Beyond the call of duty

Madge’s eyes dare me as she pulls a creased and grubby driver’s licence renewal form from her shopping bag and places it on the desk between us. She is one of my regular patients and presents once a month, although I wonder why she bothers sometimes. She is yet to comply with any of my recommendations to improve her diabetes control and is haphazard in taking her medications.

‘What can I do for you today, Madge?’

The question is superfluous. She jabs a finger at the form, nudges it closer to me.

I ignore it and wrap the blood pressure cuff around her upper arm, already knowing the reading will be too high, that she only takes her medications intermittently. At her last visit, I suggested a webster pack and she dismissed the idea with a wave of her hand. ‘That’s for old people.’

She is eighty-one, not old enough for a webster pack but old enough to need an annual medical review to renew her driver’s licence.

I listen to her heart and then check for the nonexistent pulses in her lower limbs. Poor control of her diabetes has sludged her arteries and killed off the nerves to her feet. Her neuropathy makes it difficult for her to differentiate the accelerator from the brake. I shudder at the possibilities should she get it wrong. The time has come. She knows I know. I can feel her resistance.

Unable to draw things out any longer, I try to soften the blow and put my hand over hers.

‘I think it’s time, Madge. I’ll see if I can arrange taxi vouchers or get the community flyer to pick you up and take you shopping.’

She heaves herself out of the chair and lumbers to the door without a word, leaving her blank driver’s licence form behind, curled up on my desk.

Madge returns less than a week later. My throat is tight when I see her in the waiting room. I invite her to come in.

She is brusque. ‘I won’t be able to come and see you anymore.’

I am both relieved and disappointed and wonder who will inherit recalcitrant Madge.

‘You’ll have to start seeing me at home.’

I hope my face doesn’t betray me. ‘Let’s see what I can do.’

I pull out my work diary and pencil monthly home visits into my schedule, grateful that she lives close by. She proceeds to dump a folder on my table.

‘I want you to sell my car.’

I want to protest, then realise Madge is alone in the world. She never married and has no children. She has lived in the same house since she was born and cared for her parents in their twilight years. She has no idea how to sell a car.

With help from my husband, her ancient Holden finds a new home. There is nothing in the bewildering array of Medicare item numbers that is adequate to compensate me for my time and the angst involved in this negotiation.

When I pull up outside her Queenslander, I notice the fence is missing a few palings, the gate hanging like a drunken sailor.

She nods and beckons me up the worn-down stairs. ‘I backed into the fence a few times.’

It is affirmation I made the right decision. I am relieved I can get back to what I know. Managing her diabetes, hypertension, impaired renal function and osteoporosis.

Over the next few years, Madge deteriorates. I start visiting fortnightly, then weekly. She scrawls grocery lists on the back of used envelopes. Her Laminex table is cluttered with pot plants, cuttings and gardening tips snipped out of the local newspaper.

When she falls and hurts her back, a neighbour calls me. I arrange an x-ray, which reveals several crush fractures in her spine. She is bed bound for weeks and never gets down the stairs again. To my dismay, I find several boxes of her osteoporosis medications unopened in the kitchen.

Together with our community nurse, I arrange extra supports, but Madge keeps cancelling them. Sometimes I pick up a few items from the supermarket for her and her neighbour drops in most days. Madge is not one to say thank you, but one day she gifts me one of her orchids. It does not survive under my care.

Things deteriorate and I make the difficult decision to find a nursing home. It is traumatic and feels like a betrayal. She was always such a loner, with no friends and only distant family. I visit her soon after admission. Madge has shrunk and become immobile.

She stares into space. I pull up a chair next to her and hold her hand. One solitary tear slides down her cheek.

She whispers, ‘Thank you.’

I give her hand a squeeze.

‘How is the orchid?’

I lie. ‘Fine.’

It is the last time I see her. She dies one week after admission.

Soon after, a smartly dressed woman in her sixties presents at the surgery. It is Madge’s niece, Rosa. I agree to talk to her but feel frustrated that she only turns up now.

‘My aunt was a tricky lady.’

I nod agreement.

‘We tried to help Aunty M lots of times, but she just refused. She fell out with my dad and refused to have anything to do  with us.’

I soften towards Rosa. ‘She could be pretty stubborn.’

Rosa continues. ‘I have a son with autism. He’s in his thirties now but still lives with me.’ She pauses. ‘Aunty M was just like Kyle but never diagnosed.’

Things fall into place. Madge’s rigid way of seeing the world, her inability to express her feelings and reluctance to seek help. Autism was not recognised when Madge was growing up. Would things have been different if I had considered this diagnosis? Are there even supports for a newly diagnosed octogenarian?

I guess I will never know. I smile and reassure Rosa. ‘I think you’re right.’  MT