the works

There’s a builder’s truck blocking the mews. It’s up on hydraulic stabilisers as the driver operates the winch, dropping off enormous bags of sand and gravel, the engine labouring as the next load gets taken up, the back of the truck lurching with the sudden change of weight. I can’t imagine what building project would require such a massive delivery – maybe one of those basement excavations you read about, an underground pool and cinema and gym, perhaps. A lift shaft to a cocktail bar and viewing platform at the earth’s core. Whatever the reason, the contrast with the ancient backstreet couldn’t be more extreme. Two hundred years ago these would have been a row of stables with offices, lofts and basic accommodation above; now they’re a mixture of chi-chi businesses, full-scale conversions, and the cobbled street curves down right and left not to straw and manure-heaped gutters but expensive planters, artisanal signs and cutely painted old bikes with geraniums in the basket.

We’ve had to park at the far end by the equipment van that’s here to deliver a hospital bed. They could only have beaten us by fifteen minutes and yet they’re already half-way through. Once again I’m in awe of their efficiency and sheer work ethic, like scaled-up ants in yellow jackets. A hospital bed is no light thing. It comes in sections, of course, but the main frame is pretty heavy. A feature of the flats in these mews is a steep and narrow staircase running straight up from the front door – no doubt originally to a hay loft. To make things even more awkward, the house we’re visiting has a stair lift, so really there’s hardly any room at all to get the bed in. When we stroll up, though, they’ve already got the frame delivered, and all that’s left are the mattress, a cantilever table and a few other bits and pieces.
‘What did you do – commandeer the truck?’ I say to one of them, who is so red-faced I want to lean in and loosen his collar.
He laughs, slicks his antennae back.
‘Maybe you could take the table?’ he says.

The whole thing is something of a rush job. The GP had visited George late last night. George is a ninety-five year old man with a recent palliative diagnosis who has declined rapidly and unexpectedly straight into an End of Life scenario. He was refusing hospital, so the GP had prescribed anticipatory meds, made referrals to the District Nurse and Palliative teams, and to us for urgent review first thing in the morning. Katrina had gone straight there from home and was busy by eight. By nine she’d phoned in to make her report: it was bed care only, so George needed a hospital bed with pressure mattress and slide sheet to be delivered the same day, with someone to be there to help with a pat slide; George needed care support four times a day, double-up; he needed pads, pressure cream, foam lollipops for mouth care – the works. I said I could meet Katrina there at lunchtime to get the whole thing done.

George’s wife Valerie greets us at the top of the stairs.
‘Forgive my hair,’ she says, patting it. ‘I must look a fright. But as you can imagine I’ve had quite a night.’
Both Valerie and the flat have the shocked look of something hit by lightning. Everything is essentially as it was – the pictures, the chairs, the collections of antique pill boxes and books, the Moroccan rugs and tables and lamps, the family pictures on the walls – everything so perfectly placed and orderly the housekeeper must have a tape measure in their pocket. But the furthest end of the flat – the main bedroom end – has a sprawled, disrupted appearance, with a wreckage of discarded packaging, plastic strapping and so on spilling across the hallway, whilst through the open door the sound of construction and the movement of heavy furniture adds to the feeling of emergency. The noise from the builder’s truck outside sounds like a fire engine.
‘What a business!’ says Valerie. ‘But you know, everyone’s been so kind. We really are most grateful.’

There’s a large tabby cat staring at me from the middle of the living room rug. It’s as perfectly groomed as Valerie, and I half-expect it to reach up with a paw and pat itself delicately on the head, as she did.
‘Grammaticus is very put out,’ says Valerie, walking over to him. ‘He’s nineteen, you know? Like us – old and worn out. He can’t tolerate the fuss.’
She bends down stiffly and painfully, scooping him up to cradle him in her arms, just exactly as you would a baby, pressing her nose to the top of his head, rocking him up and down, swinging her hips a little from side to side. He maintains his stare, making little adjustments to accommodate the motion.
‘He looks good for his age,’ I say.
‘Do you think?’ she says. Then – still rocking the cat – she looks off towards the window. Down in the street, the noise from the builder’s lorry has eased. It sounds as if all the deliveries might have finished, and instead there are shouts and raucous laughter, the plaintive whining of hydraulic legs being lifted, the off-kilter clattering of a concrete mixer.
‘Good God,’ says Valerie. ‘When will it all end?’

spit spot

I’m in awe of the equipment company. They have an uncanny ability to put a hospital bed into the most inhospitable place. I’m sure one day we’ll be called to a lighthouse with a bed seesawing on the roof just above the lamp. Looking around Eileen’s small and cluttered bedroom, it seems to me they would only have had two options: lift the roof off and drop it in with a crane, or beam it into position from the transporter deck of the Starship Enterprise.

Nobody needed a hospital bed more than Eileen, though, so it’s great they persevered.
Eileen is rapidly approaching the end of her life, her flesh falling away, the most vital thing about her the glassy shine to her preternaturally large eyes.

‘I want to sit out,’ she says, gripping the sides of the bed. ‘I’m sick of this.’

It’s no small ambition. Aside from Eileen’s general frailty, we’ll need to consider the two lines from the morphine drivers feeding in to her right and left, her catheter, the nasal specs for her oxygen. And if that wasn’t complicated enough, there’s the practical difficulty of the bedroom itself. We had trouble getting in the door, let alone negotiate a complicated transfer. Still, Eileen won’t be dissuaded, and (incredibly) her observations are strong enough.

‘Hmm,’ says Vihaan, looking around.

I’m standing on Eileen’s right, squeezed in between a stack of pads, bedclothes, boxes of stuff, a cantilever table, a floor-standing aircon unit, a wicker bath chair piled with towels and things, a life-sized porcelain dog – really, it’s more like a storage cupboard than a bedroom for the terminally ill. Vihaan is to her left by the window. A little clearer his side, but not much.

‘Actually, Eileen, you know, I think it’s not going to be all that easy,’ says Vihaan. ‘Okay? I think it would be safer for all concerned if you stayed in bed and rested there.’

Eileen stares at him, a little hypnotised. It happens a lot. Vihaan is so striking, with a Bollywood intensity and perfect, crow-black quiff, standing with his hands on his hips, glancing around the place, speaking so rapidly and so musically it’s easy to get distracted, like standing by a stream fascinated by the play of light, utterly forgetting you’re supposed to be catching fish.

‘What?’ says Eileen.
‘Are you sure you wouldn’t want to stay in bed a while longer?’ he says. ‘Okay? You’re absolutely sure about this?’
Eileen turns her head slowly to stare at me, then turns back to Vihaan.
‘Of course I’m sure,’ she says.
‘Okay, then, Eileen. Whatever you say. You’re the boss, actually. We’ll give it a go and we’ll do our best,’ he says. ‘But we’ll take things slowly, one thing at a time – okay? – and then if anything changes, actually, we’ll stop and think it over again. Okay? Okay.’

The hospital bed is in the only possible place it can be, in the centre of the room, the feet towards the door. The best we can do is to cheat it more to the right, making enough space to the left for the wicker chair and a zimmer frame to help with the transfer. It’s a spatial puzzle, where you have to move everything in strict order, this then this, or that over there first, to move these, and that there temporarily, whilst you hand over these – careful – back up a bit, then that can go there…

Eileen watches it all pass backwards and forwards over her bed. She’s on so much morphine I wouldn’t be surprised if she thought the room was reordering itself, flying through the air in a magical, Mary Poppins kind of way. Spit spot. A clap of the hands. Vihaan would make a great Mary Poppins. Not so much the outfit – although he’d be a sensation in that – more his brisk but warm practicality.

‘Okay,’ he says, when at last the thing is done. He leans on the zimmer, one foot up on the strut. ‘So now the room is better arranged for you to sit out from your bed actually,’ he says. ‘The wicker chair is a good height for you and we’ve made it comfortable with cushions and what have you. So let us begin to raise you up on the bed, okay? And we’ll take it very slowly, Eileen. Step by step. And we’ll help you to sit out in the chair for a while.’
She turns her big eyes up to him, and although she doesn’t smile or say anything, you can see her gratitude holding there, at some depth, but poised, and delicate, and perfectly true.

coffee & cats

Magda bangs the horn with the heel of her hand, the force of it pushing her back into the seat.
‘Fucking hell! Would it kill you to indicate? How we supposed to know what you going to do at roundabout? What do you think I am? Fucking mind-reader?’
She drives on.
‘My father used to be traffic cop. He made it big thing to learn. He say to me “It doesn’t matter if it’s one, two, three o’clock in morning and no-one on road for miles. You make manoeuvre, you indicate. Because this way it becomes automatic habit, and you do it whenever you drive, without thinking.’
She’s forced to give way to an oncoming car.
‘Jesus fucking bastard! Sorry – I know is bad to swear. But please! Where these people learn to drive? Fucking CLOWN school?’

* * *

One of our carers has gone sick, so I’ve been asked to help Magda out with a double-up call. It’s to Rita, a very elderly and frail woman who has deteriorated significantly in the last few days. The regular care company don’t have capacity to pick up the increased calls yet, so we’ve stepped in to bridge the gap.
‘Rita is lovely woman,’ says Magda, pushing her enormous sunglasses up into her bleach blonde hair. ‘But then you see, I only do lovely womans.’
She jabs at the keysafe with one hand and retrieves the keys without even seem to look, everything so slickly done it’s like watching a stage magician.
‘Rita has lovely cat,’ she says, opening the door. ‘But she is grumpy in morning, like you. Helllloooooo? Rita? It’s the carers, darling. Good morning. We’re coming up there…’

I follow her up the stairs into a large, dimly lit sitting room with a hospital bed at one end. Rita is lying in the bed, surrounded by cushions and bolsters, the mattress raised in the middle to crook her legs up. She turns her head to the side to smile at us, the skin beneath her chin spare and slack, her whole body giving the impression of a generalised falling away, as if life was a tidal force leaving her now, declining with the last phase of the moon.

Almost immediately there’s an imperious yowling sound, and an enormous black cat stomps into the room behind us. The cat is wearing an expression so furious you could simply draw an X with a marker pen and be done. She advances into the middle of the carpet, sits on her haunches with an audible plump, licks her lips once, and waits.

‘Here is cat!’ says Magda, to avoid any confusion. ‘I’m sorry, I forgot already. What is cat called?’ she says to Rita, who manages to say without any interruption to her smile that the cat is called Juniper.
‘Juniper? Huh. I thought was Jupiter. Juniper? Like berry? Is this what you call it, berry?’
I nod.
‘They use it to make gin,’ I say. ‘I think that’s where the name comes from.’
‘Juniper?’
‘I think gin is short for ginevere or something. Dutch maybe. Which means juniper.’
‘Huh.’
She turns to Rita.
‘You like gin, Rita? Is that why you name your cat Juniper? Maybe you have other cat called vodka?’
Rita closes her eyes and shakes her head imperceptibly.
‘No worry,’ says Magda. ‘Let us sort you out, darling…’

* * *

After Rita is freshened up, the sheets changed and everything taken care of, Magda plays with the cat whilst I write up the notes. Magda knows where Juniper’s toys are kept; straightaway she fetches a small plastic fishing rod with a crinkly bee on the end of a string and dandles it in the air above Juniper’s head. Juniper swats at it – a little half-heartedly, it seems to me, flashing me looks now and again as if to say: Look – I’ve just got to attend to this damned bee business and I’ll be with you directly.
‘What is matter with you today, cat?’ says Magda. ‘Is my friend here distracting you? Is that what it is? Hmm?’ She gives up, tosses the rod on the sofa, and subjects Juniper to one more colossal stroke of the head and neck – so vigorously that as a matter of survival, Juniper has to stand and brace herself with her front paws, raising her tail straight up in the air to deflect the energy into the ceiling.
Magda picks up her bag to go.
‘I love this funny cat, Rita,’ she says. ‘We have cat back home, Puszek. But he is farm cat. Like baby tiger, you know? Puszek is so big now he drive the tractor.’
Rita bats a skeletal hand in the air.
‘Okay, darling,’ says Magda, taking Rita’s hand and squeezing it. ‘You take care now. We see you later. Okay? Okay. And don’t worry. We put key back in key safe.’
Juniper jumps up onto the bed, and immediately begins paddling on the duvet with its paws.
‘Good girl,’ says Magda. ‘That’s it!’

* * *

On the way back to base we stop off for a coffee and something to eat. We take five minutes to drink it in the car before setting off again.
‘How old are you?’ she says, giving me a sideways look, twisting the lid off her cup and blowing across the top of it.
‘Fifty-six.’
‘Fifty-six? Jesus Christ! You could be my father!’
I shrug.
‘You don’t look fifty-six,’ she says, biting the end off a croissant and chewing vigorously. ‘What you do before this job?’
‘Well – I was ten years in the ambulance. Before that I was teaching English in a secondary school for a couple of years. Before that I was temping. Different companies, some for a couple of years. I worked for a publishing house in London. A warehouse, office jobs, a couple of bars. I went to university, did English and Drama there.’ I shrug, helplessly. ‘That kind of thing. You know?’
I want to tell her I tried acting for a while, but I imagine it would just add to the generally dispiriting account of my career to date, so I leave it out and sip my coffee instead.
‘You travel?’ she says.
‘No. Not really. I wanted to.’
‘No travel? What about drugs? You do drugs?’
‘Some. Not much.’
‘Hmm,’ she says, finishing the croissant, smacking her hands clean and turning the engine over.
‘You’re telling me, not much. Come, now. Done. Let’s go.’

a bottle of banana-flavoured drink

No-one knew why Alf was dying, but anyone could see that he was.

And as far as I could tell (it was difficult to ask), nobody knew why he’d refused any of the tests that might reveal the cause, chance of recovery, or time left. He’d been clear about that – certainly clear enough to reassure the medical team that he understood the consequences of his actions, and that his refusal wasn’t simply another manifestation of his illness. He may have explained his decision to them in detail. I expect he did. For us, the community health team, we simply had to accept that Alf had declined any further intervention, and wanted to be cared for at home. I can only guess why that was. Maybe he knew that anything they tried would be hopeless, and he’d lose his last weeks in a fog of operations, pain, nausea, medication. Maybe he was resolved simply to wade out with his eyes closed, and let the dark waters close over him. When I met him he was as passive as an anatomical doll, frail and uncommunicative, submitting to being rolled and cleaned from time to time, and not much else.

Alf’s deterioration had been so precipitous the family had started to gather in earnest, flying in from the extreme ends of the country, and abroad. The home they came back to was as unrecognisable as their father. Everything was in turmoil. There was a hospital bed in the front room, looking like it had been beamed up from a ward somewhere and crash-landed amongst all the fishing trophies and wedding portraits and domestic ephemera of a life. And it wasn’t just the bed. There was an abundance of medical supplies and pieces of equipment, the kinds of thing you need to treat an end of life patient at home, and beyond that, every available space was now given over to the cause, to temporary put-you-ups, and suitcases, and clothes hanging over balustrades, and then extemporary family huddles in the kitchen, or the garage, wherever they could gather together, and drink tea, and whisper severely, and let the old family rivalries play themselves out, as they ever will when families get back together for any reason, but most especially now, when one of their number is dying. They’d hurried across hundreds – even thousands of miles – and now they were here they found there was little they could do. Along with their horror of the situation they had to cope with boredom, and frustration, and being separated even temporarily from their own lives and problems, for an indefinite time. They relieved each other from their vigils at the bed. They did what they could to stay afloat. But the house was an anteroom of death, and the fact that no-one explicitly knew why made it worse for them.

Leah had been the first to come down. Leah had problems of her own. She was almost as skeletal as Alf, except in her case it was an eating disorder she’d struggled with for years. She tried to encourage her father to drink some of her own supply of fortifying milkshake, holding the straw to his lips and making softly encouraging noises.
‘He doesn’t want it,’ said her sister, Mae, her arms folded.
‘It’ll do him good. It’s designed to.’
‘Yes, but he doesn’t want it.’
Leah was wearing a strappy summer top that hung down from her, revealing the cruel extent of her illness. In fact, you’d have to say that there was only a degree or two of difference between Leah’s physique and her father’s, except – Leah was clearly on this side of the line, and he was on the other, and she was reaching over with her little bottle of banana-flavoured, fortifying drink, trying to do for him what she’d been trying to do for herself all this time.
‘He doesn’t want it’ said Mae.
‘But he might,’ said Leah. ‘Give him a chance.’
Mae was right, though. Alf’s eyes were already preternaturally large, made of some dull, inferior kind of glass, whilst Leah’s were still bright, and vital, and full of tears.

when the time comes

Margaret’s daughter-in-law Sandy is standing over by one of the bookcases, casting her eye over the spines, taking the odd book out and idly flipping through.
‘Quite what we’ll do with all these when the time comes I don’t know,’ she says. ‘I mean – it’s a shame. These Dickens might’ve fetched something, but the sun’s got to them and they’ve gone a bit foxy.’

It makes me feel uncomfortable, but it’s my own fault, of course.

I’d started setting up to take blood from Margaret, and Sandy and the two carers had been standing round the bed, saying nothing, just watching.
‘I’ve never had such an audience,’ I said, just to break the tension, because it didn’t really bother me whether I was observed or not. ‘Talk amongst yourselves.’
‘Sorry!’ Sandy said, and that’s when she started to walk round the room, pricing things up.

As it turns out, though, I’m glad the attention has switched to Little Dorrit. Margaret is quite poorly, and getting anything remotely viable is like trying to tap-up a strand of hair. I’m not even sure why I’ve been asked to try. Margaret has steadfastly refused hospital – and I’m completely with her on that. She’s in her nineties, for goodness sake. If I was her I’d be refusing hospital, too. The only thing I might do differently is ask them turn my bed around so I could face out into the courtyard garden and that flowering cherry, so vibrantly and abundantly pink it would gladden even a dying heart.

‘Alright?’ says Sandy, coming back over. ‘Getting any?’

the very model of gentleness

Midday, and the sun is the blinding centre of everything, scorching every surface, every car bonnet, brick wall, bare arm; blazing over the city; bubbling in the gooey tack of the road; dry-frying the leaves on the trees; flaming across the intersection of every street, irradiating everything with its vast and pitiless eye. It feels as if the sun has moved in close, into some newer, more punishing orbit – on a grudge, on a whim – and it absolutely will not quit until the last squeak of moisture has been drawn from the cell of every living thing.

Which is to say, I’m hot and thirsty.
Even winding up the car windows when I park feels like an act of madness.
In the seconds it takes to step out, I’m sweating.

Agnes’ daughter Janice meets me at the door.
‘Gosh, it’s hot, isn’t it?’ she says.
Inside the house is dark and cool.
‘The doctor’s still here,’ she says.
‘Great!’
I follow her upstairs.

Doctor Middleton is sitting on a blanket chest quietly fanning himself with a magazine supplement.
‘Hello Doctor,’ I say, putting my bag down and reaching out to shake his hand. ‘I’ve been sent to take some blood.’
‘Excellent!’ he says. ‘I suppose you know the circumstances?’
‘Just the basics.’
‘Well let me fill you in. Agnes has taken to her bed the last couple of weeks. Nothing specific. A little abdo pain perhaps but you could probably ascribe that to diverticula disease. No diarrhoea, no nausea or vomiting. No distressing symptoms particularly, other than this loss of energy and appetite and general decline. The weather’s not helping, of course – it certainly is warm – but let’s just say it’ll be interesting to see what the bloods show. If you’d be so kind as to throw the net wide – kidney, liver function, infection, anemia, that sort of thing. And put it in as urgent, if you wouldn’t mind. And we’ll take it from there. Okay? Great.’
He looks from me to Janice then back again, smiling broadly, shining in the close heat of the bedroom. Then he puts the magazine down, picks up his things, and with a large, friendly wave, heads for the stairs.

I turn my attention to Agnes. She’s lying on her side on furthest edge of the large bed, her left hand crooked under her head, her right hand resting on the point of her elbow. She’s staring at a small, white fan that’s been set on the floor, angled up so that a current of air plays gently across her face.
Janice sits down on a wicker chair just opposite – a position I’m guessing she’s held these past few days – as I kneel at the side of the bed and gently stroke the back of Agnes’ hand. When she opens her eyes and looks at me I explain who I am and what I’ve come to do. She listens passively, allowing me to straighten her right arm, put on the tourniquet, and tap up a vein. She barely reacts as the needle goes in and I draw off two phials of blood.
‘There! All done!’ I say, taping a little wad of gauze over the wound.
‘What do you think’s wrong?’ says Janice.
‘I don’t really know,’ I tell her. ‘The observations the doctor took don’t seem to point to anything. Has it been a marked decline, would you say? Or was it more gradual?’
‘A bit of both,’ she says, and by way of illustration raises her hand in the air and swoops it back down again, like she’s describing a rather lacklustre ride she took at the fair.
‘I wish I knew what was wrong.’
‘Well the bloods will certainly give a good indication. You’re doing the right things. though. Keep Agnes cool, give lots of fluids – doesn’t matter so much about food at this point. And we’ll take it from there.’
The phone rings, so I mime a Goodbye. She waves and smiles, and I see myelf out.

The first thing I do when I get back to the car is open all the windows. The seat is uncomfortably hot when I sit down, but at least there’s a scrap of breeze now, so I don’t need to drive off immediately and find somewhere shadier.

My habit is to make sure I have all the details I need for these phlebotomy jobs, take the sample and then fill in the form and the labels on the phials when I’m back in the car. It’s a long and fiddly bit of admin, and I don’t want to bother the patient any more than I have to. So it’s only when I settle in to do the paperwork that I notice Agnes’ date of birth.

She’s well over a hundred years old.

It makes me think of my friend Jo and his old sheepdog, Lewis. When Lewis reached the very end of his life, he took to lying by their garden pond. The last time I saw him, in fact, the day before he died, he was in his usual spot, his head between his paws, staring with his eyes half closed at the ripples in the water his fading breath made. And I think of Agnes, upstairs on the bed, quietly staring at the little white fan spinning round and round.

I drop the bloods off at the hospital.

It’s only at the very end of my shift, when I’ve arrived back at base to handover my caseload, that I hear Agnes died – an hour or two after I left. Apparently an ambulance was called, and because there was no DNACPR, the crew had to go through the resus protocol.
‘Unsuccessfully, surprise, surprise,’ says the co-ordinator, clicking her pen and pulling a fresh report sheet towards her. ‘I’m amazed there wasn’t one in place, but who knows? Maybe the family refused. You never know with these things. Shame though.’
‘I certainly wouldn’t want anyone jumping up and down on my chest when I was in my hundreds,’ I say, taking a seat next to her. ‘Or sticking me with needles, come to that.’
‘No. Me neither,’ she says. ‘Maybe it was you taking blood that pushed her over the edge.’
But she immediately smiles, and pats me on the arm.
‘Only kidding,’ she says. ‘I’m sure you were the very model of gentleness.’