Christmas came. As soon as the school holidays started, Karen took the girls to her mother’s. Slavek was left alone with his mother. He attended to her physical needs, and the district nurse called as before. Then Karen decided to stay with her mother – Slavek was devastated. He was lonely and missed his little girls most dreadfully. On Christmas Eve he got drunk and slept for two days, with a couple of bottles of vodka by his bed.
He was awakened by repeated banging on the front door. He staggered downstairs, unkempt, unshaven, and wrapped in a blanket. It was the district nurse.
‘What’s been happening? I tried to get in this morning. I saw your bike was here, but you didn’t answer, and I knocked and knocked.’
‘What time is it?’ His voice was slurred.
‘It’s four o’clock. I haven’t seen your mother for days. Has she been away with you?’
‘No. She has been here all the time.’
‘Well, I must see her now.’
They went into the sitting room.
‘It’s bitterly cold in here. Hasn’t the poor old lady even got a fire? And it smells dreadful. Who has been looking after her? Where is your wife?’
‘My wife has gone to her mother’s and she’s not coming back.’
‘Not coming back? Oh dear, that won’t do. I will have to report that to my supervisor. The old lady can’t be left alone all day while you are at work. But I’m sure arrangements can be made to care for her – Meals on Wheels, a home help – yes, there is a lot of support we can give you.’
‘I don’t want your bloody support! I want my wife and daughters. They’re not coming back, I tell you.’
‘There is no need to shout, young man. I heard you, and don’t use bad language to me!’
‘She will have to go into an old peoples’ home.’
‘That’s not so easy, as you well know. The Council Home is full, and your mother is on the waiting list. Have you tried private nursing homes?’
‘Yes, and they won’t take her. Each one we tried said she would be disruptive and would upset the other residents.’
‘Well, all I can do is organise as much home support as possible for her. Now, I must clean her colostomy. She’s in a dreadful mess, faecal discharge everywhere. When did you last attend to it?’
‘I can’t remember. A few days, perhaps…’
Muttering words of disapproval, the nurse started work.
‘And what has she been eating recently, if your wife has not been here?’
‘I don’t know. Porridge, I suppose. She likes porridge.’
‘Well, it’s not good enough. We can’t allow her to live on porridge. Meals on Wheels will be arranged as an emergency, from tomorrow. And I advise you to light a fire, young man. It’s freezing in here.’
Clucking her disapproval, the district nurse left.
Slavek did not light a fire. He went to the pub and got blind drunk.
Days passed, day after desolate day, and Slavek was utterly alone. Hatred and resentment built up inside him and he could hardly bring himself to go near his mother – stupid, useless old thing. Why hadn’t she died when she said she would, why was he stuck with her now, a miserable old bag of bones with no mind? Why couldn’t she just die? Every day, when he got home from work, he was hoping against hope to find her dead – but she wasn’t. She was always there, in Karen’s nice sitting room, where the children should be playing by the fire, and having crumpets toasted on the red coals, and stories read to them before bedtime. Every evening he spent in the pub, drinking until closing time.
Men in Slavek’s position – having lost wife and children, heartbroken, lonely, angry, frustrated, drinking more and more – can quickly spiral into a crisis from which they cannot escape. Self-neglect, repeatedly arriving late for work with a hangover, unreliability, led to warnings from the management, which were only half-heartedly observed, then ignored. Slavek was dismissed. He was too ashamed to tell Karen that he had been given the sack, so he drew his dole money, sent half to her, and spent the rest in the pub. He had never been a good manager; Karen had always handled the family finances. Perhaps he thought that he was doing enough by sending her money each week; perhaps his brain, fuddled by drink, refused to accept the inevitable consequences of the fact that no money was going into his bank account.
In March he received a letter from the bank manager, saying that there was insufficient money in his account to pay his monthly obligation to the building society. Slavek ignored it. April brought a similar letter. He didn’t even open it. Each month a letter arrived, but was ignored.
Karen knew nothing of all this. If she had, she would have done something about it. But by the time August came and Slavek was six months in arrears with the mortgage, the sum outstanding was so huge that there was nothing she could have done to rectify the situation.
In September, the building society obtained an order for distraint. The house would be repossessed and sold to recover the loan the society had made. Slavek didn’t really understand what had happened until the bailiffs arrived and ordered him and his mother out of the premises. The district nurse arrived at the same time, and, as no provision had been made for the old lady, she took control of the situation and a week’s grace was allowed.
The Court Order was the first news Karen had of the financial crisis. She was utterly distraught and rushed over to see Slavek. How had it happened? It couldn’t have happened suddenly. There must have been warning letters. Where were they? Slavek rummaged around amongst a pile of unopened letters and produced a couple.
‘You fool!’ shouted Karen. ‘Why didn’t you let me know? Why did you ignore them? Now look what’s happened. We are going to lose our home. Don’t you understand? They are going to take our home away and sell it. We will be homeless.’
At last Slavek understood. But it was too late. There was nothing either of them could do. Karen returned to her mother, and stayed there. Slavek moved into a men’s hostel, and drink took over his life.
As soon as the nurse informed the council of the eviction order, they assumed responsibility for Mrs Ratski. She was taken to a short-stay home for the elderly, but was terrified by the new surroundings, and became so disruptive that she had to be moved. This was a pattern that repeated itself several times. With each new move she thought she was going to be poisoned and wouldn’t eat or drink. With puny strength she fought the staff and other residents and had to be forcibly restrained.
Mrs Ratski ended up in a psycho-geriatric ward where she could be kept under nursing care and more or less continuous sedation. All her fear, suspicion and aggression faded away and she became quiet and docile. She no longer resisted the nurses, and meekly swallowed the tranquillisers, and everything else that was given to her. Every so often she developed a chest infection or a kidney infection and obediently she swallowed the antibiotics. She lived like this for three years, not able to understand where she was, or how she had got there; maybe not even who she was. She could not speak to anyone, nor comprehend a word that was said to her. She had no visitors. The hospital chaplain arranged for a Latvian priest to come, but she stared at him strangely and did not speak. Her loneliness and isolation were more total and more terrible than if she had been transported to a distant planet inhabited by aliens.
The end came in 1957 when she fell out of bed and broke her pelvis. It was virtually impossible for the pelvic bone to mend because it could not be immobilised. An operation was performed to try to pin the bone, but the wound did not heal, and staphylococcal infection developed, which did not respond to antibiotics. Generalised septicaemia set in. From this, Mrs Ratski died, alone, in the brittle whiteness of an English hospital.
This is a family tragedy that could only have been prevented by the old lady’s death. Yet there is not a doctor in the civilised world who would fail to treat a simple intestinal obstruction. Nor, I think, are there many lay people who would say, ‘Leave her alone – she must die.’ No one could have foreseen that it would lead to t
he break-up of a family, and the downfall of a good man.
RETIREMENT
It’s some years since
I felt my servant’s discontent;
The vigour of his service seemed to pall.
I noticed this without undue dismay
At first.
The sometime faltering foot
Or wheezing breath
Or jack-knife on the exit from a car —
All brushed beneath the carpet
Of my mind —
An easy-going master.
But the incidents grew more
Till, patience fled, I turned on him,
Upbraided him with negligence, or worse.
He said: ‘Your lifetime, now
I’ve been your faithful slave,
Attending to your every need,
Drew in clean air for you
And made your blood,
Remodelled you from food,
Ejected what was not required,
Enabled you to see and hear
This varied world;
Gave you mobility,
Produced your thoughts and passions.
But now, at last, I’m weary,
Wish to rest,
Return to earth and air
Which nourished me,
As all things must,
While you go free.
What say you, master?
Will you grant me my release?’
‘That is not mine to do,’
I countered;
‘I serve too;
I serve one who
Would rage at my presumption
If I gave you leave to go.
He is the great Disposer.
For Him, it’s you who must depart,
Give notice, go,
Not wait for your release.’
And so it was;
My servant went
And left me here and everywhere,
No longer part but whole.
— Philip Worth
THREESCORE YEARS AND TEN
My grandfather’s death has an idealistic quality about it. His span of life had run out, he was cared for by his family, and he died peacefully in his own home. We would all wish to die like that. But, half a century later, we have to face the stark fact that for most of us it is unlikely.
Not so long ago old age was seen as the natural winding down of life, but somewhere along the way that attitude has changed. Now our waning years are viewed as a series of illnesses requiring medical intervention. A GP can prescribe drugs to arrest the symptoms of ageing, but a time will come when this is not enough and, at that stage, the elderly person is taken into hospital for treatment. This is almost compulsory these days; consequently, the majority of us will die in hospital or an institution of some sort.
It is a strange fact that a doctor cannot sign a death certificate having entered the cause of death as ‘old age’. This is illegal, and a doctor who did not conform would be censured. Death has to be caused by a named disease. In countries where births and deaths are registered, this is required by all governments, and endorsed by the World Health Organization. It is unlawful to die of old age. This is illogical, but as Mr Bumble the Beadle famously remarked in Oliver Twist, ‘The law, Sir, is a ass.’
We who are growing old know that we are. We feel it each day in our bones, in our joints, in our balance, and our slowing down; we see it in our hair and wrinkles; we find that little things we used to do without thinking have become difficult, and the struggle gets harder as the years go by. Strength, eyesight, hearing, memory, all begin to fail us. This is ageing, and we accept it because there is no alternative. Although we try to shut it from our minds we know that death is approaching; we ‘know not the day nor the hour’, but we know it will come.
We all react differently. In earlier generations it was time to ‘take to one’s bed’, for those who could afford it, and I have known many people who did exactly that. No doubt a bed, an armchair by the window and no exercise shortened life, but no one expected to live beyond the age of seventy. I don’t know of anyone who would want to do that now. Life has lengthened, thanks largely to drugs, but also to diet, general health, attitude and expectations. We know that the Horseman of Death is fast approaching, and it seems to have stimulated a collective desire to cram as much as possible into the few remaining years. Thousands of old people, with the help of medication and artificial hips and knees, are gadding about all over the world, doing things they have never done before, and enjoying life hugely. In 2005, to celebrate my seventieth year, I aimed to cycle one thousand miles for charity, and achieved fourteen hundred. This sort of crazy venture is not unusual. The organisers of activity holidays, such as a trek in the Himalayas, or perhaps the Road to Katmandu, often find that the majority of their clients are between sixty and ninety years old. Such activity would have been unthinkable a generation ago.
Active old age is wonderful, but it is entirely dependent on good health, which is a gift of God, or if you prefer, the luck of the draw, and not a right of man. We all know that any day, at any hour, something catastrophic could happen – a stroke, a heart attack, a broken hip – that would put an end to the life we have built. And then we would be dependent on others. A chill of fear enters the heart. The medication that has given us an extra decade of active life can still keep a tired and ageing heart pumping; can maintain sufficient pressure to keep the blood circulating and prevent it coagulating; can make liver and kidneys continue to function. Medication can help us for a long time, even when the body is manifestly worn out. Legs cannot function, a tremor affects the limbs, eyesight and hearing go, voluntary and involuntary control deserts us, the brain … well, let us not speak too much of the brain, for that is the most frightening thought of all. ‘I would rather be dead,’ people say.
Not so. The instinct to live is far, far stronger than the rational mind, and when the time comes, instinct will win. People will consent to operations that will keep them alive for a bit longer, or take pills that they know will prolong their infirmities, though they know in their hearts that it is the fear of death that drives.
In the natural course of events, the period when death is taking over a body is fairly brief. My grandfather (who had no medication) had about a fortnight of this period in his life. Today it can drag on for months or years.
I spent twenty years in medicine, and I loved every minute of it. For me, it was a vocation and a privilege, working with the sick and the dying. To cure the sick was a joy, and exhilarating. To ease the process of dying was a sacred duty. I respect and admire the medical profession more than can be expressed. And I lament the sublime irony that the profession that has cured so much disease, and enhanced the quality of life for millions of people has, through its own success, been the instrument of distress at the end of life.
Healing the sick used to be described as ‘the art and science of medicine’. Recently I have heard it called ‘the science and technology of medicine’.
In the last fifty years medicine has changed profoundly. The scientific advances in pharmacology, made by multinational drug companies, are mind-blowing. The technology of medical treatment has advanced exponentially, and this will continue. Surgery and anaesthetics are such that staggering things can be achieved. And all is directed towards preserving life. This is what most people want, expect and sometimes demand, as though we have an intrinsic right to good health. In a post-religious age we place vast and unmerited confidence in the powers of medicine. When someone goes into hospital, it is expected that the doctors will be able to cure whatever is wrong. If they cannot, there is often a sense of outrage amongst aggrieved relatives. Even if someone is ready to go, relatives often feel that death cannot simply be allowed to take its course. They do not realise how quickly active old age can slip into extreme old age and imminent death.
If you look out for it, you will find in many local newspapers an indignant relative telling a story to an editor, who can see a good front page h
eadline: ‘Hospital allows Dad to Die!’ This will be accompanied by a picture of a tearful woman holding up a photo of Dad. Then follows the story that the old man was around ninety, had had a heart attack or a stroke, or perhaps had broken a major bone, which had led to immobility, and in consequence he had developed a lung or kidney infection and died. The relatives claim, ‘It shouldn’t have happened. It was sheer neglect. He was in good health, enjoying life. He shouldn’t have been allowed to die like that. I blame the hospital.’
Doctors and nurses are the first to see the futility of strenuous intervention, but the fear of legal action can drive them into what is known as ‘defensive medicine’. This is bad medicine. The beleaguered doctors and nurses feel unable to make a decision based solely on professional judgement. They must always temper it with the thought that a decision or action might lead to an accusation of professional incompetence or neglect, or worse. Hospital practice today is driven by this necessity, and even if death is inevitable, doctors and nurses must be able to prove that they made every effort to prevent it. This is widely expected, nay demanded, by the general public and the law.
If people were with their elderly relatives all the time, day and night, as nurses are, they would be able to see for themselves the suffering and manifold indignities caused by the strenuous efforts to maintain life. Then perhaps they would be more inclined to say, ‘Enough is enough – and no more.’ Such a statement from a layman to a medical team is, I know, incredibly difficult. But the professions will usually accept it, and frequently with relief and gratitude.
Not infrequently an elaborate game of double-bluff is going on. Medical teams find it hard to suggest ‘no more, this is futile’ because they fear the reaction of relatives; at the same moment, relatives are perhaps thinking the same thing, but feel constrained from saying so in case someone thinks them callous or avaricious. No one will speak openly and truthfully. And whilst this is going on, a helpless old person at the end of life is unable to die.
In the Midst of Life Page 5