Kathryn Mannix - With the End in Mind

I wash my hands in the kitchen to prepare to give the antidote injection. Someone has tidied the flat since earlier today, and all the surfaces are gleaming. Then I insert a tiny needle under the loose skin of Holly’s forearm, and give the first small dose. Conversation continues around the room; Barry and Tony depart with their mum’s wheelchair; Nan and Amy settle into armchairs while Holly’s sister, Poppy, sits beside me on the sofa, from where we watch Holly threading her restless way around the room, the leader beside her in case she falls. She is still describing the fun of her afternoon.

Eventually she takes a seat on the sofa beside her sister. She fidgets, but remains sitting. She gradually stops talking, and listens to the chatter around her. I can see the leader watching her intently.

‘Are you sleepy, Holly?’ he asks gently. She nods. Poppy and I make space for her to lie on the sofa, but she twists and turns. She is too frail to get upstairs to bed, so Amy, always the practical one, brings down the rolled-up mattress she uses when friends sleep over. Nan and Poppy make up a bed, and Holly lies down. Her eyes are closing.

‘How are you feeling now, Holly?’ asks the leader.

No reply. Holly snores gently, and Amy laughs, but Nan leans forward and says, ‘Holly? Holly?!’ She is afraid.

The leader sits on the floor beside the mattress and takes Holly’s pulse. She is lying completely still now, breathing gently and occasionally snoring. The leader looks up at us all, and says, ‘Can you see how she is changing?’ And she is. She is becoming smaller. Her energy is gone, and the weariness that has been creeping up on her for the last couple of weeks is now overwhelming her.

Nan reaches for Holly’s hand, and says, ‘Amy, get your sister.’

Amy looks perplexed. Her sister is at a friend’s house for the weekend. She won’t want to be disturbed. Amy has not understood what is happening here.

‘Amy,’ I say, ‘I think your mum is so very tired that she may not wake up again.’

Amy’s mouth drops open. Her eyes dance between her mother, the leader taking her pulse, her Nan, and my face. ‘It wasn’t what she did today that tired her out,’ I say. ‘What you helped her to do today was fantastic. But she was already exhausted before her busy night last night, wasn’t she?’

Amy’s wide-eyed stare makes her look very like her mum as she nods in agreement. ‘And that exhaustion is caused by her illness, not by how busy she’s been today,’ I explain. ‘But if your sister wants to be here for her mum, then now is the time to come.’

Amy swallows and gets to her feet. She picks up a notebook and begins to look for a phone number.

‘Give it to me,’ says Nan. ‘I’ll phone.’

Amy silently points out the number, and Nan moves across to the window ledge, where the phone sits beside the cassette player. She dials. We hear the buzzing drone of the ring; we hear a voice answer the phone; then Nan gives her message as Holly opens her eyes and says, ‘Why am I lying down here?’

‘Too drunk to get to bed again,’ says Poppy, trying to smile but with tears running down her nose.

‘Don’t cry, Poppy,’ says Holly. ‘I’m OK. I’m just so tired. But haven’t we had a lovely day?’ She wriggles herself into the eiderdown and says, ‘Where’s my girls?’

‘I’m here, Mam,’ says Amy, ‘and Tanya’s on her way.’

‘Come and snuggle down with me,’ smiles Holly. Amy looks up at us. The leader moves back to leave space and nods at her. Amy lies down alongside her mum, and hugs her.

The front door bangs open, and a girl shoots through it.

‘Mam? Mam! Is she here? Where is she? Nan? Nan! What’s happening?’

Nan walks over and hugs her, then draws her across the room, saying, ‘She’s here, Tanya, she’s here. She’s so tired we’ve made her a camp bed. These are the doctors. Mam’s OK, but she’s very tired, and she wants a cuddle.’

Tanya kneels on the floor by her mother’s head, and Amy reaches up to take her hand, drawing it down to touch their mother’s cheek.

‘Here’s Tanny, Mam,’ she says. Holly puts her hand over the girls’ hands, and sighs.

Over the next half-hour, the light fades outside and the room becomes dark. No one moves. We sit in the semi-dark, an orange glow lighting the room from the streetlamps outside. Every now and then, the leader gives a quiet commentary.

‘Look how peacefully she’s sleeping.’

‘Can you hear how her breathing has changed? It’s not so deep now, is it?’

‘Have you noticed that she stops breathing from time to time? That tells me that she is unconscious, very deeply relaxed … This is what the very end of life is like. Just very quiet and peaceful. I don’t expect she will wake up again now. She is very comfortable and peaceful.’

And then Holly’s breathing becomes too gentle to float a feather.

And then it stops.

The family are so mesmerised by the peace in the room that no one seems to notice.

Then Nan whispers, ‘Is she still breathing?’

The girls sit up and look at Holly’s face.

‘I think she stopped breathing a few minutes ago,’ says Poppy, ‘but I was hoping it wasn’t true.’

‘Did you feel her move at all?’ the leader asks the girls, and they shake their heads as their tears begin.

‘Well done, you lovely family. You gave her the most wonderful day and the most peaceful evening. She has died’ – the girls gasp and sob, and he waits for quiet before he continues. ‘She has died so peacefully because she felt at peace with you here. You have done her proud.’

The girls move away from the mattress. The leader encourages them to touch their mum, to talk to her, to maintain the calm in the room. I am fascinated to see them lie down beside her again, weeping gently and whispering their love to her. It is almost unbearably sad, but this is not my family, and I feel my tears would be misplaced. I struggle to focus on the guidance being provided by the leader.

To Nan he says, ‘We need to telephone an on-call GP to certify her death, and then you can call a funeral director. But there’s no hurry. Give yourselves time. I’ll call the doctor now. She can stay here all night if that helps you and the girls.’

Nan knows what to do. She has buried two husbands and a son.

She offers us more tea, but the leader has informed the on-call GP of the death, and says we must be going. We let ourselves out of the smoky flat and onto the lamp-lit balcony, walk in silence down the gloomy stairs and out onto the pavement.

‘You OK?’ asks the leader.

Of course I’m not. I think I just killed someone. ‘Yes, fine,’ I reply.

‘You know the injection didn’t kill her, don’t you?’

‘Mmmm …’ I sniff.

‘She was so exhausted that she would probably have died last night if she hadn’t got that false energy from the akathisia. If you hadn’t controlled it she would simply have danced herself to death, agitated and upset. Instead, you managed her restlessness. And that gave her the peace to lie down and cuddle her girls, after her magnificent last day.’

We walk back to the car as a new mist rolls up from the river, and evening turns to night. My first day on call for the hospice. Not a day I will ever forget.

I learned a very important lesson watching the leader talk Holly’s family through the sequence of changes as her body relaxed, and dying displaced the restless energy she had been given by her anti-sickness medication. He was naming what they could observe; he was leading them through the process; he was reassuring them that all was expected, and usual, and safe. This is the task of the experienced midwife, talking the participants through the process, delivering them safely to the expected place. It is a gift that allowed the daughters to remain present and involved, and enabled them to look back and know that their calm presence was their final gift to their beloved Mam. It was a rare opportunity to watch a master at work, and to learn from that gentle, observant example.