In the Midst of Life

January 29, 1990, in the sixth year of his illness, puffing breathlessly from the effort of one of his fast, forced marches, he stumbled into his chair and fell to the ground, pulseless. When the paramedics arrived a few minutes later, they tried CPR [cardio-pulmonary resuscitation] to no avail and sped him to the hospital, which was right next door. The emergency room doctor pronounced him dead of ventricular fibrillation leading to cardiac arrest … *
     
    The Methodist Homes for the Aged is an excellent, non-profit-making charity, and takes a high percentage of patients with Alzheimer’s who require twenty-four-hour care. The carers work cheerfully, motivated by a sense of vocation and duty. The Methodists have a specific policy for care of the dying, set out in their booklet
The Final Lap.
The teaching is based on acceptance of death as a fact of life, and the need to prepare for its coming, and I was discussing this with a chaplain for one of the Methodist Homes. All of their chaplains are closely involved with, but not responsible for, medical practice. Citing Nuland’s description of his friend’s condition and death, I posed the question, ‘Would you really allow such an aggressive resuscitation attempt upon anyone in that condition?’
    I expected him to say, ‘No, we accept death and respect the dead.’ But he didn’t. He left it open by saying, ‘The trouble is, it is increasingly hard to define death – the boundaries are so blurred, and we do not have in each individual Home a member of staff who is qualified to pronounce death.’
    Hesat pondering for a minute, and then continued.
    ‘Apart from that, no Home wants to have too many deaths. You see, it is our policy to integrate the Home into the community, so that residents are not isolated. If too many coffins are seen leaving the premises, this could start fear and suspicion and gossip among people living in the area. You never know what might be said. This would be bad for the Home, and all the residents would suffer.’
    As he said that, the memory of my neighbour’s experience flashed through my mind. The house is large, with about ten rooms and half an acre of garden, and at the time, a young family was living in it. The wife, Ginnie, was a trained nurse who enjoyed looking after the elderly, so the family decided to open four of the rooms as a residential home. They all lived and ate together, and it was a happy arrangement. The old people enjoyed the company of the children, who in turn had the advantage of seeing and living with old age. The young husband kept chickens and geese and grew vegetables. One of the old men made it his responsibility to feed the chickens and collect the eggs. A couple of ladies helped in the kitchen.
    Then misfortune struck. Within a month, two of the old people died. Police investigations followed; then the local press. Repeated interrogations reduced Ginnie to a shadow of her former self. The local paper made it a matter for front-page headlines. The coroner’s verdict was that the deaths were from natural causes, and Ginnie was completely exonerated, but the two remaining residents were taken, against their will, to a registered care home, and quite a crowd gathered outside the house to watch their removal. Ginnie was distraught, because it did not end there.
    The things that were said locally about Ginnie were vicious. I know, because I heard them. Matters got so bad that, eventually, the family was forced to move.
    I told this story to the chaplain. He said, ‘I am not surprised. It is the sort of local reaction I would have expected.’
    ‘What do you do, then, if someone looks near to death?’
    ‘Itwould depend on the circumstances, but quite probably we would send the person to hospital.’
    ‘That’s not satisfactory, is it?’
    ‘No, but we have to be so careful, and it gets harder for us all the time. We even have people with feed-pegs coming into our Homes. So then someone has to make the decision to remove it.. .’ *
    His voice trailed off, and I could sense the heartbreaking difficulties that have to be faced.
    A feed-peg - or gastrostomy, or jejunostomy or other parenteral routes - is an alternative to a naso-gastric tube. It is a plastic tube inserted through the abdominal wall into the stomach and fixed in position. The purpose is to enable liquid feeds to be given directly into the stomach. A study of the care of patients in the USA with Alzheimer’s, or advanced dementia due to