'Oh, how much I like my office on a morning like this' I thought to myself as I opened the door to a spacious and airy room. Situated at the back of the hospital it was very quiet and it also had most beautiful views of vast gardens. It was early November and through large Victorian window I could see my favorite old cedar tree, enveloped in mist. It must have been there long before me and will remain long after I am gone.
On that day I came earlier hoping to dictate a few letters, while my mind was still fresh. But barely did I manage to sit down behind my desk when the knock at the door interrupted the silence. It was Adrian, a senior doctor who often deputised for me in my absence.
'I must talk to you about a patient I saw at home yesterday afternoon. Can I? ' he asked, looking worried and responsible.
'Now?' I tried to protect my rare moment of solitude.
'Yes, it is rather urgent' he insisted.
‘It's about this 83-year old widow’ he began to unfold the story. ‘She lives alone in a warden supervised flat and has quite a lot of support from the Social Services. Her GP was very concerned about her behavior and her threats of suicide. She told her next-door neighbour, and also informed the doctor, that she was going to kill herself but would not say how she was going to do it.’ ‘She said to me’ – he continued – “I have made up my mind, I have got it all planned. Of course I am not going to tell how, but it is going to happen soon, perhaps tonight!” She has been pulling the alarm cord but would not answer the intercom when the warden came to see to her. The police became involved and went round to check on her. She has also been refusing medication for a congestive heart failure! Only a week ago, she discharged herself from a medical ward, stating that she had been “kidnapped” by the doctors. I think she has developed a depressive illness and is suicidal. I spent almost two hours trying to persuade her to come to hospital, but she flatly refused’ he ended his report., exasperated.
‘So what do you think we should do?’ I asked.
I didn’t quite know why but I found myself making an effort not to burst into an incongruous laughter.
‘Do you find it funny?’ Adrian asked scornfully. He then posed for a moment and reflected:
‘Perhaps you are right, there is something comical about her’.
We went to see Hilary together the very same afternoon. Adrian had made arrangements for an assessment under the Mental Health Act, so that she could be admitted to a psychiatric ward to have treatment against her will, should it be necessary. To do that two doctors (one, usually a patient's GP, the other, usually a psychiatrist) as well as a specially trained Social Worker have to agree that such course of action would be in the patient's best interest. It also means that quite a crowd descends on a prospective candidate for treatment, but perhaps it is a small price to pay for good clinical practice and respect for individual's liberty.
When Adrian and I arrived in Hilary's home a sizeable gathering had already assembled in her bedroom. Dr. Gosh, her General Practitioner was sitting on the chair, next to her bed, engaged in a conversation. Jeremy, the Approved Social Worker, and his colleague took strategic positions at the foot of the bed, and a Home Help was hovering round the door. Two trendy-looking granddaughters, students in their early twenties, were sharing a large armchair. Hilary, a rather pale and thin woman with long gray hair, was lying in bed amidst lace-adorned cushions and embroidered blankets. Freshly cut flowers, gathered in several vases of various shapes and sizes, were crowding on the bedside table. Although it was early November, the scene looked almost spring-like. She greeted me with the words
‘And you, who are you? A psychiatrist? I haven’t sent for one!’
I sat on the edge of her bed and after a short period of humble silence, Hilary and I managed to engage in a lively conversation, almost forgetting that there were seven other people in the audience. She told me about her hard-working life, the unfaithful husband, her two sons, one in Australia and one in Spain, and several grandchildren. She made very warm remarks about the two granddaughters present in the room. They smiled approvingly. I also learned about her younger sister of whom she had been very fond and who died last year.
‘She shouldn’t have gone before me’ muttered Hilary.
I was surprised how willingly and easily the old lady talked to me. Suddenly, the sound of a telephone interrupted our conversation. It was her son from Spain. She listened to him for a moment and then exclaimed
‘They are all here, you know, won’t leave me alone! Of course, I have not invited them; they descended on me, just like that! I don’t understand why such fuss. I might even do something silly because I have enough of it!’
Probably at the initiative of the son, she passed the receiver to me, adding
‘Perhaps you want to speak to him?’
In a brief conversation, I suggested that he should come over to see his mother. He promised to be in England within the next couple of days. Later I asked Hilary, posing naïve
‘If we all leave you now, will you promise not to kill yourself?’
‘Oh,’ – she responded with a tinge of imperial superiority – ‘I am not into promises.’
Leaving Home Help behind to keep the patient’s company, we left Hilary to have a discussion in a sitting room. Unconvinced about her alleged psychiatric illness, I asked the granddaughters what kind of a person granny was: modest, shy, wilful, flamboyant?
‘A person who makes herself and her wishes known ‘ said one.
‘A very special person’ added the other.
‘Hmm... Then, perhaps, all she needs is … to be acknowledged, while she is taking a decision to die’ I hesitantly shared my intuition.
Dr. Gosh smiled and nodded slightly. He and I had met before and I found him imaginative, able to tolerate unorthodox views. Perhaps with another GP I would have been more inhibited.
‘We must make her feel very special. The very special person that she is’ I pursued my line of thinking.
A small 'task-force' was formed. The two granddaughters were going to take it in turn to sleep in her house, the GP would visit her daily, the Home Help was to continue with her regular practical help, whilst I promised to come and see her next week. I noticed that the granddaughters looked close to tears.
For a moment I returned to Hilary, sat on her bed and gently took her hand. She did not try to remove it. Neither of us felt the need to speak. As I was departing, she gracefully waved her hand.
Less than a week later, I received a telephone call from her son who had arrived from Spain. He told me that his mother had been rushed to hospital again, but had improved rapidly and plans were being made to send her home. He thought of returning to Spain soon. However, I tried to persuade him to stay a little longer saying that Hilary might not last a fortnight.
‘What do you mean?’ he asked. ‘They are impressed with her improvement as never before. And she looks so well!’
‘Precisely’, I replied. ‘I think she has now made up her mind to die. And she needs you to be with her.’
Somewhat perplexed, he agreed to stay for two more weeks.
A few days later, I visited Hilary on the medical ward. I was dying to know more about the dynamics of her family life, her unfaithful husband, her sister and the meaning of the anniversary of her death, the feelings of love and of jealousy between them, and more…
I greeted her, tentatively trying to ascertain her cognitive state -
‘Do you recognize me?’
‘Of course, you are my psychiatrist!’ she exclaimed in between sips of hot chocolate. I felt slightly flattered.
‘And they are so good to me here, the nurses, the doctors. Everyone! And you know, my son came all the way from Spain and yesterday he spent the whole afternoon with me. He is such a wonderful boy, and his two daughters came as well!’ She looked radiant.
I immediately abandoned the idea of venturing into any psychoanalytical stuff, sat by her side and we talked about everything and nothing instead. As I listened to her lively talk, I noticed an old, tall maple tree just outside the large Victorian window. Its last remaining leaves were quivering in the wind. ‘Will she see another spring?’ a thought flashed through my mind. I gently squeezed her hand and said goodbye. Hilary reciprocated. I stood by her bed for a moment longer, having a distinct feeling it was the last time I was seeing her. I thought she knew it also.
A week later, her son telephoned to say that his mother died peacefully at home from a heart failure, with him and the granddaughters at her side. He was pleased he had stayed.
