With the End in Mind. Kathryn Mannix

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СКАЧАТЬ of a variety of medical specialties, some training in cancer medicine and a freshly minted postgraduate qualification, I probably saw myself as quite a catch. I know that I was buoyed up by the discovery that palliative care fitted all my hopes for a medical career: a mixture of teamwork with clinical detective work to find the origins of patients’ symptoms in order to offer the best possible palliation; of attention to the psychological needs and resilience of patients and their families; honesty and truth in the face of advancing disease; and recognition that each patient is a unique, whole person who is the key member of the team looking after them. Working with, rather than doing to: a complete paradigm shift. I had found my tribe.

      The leader of this new hospice had been on call for the service without a break until my arrival in early August. Despite this he exuded enthusiasm and warmth, and was gently patient with my questions, my lack of palliative care experience, my youthful self-­assurance. It was a wonder to see patients I already knew from the cancer centre, looking so much better than when they had recently been in my care there, now with pain well controlled but brains in full working order. I may have thought highly of myself, but I recognised that these people were far better served by the hospice than they had been by the mainstream cancer services. Perhaps my previous experiences were only a foundation for new knowledge; perhaps I was here not to perform, but to learn. Humility comes slowly to the young.

      After my first month of daily rounds to review patients, adjusting their medication to optimise symptom control but minimise side-effects, watching the leader discuss mood and anxieties as well as sleep and bowel habit, attending team meetings that reviewed each patient’s physical, emotional, social and spiritual wellbeing, the leader decided that I was ready to do my own first weekend on call. He would be back-up, and would come in to the hospice each morning to answer any queries and review any particularly tricky challenges, but I would take the calls from the hospice nurses, from GPs and hospital wards, and try to address the problems that arose. I was thrilled.

      Holly’s GP rang early on the Saturday afternoon. Holly was known to the city’s community palliative care nurses, whose office was in the hospice, so he hoped that I might know about her. She was in her late thirties, the mother of two teenagers, and she had advanced cancer of the cervix, now filling her pelvis and pressing on her bladder, bowels and nerves. The specialist nurses had helped the GP to manage her pain, and Holly was now able to get out of bed and sit on the outdoor landing of her flat to smoke and chat with her neighbours. When she developed paralysing nausea in the previous week, her symptoms were improved greatly by using the right drug to calm the sickness caused as her kidneys failed, as the thin ureter tubes that convey the urine from kidneys to bladder were strangled by her mass of cancer.

      Today she had a new problem: no one in her flat had slept all night, because Holly wanted to walk around and chat to everyone. Having hardly walked more than a few steps for weeks, overnight she had suddenly become animated and active, unable to settle to sleep, and she had woken her children and her own mother by playing loud music and attempting to dance to it. The neighbours had been banging on the walls. At first light her mother had called the GP. He found Holly slightly euphoric, flushed and tired, yet still dancing around the flat, hanging onto the furniture.

      ‘She doesn’t seem to be in pain,’ the GP explained to me, ‘and although she’s over-animated, all her thought content is normal. I don’t think this is psychiatric, but I have no idea what is going on. The family is exhausted. Do you have a bed?’

      All our beds were full, but I was intrigued. The GP accepted my offer to visit Holly at home, so I retrieved her notes from the community team office and set off through the receding autumn mist to the area of the city where long terraces of houses run down to the coalyards, ironworks and shipbuilders that line the river’s banks. In places the terraces were interrupted by brutal low-rise blocks of dark brick flats crowned with barbed-wire coils and pierced by darkened doorways hung with cold neon lights in tamper-proof covers. These palaces bore unlikely names: Magnolia House, Bermuda Court, and my destination, Nightingale Gardens.

      I parked my car at the kerbside and sat for a moment, surveying the area. Beside me rose the dark front of Nightingale Gardens. On the ground floor, a bare stone pavement ran from the kerb to the tenement block: not a tree or a blade of grass to garnish these ‘gardens’, which certainly never saw or heard a nightingale. Across the road, a terrace of council-owned houses grinned a toothy smile of white doors and window frames, all identical and recently painted. Some of the tiny front gardens displayed a few remnants of late-summer colour; rusting bed-frames or mangled bicycles adorned others. Several children were playing in the street, a game of catch with a tennis ball played while dodging a group of older boys who were aiming their bikes at the players. Yelps of excitement from the kids, and from a group of enthusiastic dogs in assorted sizes who were trying to join in.

      I collected my bag and approached Nightingale Gardens. I needed to find number 55. An archway marked ‘Odds’ led to a dank, chilly concrete tunnel. My breath was visible in the gloomily lit staircase. On the landing, all the door numbers were in the thirties. Up another couple of flights I found the fifties, and halfway along the balcony corridor that overlooked the misty river, and was itself overlooked by cranes rising above the mist like origami giants, number 55. I knocked and waited. Through the window I could hear Marc Bolan telling me that I won’t fool the children of the revolution.

      The door was opened by a large woman in her fifties wearing a miner’s donkey jacket. Behind her was a staircase leading to another floor, and beside her the living-room door swung open to reveal a diminutive, pale woman leaning on a table and moving her feet to the T. Rex beat.

      ‘Shut the door, will you?’ she trilled across to us. ‘It’s cold out there!’

      ‘Are you the Macmillan nurse?’ the older woman asked me. I explained that I worked with the Macmillan nurses, but that I was the doctor on call. She beckoned me inside with an arc of her chin, while simultaneously indicating with animated eyebrows that the younger woman was causing her some concern. Then she straightened up, shouted, ‘I’m off to get more ciggies, Holly!’ and left the flat.

      Holly looked at me and explained, ‘We smoked ’em all last night. Gaspin’ now!’ Then she invited me in, saying, ‘Wanna cuppa?

      There was something childlike about Holly, with her tiny frame and her dark hair swept up into a high ponytail. Her skin shone with an alabaster clarity, stretched taut over swollen legs and a pinched face. She seemed to emanate a faintly yellow light, like a fading lightbulb. She was in constant motion, as though driven by an unseen force. Her feet danced while her hands leaned on the table; then she sat down abruptly in one of the upright chairs and began to rub her hands along her arms, along her thighs, along her calves, shuffling her bottom and nodding her head in time to the music. Alice Cooper next: Holly drummed her fingers, then played air guitar, tossing her ponytail to celebrate school being blown to pieces. Throughout, she sang along in a thin contralto embellished by occasional hiccups.

      The music stopped with a click that drew my attention to the cassette player on the window ledge. These must be mix tapes she had recorded in her teens. Without the music to give shape to her movements, the choreography broke down and she simply rocked on her chair, rubbing her limbs with her thin hands and tossing her hair like an angry genie. She looked up at me, as though noticing me for the first time, and asked, ‘Got a ciggie?’ When I shook my head she laughed and said, ‘Oops, no, you’re the doctor, aren’t you? You won’t approoove of ciggies!’ in a sing-song voice tinged with sarcasm.

      ‘So, what’s the deal, doc?’ she said next. ‘I feel GREAT today! I wanna sing and dance and get outta this bloody flat!’ Casting her gaze around the room, she sighed heavily. ‘It’s like a pigsty in here. Needs a good cleaning. Amy! AMY!!!’ she moved her gaze to the ceiling, brown with cigarette smoke, as though to look at Amy, who was presumably upstairs.

      A teenage girl СКАЧАТЬ