The Blogs: Pessach, gravestones and what matters to you

Yesterday*,

I travelled by train,

to Edinburgh.

East Coast Mainline.

Doncaster to Waverley.

It was the same journey featured in the novel

When Will There Be Good News?

Kate Atkinson

Which my daughter is studying for

A-Level English.

In the story,

There is a fatal crash

At Musselburgh

A town on the outskirts of Edinburgh.

Fortunately

As can be surmised from the writing of the blog

We made it there and back in one piece

No mangled

Ironwork

Or emergency vehicles.

We met my sister and nephew and toured some of the sites.

It you have never visited Edinburgh,

It is a fantastic place.

The Castle

Royal Mile

And

Arthur’s Seat

Are all otherworldly.

Athens of the north

They call it.

During the visit we discussed gravestones.

There is at present, family discussion about the renovation of our parent’s stones.

They are in the Jewish Cemetery in Glenduffhill, Glasgow.

A bleak, windswept, constantly raining place

East of that city.

My parents died around 15 years ago – I am sorry, I am a failure at dates.

Just accept,

That for all you readers,

Who might remember dates in the calendar,

Yours and others’ birthdays,

I can’t

I struggle with my own

I learned my birth-date in reverse-order.

As a child as we lived at 27 Melford Avenue; I remembered the date of my birth from the number of my house.

This is, I believe a form of dyscalculia.

Let’s leave it at that.

My parents rest in adjoining plots – an act of love that we only discovered after my mum died when we discovered her plot was next to my dad’s.

Never much of a planner, this was something he kept from us.

My dad’s stone has a quote from Tennyson and my mum’s the Bible.

My dad has an emblem of the Freemasons of which he was part and my mum, a Celtic emblem of a horse based upon the design of her favourite necklace, a one-time present from my dad following a trip to Norway in the ’70s.

(My gift was a troll which I still have).

The stones have not weathered well, and the inscriptions are difficult to read.

The cause of this deterioration is the Scottish climate – wet, and the stones lying supine as opposed to upright/erect as you might find in other cemeteries.

Jewish people have adopted the flat-stones because of the risk of vandalism and the ease with which the stones can be pushed-over during periods of Antisemitism.

We Jews are a canny lot; we plan. Two thousand years of persecution have taught us to be prepared.

Even with some rubbing or polishing, the inscriptions have faded.

There is a separate issue with my grandparent’s stones as those are upright and because of the climate and the wind are now wobbly, at risk of toppling.

Last year, my brother visited from Israel and the four of us – my brothers, sister and me all travelled to the graves.

From this arose a plan to undertake some renovations.

This is where the miscommunication began.

I was of the understanding that most pressing was fixing the listing stones of my grandparents (when they are at major risk of toppling, the burial society lie them flat, which is not very aesthetic but prevents any inadvertent mourner crushing).

My brother was more concerned with the ability to read our parent’s inscriptions which will be illegible in another decade.

Eventually, working with an intermediary, a stone mason was contacted who provided a quote of £700 to fix the writing for five years.

It was the five years that I found problematic.

This would imply that in five or 10 years time, the writing would have deteriorated again, and we would be back to hiring this stonemason, or his family (stonemasonry appears to run in families).

For me, it wasn’t the cost, more the longevity or perhaps, brevity of the repair which gave me pause.

This caused a temporary dispute between siblings that we are still working-through.

My preference would be to redo them so that they will last a hundred years.

Then again, what is a century and what is a grave?

During our meal we discussed, asking my daughter and nephew as representatives of the next generation their opinions.

Their views were mixed although the equation of assuming the responsibility for not only their parent’s graves (supposing we have graves (as opposed to ash scattering)), but those of their four grandparents a piece and any great-grandparents.

This might become complicated.

An intergenerational rift that would be difficult to contain.

I have a friend whose wife’s family used to own a part share in a house in the New Forest – this was overseen via a complex system of coordination between family members.

Do these things ever last beyond a generation or two (without an assumption of primogeniture)?

Remember the Tolstoy quote about happy families?

Yes, within families there is limitless potential for complication, understanding and divergence of opinion.

This has been a circular blog and not the intended purpose of today’s focus.

I’d wanted to address another family member.

He is an old man living in a care home in London.

My sister-in-law supports his affairs from Israel.

The old man, I’ll call him Michael is in poor health; he has had strokes, he is frail and most recently his diabetes has become unmanageable to such an extent that the hospital started treatment with insulin.

I don’t know how Michael has accepted the insulin, for example, whether he was counselled, provided options or was more of a ‘this is what I going to happen’ doctor knows best process; as Michael has aphasia I imagine it was more towards the latter.

And, so, in his 90s, his frailty is increasing.

The day after discharge he was readmitted to hospital after falling in his care home. The following day a nurse called an ambulance as his blood sugars and ketones were too high.

High blood sugars and ketones are a general indication of physical dysfunction either related to infection, other inflammatory process or decline.

Michael refused to be taken to hospital.

A doctor was called, still Michael refused.

Michael remains at his home.

He has a ‘DNACPR’ in place – a document indicating that in the event of his dying, he would wish to be left in a dignified state of passing.

My sister-in-law has learned that they haven’t ‘adopted’ ReSPECT in London.

Therefore, the potential for Emergency Care Planning is, despite the national trend to support people to achieve their preferred places of care and death, absent which I find incredible.

The question therefore is how to avoid these coercive conversations between doctors, nurses and paramedics with Michael, all of whom are saying ‘hospital’ when Michael says ‘no.’

These clinicians to my mind represent the ‘system’ and it is unfair for a sick old man to have to fight their will.

If it weren’t so sad and frustrating, I would say it is Kafkaesque.

What to do?

Michael and our family don’t want him to move from his current residential home where he is settled and receives fantastic care, the alternative would be relocation to a nursing home with all that entails (moving house, whether you are young or old is one of life’s most traumatic events).

My proposal, when I call my sister-in-law will be to discuss palliative care.

I know some reading those words will associate the term with those who are dying – in the last days of life.

Palliative care is however much broader – it encompasses care and support for those living with life-limiting or incurable illnesses.

Palliative care sends a message to ‘the system’ that this person is not up for grabs. Not an object who can be transported from hospital A to B to C (his initial admission took him to the local hyper-acute stroke unit then to the nearby district general when a stroke was exclude).

The way we move old people and those in the last year of life around our health and social care system is a disgrace.

If you are lucky and you are able to advocate for yourself or others can act for you, things might not be so bad – particularly if you a condition that belongs to a disease specific pathway – breast or bowel cancer; with these conditions you will very possibly have a physician, surgeon, oncologist, specialist nurse and GP advocating for you; just being old and frail is more complex – there are so many old, frail people in our system (and I imagine, in London in particular) that the individual-level, person-centred care necessary is absent and you will hospital or care-facility hop until you die.

We will see if Michael can remain where he is living and receive palliative care, it will be the right thing; providing him with a degree of control (which we know is critical to psychological and physical wellbeing, particularly in someone who has a communication difficulty) is critical; fundamental.

He should be able to express his wishes as to how he wishes to be treated if his blood sugar goes too high or too low, if he has chest pain or symptoms of a stroke, if he breaks a bone or has a chest infection.

All these can be managed or supported in different ways that do not necessitate a trip to hospital.

What matters to you is a mantra that is central to my work as a physician, and which appears absent from this narrative.

Let’s see what can be done.