‘Where the card table was,’ she says. ‘Which is great, ‘cos there’s plenty of room…’

don’t mention the tattoo

Even without the diagnosis from the discharge summary, you’d know Charles was at the end of his life. He’s lying on his side, propped up on pillows, one leg hanging out of the bed, his face mottled and ghastly, his lips puce, his limbs puffy with fluid, a horrible rasping sound shifting deep in his chest. I hardly need put a hand on him to know how bad he is, but I do – not because I’ll be calling an ambulance, but because I might need to get one of the palliative team out, and it’s good to have the leverage.

His wife Maureen watches from behind me, leaning with her arms folded on the bedroom door.
‘Listen to the nurse,’ she says, her arms folded. ‘If you won’t listen to me.’
‘Ah! Woman!’ says Charles.

The District Nurses are case managing. They’ve only referred to us for some bridging care, and to see if we can persuade him to agree to some changes in the set-up at home. There’s a perfectly good hospital bed in the front room, but Charles refuses to use it. He wants to die in his own bed, even though it makes caring for him extremely difficult. There’s no room to move about, the bed’s too low, and Maureen has been struggling. They’ve had the ambulance out twice to get him up when he’s fallen. A patient his size? In this condition? In this tiny room? I can’t imagine how they did it.

‘How about we help you to the bed next door?’ I say. ‘It’ll be much better for you. It’s got a special mattress so you’ll be less likely to get pressure sores, it goes up and down to make it easier on the carers, and you’ll be in with the TV so you can watch the football.’
He snorts.
‘Football!’ he says . ‘There’s not much football where I’m going.’
‘No. The ball’d catch fire,’ says Maureen.
‘Yeah?’ he gasps, struggling to sit up. ‘Well at least I can pass your respects on to your mam.’
‘There now,’ says Maureen. ‘Isn’t that charming?’
‘Ah!’ says Charles.
‘So will you come with us into the front room?’
‘No I will not.’
‘Why not?’
‘I don’t want to.’
‘Take him. I’m done,’ says Maureen, and hurries away.

I lean back against the wall and sigh.
He opens one eye and glares at me.
‘Don’t let me keep you,’ he says.
‘The thing is, Charles…’
‘What’s the thing, now?’
‘The thing is – I respect your decision to stay in your own bed.’
‘Do you? Well that’s big o’you.’
‘But what about Maureen? You’ve got to think about her, too. And the carers. As your condition worsens you’ll need looking after in bed, and this one’s just not up to the job. They’ll hurt themselves trying to change your pads and whatnot. It’s too low, and there’s hardly room to swing a cat.’
‘Don’t be taking to me about no cats.’
‘And anyway, Charles – next door’s so much nicer. You’ve got that lovely big window you can look out. You’ve got the TV.’
‘No,’ he says. ‘I’m staying put.’
‘The other thing is – that hospital bed is so flexible. You can sleep more upright, and that’ll help your breathing. ‘
‘I’m staying where I am, thank you.’

My colleague has been on the phone to the DNs. He comes back in and says they’ll be visiting to review things later in the afternoon.
‘Good!’ I say to Charles. ‘That’s brilliant! How about we get you next door onto the hospital bed, so you’re ready for them.’
‘You don’t give up, do you?’
‘I know. I’m really annoying.’
‘I wouldn’t say annoying. I’d say something far worse.’
‘What d’you think, though, Charles? Shall we give it a shot?’
‘Give what a shot?’
‘Going next door onto the bed.’
‘How’m I going to get there, then?’
‘We’ll use this bottom sheet to slide you over to the other side of the bed. Then we’ll help you sit up, and when you’re strong enough we’ll help you stand and scooch over onto the wheeled commode. Then we’ll wheel you through to the living room, and do it all in reverse.’
‘Just like that.’
‘Just like that.’
‘And if I do it you’ll shut up about it.’
‘Promise.’
He sighs and shakes his head.
‘Give me five minutes,’ he says.
‘No worries.’
Maureen reappears in the doorway.
‘Is he going then?’ she says.
‘He is, yes.’
‘Oh my God,’ she says. ‘It must be the uniform.’

Charles has softened back onto the pillows.
There’s a faint outline of an old tattoo on his forearm. It looks like the number ten.
‘What’s that?’ I say, tapping it. ‘The number ten. Why’d you get that on your arm?’
He raises his arm, blearily stares at it, then plops it back down again.
‘That’s not a number ten,’ he says. ‘That’s a heart with a scroll underneath.’
‘Oh! Yes! I see it now! And what does it say on the scroll?’
Phyllis,’ says Maureen. ‘And no – it’s not his mother.’

peanut takes the fifth

The estate is so perfect it hardly seems real. A collection of the kind of houses you might see on a Monopoly board, except red not green, and made of wood not plastic. I imagine a giant hand reaching down from the sky and carefully setting each one in place, followed by the bushes, the young trees, a cute little twist of driveway. Kids playing in the street.
One of the kids cycles up to me as I park in the drive.
‘Hello’ he says, with a blank expression.
‘Oh – hello! Alright?’
He doesn’t say anything, but leans on the handlebars of his bike and watches as I take my bags out and shut the door.
‘Well… have a nice day!’ he says, satisfied everything seems to be in order. Then jumps up on his pedals and sprints away.
‘You too!’ I call after him.

I’d phoned Maud earlier to say I was coming.
‘The front door’ll be open’ she’d said. ‘Ring the bell, come into the hallway, but don’t open the inner door till I say. Only I’ve got the dog and he’ll run out.’

There are half a dozen wooden steps up to a boxy porch. I ring the bell, then open the door and step inside.
‘Just a minute!’ shouts Maud above the excited barking of a small dog. I close the main door behind me and wait. The moment Maud opens the inner door, the dog hurls itself through the gap, stretches its paws up my leg and stares at me with crazy eyes.
‘Peanut!’ says Maud.

Peanut is about the size of a Jack Russell, but one that’s been cut-and-shut with a Yorkie or a Capybara or something. It has wild, overgrown eyes and a bottom jaw cocked to the side with the tiny teeth showing, giving it a vexed kind of look, the kind of look you might see on the face of an ornery town sheriff who can’t decide whether to shoot you or make you deputy.
‘He’s so cute!’ I say, reaching down to pet his head.
Peanut licks my fingers then jumps back down and hurtles away back into the house. Maud trudges after him, waving for me to follow.

Maud’s front room is as cosy as any I’ve seen, the large patio window overlooking a lush and flowery garden.
‘Take a seat!’ says Maud, throwing herself down into her mission control recliner. ‘I don’t mind where.’
‘That’s the second dog I’ve met called Peanut’ I tell her, putting my bag down.
‘What was the other one like?’ she says. ‘Was that a pest, too?’
‘Actually…’
‘I didn’t name him,’ she says. ‘He was like that when I adopted him. I wanted an older dog. I said to them I said – I’m eighty-six! What do I want with a young dog? But they didn’t have anyone else and he’s only little so I suppose they figured he’d get enough exercise out in the garden. Plus I have a woman come over every other day to take him over the racecourse, and that seems to work.’

I picture Peanut racing alongside the horses. When they jump over the hedges, he dives straight through…

‘…mind you, it’s company,’ she says. ‘I wouldn’t be without a dog. It makes a place, d’you know what I mean?’
‘I do,’ I say. ‘We’ve got two lurchers.’
I show her the pictures I’ve got on my phone.
‘Oh – now!’ she says. ‘Look at that!’
She doesn’t stop long over the pictures, though. She immediately struggles back up again and takes me over to a wall that’s covered in framed pictures of all the dogs she’s ever had, which is quite a number. There’s one she seems to avoid, though – a Bichon Frise in soft focus, reclining on a pink bed, looking as pampered and comfortable as Barbara Cartland. Eventually she comes to it, though.
‘And that’s Billie,’ she says, reaching out to stroke the frame. ‘Billie was just.. I don’t know… Billie!’

Meanwhile, Peanut has taken the opportunity to climb headfirst into my bag, pedaling his back legs furiously in the air to push himself further in. I reach down and gently lift him out again.
‘Tempting as it is to kidnap you,’ I say, setting him upright on the carpet where he stands panting indignantly.
‘You’d be welcome,’ says Maud. ‘Yesterday he ate two marigolds.’
‘The gloves?’
‘No – the flowers!’ she says. ‘He came running in with them sticking out of his mouth, then chewed them down before I could pull ‘em out.’
‘Oh Peanut!’ I say.
He looks up at me, his jaw synched to the left, his bottom teeth poking up, as if he knows exactly what Maud’s talking about but has decided to take the fifth.