Ceiling of Care

I unravelled the thin plastic filmed aprons, separating their static and tearing them at a marked edge, just as you would for black bin bags, except these were aprons. Disposable aprons which I handed to both my colleague and the consultant we were shadowing. Disposable just as everything in this world eventually is.

The thin red plastic was unflattering and of poor quality. I took care not to overstretch and break it. Picking out two appropriately sized gloves to fit my hands, I wiggled my fingers in against the elasticated resistance, and pulled the gloves edge down to reach my wrist. Nothing like cinema or television where the glove snaps back with a ‘thwack’. I have never seen that happen in medicine.
We stood in a semi-circle, huddled outside a side room placed in the middle of an elder care ward. The consultant plucked a folder out of a plastic tray that had been screwed tightly against a cream coloured board. The walling was framed by dark varnished wood. This ward was infested with gloomy brown panelling which made up each door, door frame and a structural framework that extended throughout. Perhaps it looked pleasant 30 years ago. It did not look pleasant now.

Another larger group of doctors passed by us as we stood in the short corridor, perhaps a metre or two in length, through which transit was necessary to permit entrance to the room containing our patient.
“Have you been in to see her yet?” A senior doctor from the group asked, peeping his head back around the corridor’s corner as the other members of his ward round continued onward.
“Not yet,” my consultant replied.
“It doesn’t look good,” he expressed, “I’d be surprised if she makes it back out from this.”
“Ah,” said my consultant, whom specialised in end of life care. “Let’s see what we can do to help her.”
The other consultant nodded and smiled glumly.  It was a forced smile which couldn’t conceal his frowning eyebrows, nor his sorrow.
Warm, stuffy air flowed through the gap left by the room’s slightly ajar door. It smelt strongly. A smell unlike any other I have come across. Unique to a hospital. A combination of stale air, incontinence- both urine and faeces, and illness. Sick patients, really sick patients smell like this. Standing outside the door I was already aware of this smell. This patient was really very sick. Yet throughout the smell was never mentioned by myself or my colleagues. It was not ignored, in some sense I feel it was far better acknowledged by our respectful silence. The atmosphere felt taut. I began to mentally prepare myself for what was ahead.

The consultant I shadowed started talking about what is known as the ‘ceiling of care’ for a patient, the point at which a patient is deemed inappropriate to receive resuscitation. This patient had reached her ceiling. I imagine it as an old country cottage ceiling, the type where tall visitors stoop to avoid banging their heads. Perhaps this patient had lived in a similar rural home, way out in the Cornish countryside that surrounded the hospital. An old country cottage with heavy stone masonry crumbling at the corners. Finally succumbing to the elements it had so defiantly stood against for many years.

The consultant led the way into the room. I stood just past the doorway and watched as the consultant made her way to the end of the bed at which the patient’s head rested. She achieved this feat in a few strides and soon found herself at the opposite end of the cuboidal room. Broken rays of sunshine scattered throughout, cast from the windows that lined one side of the room. Out of these windows a beautiful early autumnal morning could be seen, the view four stories high, looking out above a carpark amongst the trees. People are not supposed to die in beautiful weather. The glass had been covered with a one-way light polariser to protect the patient from the open view outside. Perhaps it served the opposite purpose here. Outside the blissful morning was protected from the abject scene inside.

The smell from outside the room intensified, as did the mood. No words of pity were exchanged by us the healthy.  The discord between the smell and the state of the room was confusing. It was a clean, ordered and uncluttered besides a syringe driver that stood in the far corner. Next to this was a small bedside cabinet that could be moved thanks to the four wheels at its base. The walls were painted light blue and were patterned by wavering shadows from the trees moving in the wind outside.

Curled up, with her knees brought close to her chest, lay a small sickly woman in the furthest third of the bed. The lower half of her body was covered by white sheets, folded neatly over a double layering of blue cotton blanket. She lay with her back towards the windows and her hands reached up to her mouth holding a paltry cardboard bowl at an angle beneath her cheek. It was not clear whether she was conscious, but I could see the muscles of her chest and neck contracting repeatedly, militantly fighting the overwhelming weariness that exhausted the rest of her body. Three pillows supported her in the bed, one of which directly cushioned her resting head.

Against this pristine white was an unsightly auburn stain, most likely dried vomit that had not made it into the cardboard bowl.  I watched closely for her expression and saw nothing except an elderly lady with a wrinkled face and curled white hair. She lay pale, motionless, deep within an incongruous mental space. A place in the human mind reserved for those at the precipice. I hoped this was a peaceful place, ignorant to its surroundings. Or perhaps it was filled with nothing, no thought, no perception. Nothing. This at least would be better than suffering a space filled with anguish and torture. An aching, painful misery. This is what we all fear. Us the healthy.

Perhaps she lay nestled in her bed, tucked away in her Cornish cottage. Her cherished home for its views extending out across the untouched craggy moorland and blue ocean beyond. The great expanse of the sky, animated by the drifting white clouds, floating peacefully upon the coastal breeze.

The consultant leaned in closely to her face and asked in clear wording:
“Are you in pain?”
Out of the dying woman’s mouth came a quiet bewailing cry. Juvenile and innocent she made no other movements besides her constant heavy breathing. We interpreted this as a yes.
The consultant held her hand and stroked her head softly for a moment, before gently wiping some spittle that seeped from her mouth. Seconds passed before she stood and checked the patient’s undergarments concealed beneath the sheets. After this she removed her protective clothing, washed her hands and left the room.

I followed suit, afraid of glancing back at the bed behind me or catching the eye of the consultant or my fellow student.
Back outside the doctor conferred with a nurse, and then went on to speak to the other consultant who had previously shown interest.
All the while I stood with my sadness, looking up to the ceiling.

Ceiling of Care

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