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.’

the swans

We’re standing round waiting for the enema to work.
‘Anything yet?’
William moves his head tentatively from side to side without lifting it from the pillow, the tube of his nasal specs shifting only slightly, the air compressor in the corner of the room clunking and whirring. Ralph the dog gives a harrumph from under the bed, rests his chin on his paws. Tina the nurse, William’s daughter Bella and I do much the same.

It’s a peaceful scene, all in all – quite a contrast from the cries of pain William made when we rolled him onto his side to administer the enema.
‘Shouldn’t be long now,’ says Tina.
‘That’s what you said when you give me the suppository,’ says William. ‘What’s the next thing on the list? A stick of dynamite?’

Only Fools and Horses is playing quietly on the TV behind me. I glance back at it. Del boy, Rodney, Grandad and Trigger are all sitting on the sofa, looking depressed. It’s a strangely bleak scene for a sitcom. More like a downbeat suburban drama.

William reminds me of one of the other characters, Boysie, the dodgy guy who ran the car showroom, the one who put on airs and graces and wore a mohair coat over his shoulders like a count but was really as rough as the others. His living room is the kind of living room Boysie might have had – plush velvet drapes pleated like cinema curtains, fancy plates wired to the wall, carved gilt chairs, comedy scatter cushions. It’s an expensive house though, overlooking a quiet stretch of the river.
‘Are the swans back?’ he asks Bella.
‘The what?’
‘The swans. Are the swans back?’
‘The white one is. Not the black one.’
‘I like the black one.’
‘Well he’s not back yet.’
‘Where is he?’
‘I don’t know, Dad. Maybe he’s on his holidays.’
‘At least someone’s having a nice time. This? This is suicide.’

It’s a pretty tough situation for William. He went into hospital with a broken arm and came out with a diagnosis of terminal cancer, prognosis four weeks. We’re filling in for the palliative team, but at least he’s got a hospital bed and so on.

‘How about now? Anything?’ says Tina.
‘You’ll know about it when it happens,’ says William.
‘Dad – the whole neighbourhood’s gonna know about it when it happens,’ says Bella.
‘Yeah,’ says William, then appears to fall asleep.

Tina takes her gloves off, checks her fob watch, then sits outside in the hallway to write up the notes so far. The front door bell rings; Bella hurries downstairs to answer it. I stay standing next to William. He opens his eyes and looks directly at me, as if he’d secretly been watching me from behind his eyelids.
‘I mean – landmines,’ he says, as if we’d just been talking about that.
‘I know,’ I say. ‘It’s a terrible thing.’
‘Why would you make something like that? Killing and maiming innocent people. What’s that all about, then?’
‘I’m pretty sure this country still makes them, though. And other stuff. The arms trade is pretty big.’
‘Why can’t we all just get along? If you want to go to a church, or a mosque, or wherever – fine. It’s none of my business. But the next thing you know, we’re at each other’s throats.’
‘That’s a good point,’ I say. ‘Too many wars over nothing at all.’
‘Then of course what happens is – you say one thing – I say another – fine – your lot have a go at my lot – I say what’s going on here – they move over there – I say hang on a minute – and the next thing you know millions are being slaughtered.’
‘It’s complicated.’
‘Is it really so hard for us to share this planet?’
‘That’s true.’
‘But I tell you one thing.’
‘What’s that?’
‘There ‘ain’t half been some evil bastards in this world.’
‘It’s definitely had more than its fair share.’
‘Take that Clinton woman.’
‘Hillary Clinton?’
‘I read a book about her. Now that’s evil on a whole other level.’
Hillary Clinton?
‘If I wasn’t laid up in bed – if I could get outta this bed – you know what I’d do? I’d take a machine gun and machine gun the lot of ‘em.’
Bella comes back in the room.
‘Amazon delivery,’ she says. ‘Any developments?’
‘The lot of ‘em!’ says William.
Bella looks at me and raises her eyebrows.
Tina walks in, snapping on fresh gloves.
‘Alright?’ she says.
Behind me, the Only Fools and Horses theme tune starts to play.

a second set of clothes

‘They said there’s nothing more they can do for Jean. They said it’s terminal. Do you think that’s right? Do you think there’s anything more to be done?’
Stan’s eyes bore into me. There’s a slack and waxy look to his face, like he hasn’t slept for a week.
‘I don’t know, Stan,’ I tell him, and look down again at the discharge summary in my hands. The journey Jean has taken from ambulance admission to A and E and then back again is described in lean, jargonistic language, but no less damning for all that.
‘What did they say at the hospital?’
‘Not much. But then a doctor came round here the day after Jean came home and said that was it, basically.’
‘It’s so hard,’ I say. ‘How are you bearing up?’
He massages one fleshy hand with the other, working the thumb into the palm, like he only needed to get a little strength back there and he’d be able to do something, to make some change.
‘I’m used to sorting things out, getting things done,’ he says. ‘I’m the one they all came to. I even organised the skiing trips. But this? I just don’t know. I just don’t know.’
‘Do you have family around, Stan? Friends, neighbours?’
‘We didn’t have children,’ he says. ‘Not that it bothered us, after a while. We had Jean’s family, our friends, of course. They’re all elderly, now. Half of them are dead. I think I’m the only man left amongst the old lot. So – what do you think? What should I do?’
I lay the discharge summary gently on the table, beside the DNACPR and the scrip for the anticipatory meds.
‘You know – just reading what the medics have written here, it does look like Jean’s cancer is untreatable. So the thing is to take care of her at home now, if that’s what you both want. It’ll be about symptom control, making Jean comfortable. Have the palliative team been round yet?’
He nods.
‘There’s been a lot of people in and out.’
‘It gets confusing. Whoever comes in should write in the folder here – who they are and what they’ve done – so there’s that. And there’s a list of the main numbers to ring if anything changes or you’ve got any questions. I’ll give the palliative team a call in a minute and ask where we are with visits and things. What to expect next.’
‘They left all these medicines. What am I supposed to do with them?’
‘Those are what they call the Just in Case meds. It’s things for pain relief, to help Jean’s breathing, anti-nausea meds, that sort of thing. You don’t have to worry about them, Stan. The District Nurses will be in to take care of all that. Is that okay?’
‘I suppose it’ll have to be.’
‘They’ve referred Jean to us for some urgent equipment and care support.’
‘Right. Got you.’
I wait a minute, then stand up.
‘What d’you think? Shall we go up and say hello to Jean?’
‘Yes. Sorry,’ he says. ‘It’s funny. She’s normally up with the lark, but she’s feeling pretty worn out so she’s staying in bed.’
‘I don’t blame her.’

He leads me up a narrow, carpeted staircase, worn to the thread in the middle, the boards sagging and creaking. The landing window is open and an unseasonably warm afternoon breeze nudges through the curtain.
‘Jean?’ says Stan, as we go into the bedroom where Jean is propped up on four pillows. She’s breathing quickly, her cheeks flushed and her lips pursed, with the rapt expression you sometimes see on patients who are riding their discomfort and don’t have room for anything else.
‘Hello, Jean!’ I say, waving. ‘Shall we sit you up a bit? It’ll help with your breathing.’
Once she’s more upright her breathing does ease a little, and her oxygen levels are surprisingly good. Despite her wasted condition, she still manages to tease me. Stan sits in the wicker chair beside the bed, and starts kneading his hands again.

‘I’ll need to make a quick call to the palliative team,’ I say to them. ‘Is that okay?’
Jean squeezes my hand.
‘You do what you have to do,’ says Stan.
I step away from the bed to make room for him, then make the call standing at the bottom of the bed, using the duvet as a desk for the open folder, which Jean moves with a cheeky nudge of her foot.

Luckily, Sandy answers the phone. Sandy’s a palliative nurse I’ve never met in real life but who always exudes great competence and compassion.
‘We’ll send a nurse out in an hour,’ she says. ‘Meanwhile, have a scootch around and see what you can do in the way of equipment. And start the care as soon as you can.’

‘I think you’ll really feel the benefit of a hospital bed,’ I tell Jean, putting the phone back in my pocket. ‘They’re fantastic, these beds. You can adjust the height, sit the back up – all sorts. All at the touch of a button. The pressure mattress is nice and comfortable, and means you’ll be less likely to get a pressure sore. We can get it installed pretty quick. All we need to decide is where it goes. We’ll need to clear space for it.’
‘I’ll show you the second bedroom,’ says Stan. He gives Jean a kiss then takes me next door.

The second bedroom is half the size of the first, with a single bed in the centre, a wardrobe in the corner and not much else. I’d guess it was the room Stan’s been sleeping in, although you’d hardly know it. There’s a shirt, a pair of trousers, a pair of pants and a pair of socks neatly laid out on the bed, side by side. They look exactly like the clothes he’s got on already.
‘This is great!’ I say, looking around, but not moving. ‘Plenty of room for the hospital bed once this one’s gone. A nice view of the garden. Lovely! What do you think you’ll do with this bed?’
‘I’ll just stand it on its end in the corner by the wardrobe. Maybe throw a sheet over it.’
‘Do you want a hand to do it?’
‘Me? No,’ he says. ‘That’s one thing I’m still good for.’
And we both stand there, side by side, staring at the clothes on the bed, like we fully expect them to magically jump up, throw themselves together and start flying round the room.
‘I’ll make the order,’ I say.
‘Stanley?’ cries Jean.
‘Yes, love…’ he says, and hurries back.

two dwaynes

I’ve come to do Elaine’s assessment with Lisa, one of the physio assistants. Elaine is eighty, her cancer advancing rapidly towards end of life, to the point where she needs a great deal more equipment and care. The District Nurses want her to go into a hospice, because she has no family or friends to help out, she’s isolated and vulnerable where she is, and there’s a limit to what the various community health teams can do. Elaine doesn’t want to go, though, despite numerous falls and incidents. The DNs have referred her to us to see what else we can provide, including night sitters.

We’re told that Elaine is able to buzz us into the building with a remote device, but when we ring her number there’s no reply and nothing happens. The building manager isn’t in his office, so we push the emergency buzzer on the console. Because we don’t know the password, and the door’s not camera monitored, they won’t let us in. We ask if they’ll phone the hospital and check that way. It’s not part of their protocol, they say. They can’t do it.
‘She might be on the floor,’ says Lisa.
‘Sorry.’
They ring off.
Lisa curses, buzzes random flats. Eventually someone takes pity on us and lets us in.

Luckily, Elaine’s door is unlocked. She’s sitting on the floor leaning back against the bed. The only injury she has is a skin flap on her arm, so together we gently help her up again and settle her back in bed. I check her over and dress her wound.
The phone rings. Lisa answers on Elaine’s behalf.
‘It’s Dwayne,’ she says. ‘From the Salvation Army. He says he’ll call back later.’
Elaine nods, gently raising and then lowering her uninjured arm like a marionette sadly acknowledging some change in her surroundings, then she gently closes her eyes and rests her head back. She’s so frail and emaciated she hardly makes any impression on the pillow.
‘Dwayne is so sweet,’ she says. ‘There are two of them, you know.’
‘Two Dwaynes?’
‘Identical twins.’
‘Buy one get one free,’ says Lisa.

Gently holding the primary dressings in place, I wrap Elaine’s arm in a bandage.

‘I used to play tennis with this guy,’ I tell her. ‘It was only a year later I found out he had an identical twin. For some reason it just never came up. I went round to pick him up one day and when he came to the door I thought Whoa! What’s different? He just stood there looking at me whilst I tried to figure it out. Was he wearing new glasses? Has he cut his hair? What was it? After a while he said So I’m guessing Simon never told you he had an identical twin? It was so weird! They were the same but different. Very unsettling.’
‘I’ve not met Dwayne’s brother,’ says Elaine. ‘I’ve only ever seen pictures.’
‘What’s his name?’
‘Dwayne.’
‘What – they’re both called Dwayne?’
‘No. Dwayne’s called Dwayne. I don’t know what the other one’s called. Something or other, I expect.’
‘I was gonna say. If you had identical twins you wouldn’t call them both Dwayne. It’s confusing enough.’
‘I dunno,’ says Lisa. ‘Might make it easier.’

I tape the bandage.

‘There! Good as new!’
I gather all the rubbish together.
‘You know – it’s only recently I found out you can’t have identical twins of different genders,’ I say, peeling off my gloves, adding it to the waste bag, then putting it in the kitchen bin.
‘You can, actually,’ says Lisa. ‘It’s pretty rare, but it can happen. It’s all about the fertilisation. If you get two eggs developing in the uterus you get fraternal twins; if you get one egg that splits in two you get identical twins, boy boy or girl girl. But then sometimes one of the halves drops the Y chromosome and you get boy girl identical twins. Very rarely though. See what I mean?’
‘‘How do you know all this stuff?’
She winks and points.
‘Stick to the bandaging, Florence. Leave the science to me.’
Elaine tentatively flexes her bandaged arm.
‘Oh dear,’ she says. ‘I look like Boris Karloff.’
She sighs and closes her eyes again.
‘Maybe I had better think about that hospice,’ she says.

smashing trucks

It’s a complex family situation – as they often are – but the long and the short of it is, Jimmy’s been sent home to die.

Although the end has come quickly, it’s not entirely unexpected. Jimmy has had an alcohol problem for a good many years, as punishing to his family life as his liver. Nothing helped, not counselling, drug and alcohol rehab, surgical corrections, medication – it all turned out to be a grave but ineffectual chorus singing downstage of the tragedy.

At least Jimmy still has people around him, though. In fact, the house is pretty full. There’s his brother, Tom, Tom’s wife Stella, Jimmy’s stepson Al and Al’s little boy, Kevin. Kevin is about three years old I’d guess, a cheeky, tow-haired kid in a dinosaur T and red shorts, loving the drama of all these people, showing off by diving onto the sofa, smashing his toy trucks together, sneaking up behind you, touching you on the shoulder and then running away screaming, bending over for no apparent reason and looking at you from upside down.
‘Kevin? Why don’t you settle down on the sofa and watch the Formula One?’ says Al, although I’d guess that’s really what he wants to do.
‘No!’ says Kevin, diving under the table.
‘Don’t worry, Al. I don’t mind,’ I say.
Al shrugs, and carries on unpacking the shopping.

It’s the first time I’ve met the family. Truth is, I’d been blindsided by the whole situation. I thought it’d be an easy call, dropping off equipment and doing some obs on a patient before returning to the hospital to take care of all the referrals that’d piled up that day. When I got there I’d found a patient who was actively dying, and insufficient preparation made for any of it. I couldn’t figure out how it could’ve happened like this. After I’d made Jimmy as comfortable as I could, cutting off his hospital gown with my shears to avoid disturbing him too much, giving him a stripwash on the bed and so on, all helped by Tom and Stella, I’d spoken to the office to confirm we were putting in double-up care that evening, then called Jimmy’s GP, who was as confused and disturbed as I was. She’d promised to get clarification from the hospital, and said she’d call straight back.
‘You’ve been so helpful,’ I say to Stella and Tom as they sit down with me at the table with some tea. ‘I’m sorry it’s been stressful and messed up.’
‘Don’t worry,’ she says. ‘These things happen. At least he’s not in pain.’
Tom puts his hand on Stella’s shoulder; she gives him a brave smile, then wraps both her hands round the mug of tea, to feel the warmth of it.
‘Our son Billy died this year,’ she says. ‘I suppose I’m getting used to it.’
‘I’m so sorry to hear that.’
‘I was with him at the end. He was struggling, so I put my arms round him to help him sit up. He was trying to say something, but he couldn’t get it out, and I couldn’t understand what it was. So I held him like that, and I said I loved him, and then he fell back, and that was that. And that was the start of the year.’
‘I’m just going to sit with Dad for a while,’ says Al, heading towards the stairs.
‘Okay then’ says Tom. ‘Good lad.’
‘Now you be good’ says Al to Kevin.
‘Look at my trucks!’ yells Kevin, bouncing up and down on the sofa, smashing the trucks together, head to head. Peeyow! Pow! Kapooooof!

met

Maud’s designated next of kin, Alan, lets me in. A tidy man in his early sixties, his grey beard is as scrupulously clipped and pressed as his Nordic woolly jumper.
‘Just through there, in the living room,’ he whispers, giving a little bow of the head, his eyes closing momentarily behind a glint of steel-rimmed glasses, like a kindly psychoanalyst welcoming a new client. ‘The social worker’s with her at the moment. I don’t suppose Maud will mind the two of you.’

Maud is sitting out of bed in an armchair, still wearing her cat-print pyjamas, looking around with a detached, slightly befuddled air. Beside her, on a hospital table, is a selection of the things she needs: tissues, beaker of tea, remote control, reading glasses, and a copy of Anna Karenina.

I introduce myself. When I shake hands with Maud she holds her hand out limply, looking up at me like someone who thinks they might still be asleep.
‘I can’t believe you’re a hundred years old,’ I say to her, sitting down opposite.
‘Am I?’ she says. ‘Well, then. Neither can I.’
The social worker fills me in on the situation. Maud has Alzheimer’s, but has been coping pretty well with care support and so on. Just recently there’s been a bit of a decline, and people were worried.
‘It doesn’t look like an infection, so that’s good,’ says the social worker. ‘Maud would like to stay in her home, but we’ve just been talking about that, and what we might be able to do to help.’
‘I’m in your hands,’ says Maud, then nods at Alan. ‘You’ll know what to do, won’t you, dear?’
‘It’s whatever you want, Maud,’ says Alan, smiling. ‘But don’t worry. Nothing’s decided til it’s decided.’

I carry out a quick set of observations whilst the social worker reads through the notes. Everything seems fine. Maud seems to be in rude health, considering her extreme old age.
‘The thing that bothers me most,’ says Maud, ‘is I can’t get up the stairs to look after Mum and Dad. And if I can’t do it, who will?’
‘By upstairs do you mean – upstairs? In the bedroom?’
‘Where else would they sleep?’
‘It’s understandable that you’re worried about them,’ says the social worker, pausing a moment to choose her words. ‘But I think they’re safe now. I think they’re pretty much at rest.’
‘I know that!’ says Maud. ‘I’m a hundred years old! I’m not daft!’
‘No,’ says the social worker. ‘You’re certainly not.’
‘It’s just they’re upstairs waiting for me, and I’m stuck down here, and I can’t do anything about it.’

When it’s time for me to go, Alan shows me to the kitchen door. I take this opportunity to ask him what he thinks about Maud. He stops to listen, adopting a thoughtful attitude, supporting the elbow of his right arm with the hand of his left, gently pinching his upper lip.
‘I haven’t met her before,’ I tell him. ‘So I don’t know how much of this is new.’
‘You mean this thing about her parents?’
‘Has she talked about them before?’
‘Off and on,’ he says. ‘I know how it sounds, but I suppose there are two ways of looking at it. One is that it’s all just a symptom of her cognitive decline, some organic disease and so on. The other is to say that perhaps, yes, she can actually see her parents. You might think it odd to hear me say that; other people, in other cultures, with certain religious beliefs, would probably understand it quite well. You see, it’s been my experience in circumstances like this that people nearing the end of life are – how shall I put this? – met?’
‘That’s certainly a different way of looking at it.’
‘It is, isn’t it!’ he says, brightly, patting me on the shoulder. ‘Now then. Good to see you, and thank you so much for coming!’

I walk over the road to my car and throw my bags in the boot. When I turn round to look, Alan’s still there, watching me from the kitchen door.
I wave.
He waves back, then turns and goes inside.

For the life of me, I can’t help glancing up at the bedroom window.