An advert on a bus shelter caught my eye recently. The gist was: if you’re over 60 and you feel the slightest bit peaky, you’d best get yourself along to the doctor, because illness can be so much more serious at that kind of age. It filled me with gloom. There seems no room for common sense any more; everything must be devolved to a professional. The logic – encourage people to seek help at the first hint of trouble and you’ll catch anything major at an early stage – is seductive yet flawed. Waves of the worried well suck vast amounts of time out of the health service, to the detriment of those with serious disease. Even important diseases can be vague and undifferentiated in the initial phases, making it hard to diagnose them. And then there’s the psychological downside of continually sapping people’s confidence in their own judgement.
Having said that, the folk who devise these awareness-raising campaigns mean well, and there is certainly another side to the coin. The advert put me in mind of Colin and Mary. They were an unusual couple, she in her late seventies, he about 15 years her junior, and they were devoted to each other. They’d never had children, and kept themselves to themselves, rarely bothering with doctors – perhaps in part because Colin was tired of being nagged about his inveterate smoking. It was highly unusual to be asked to visit Mary.
She was sitting in their somewhat dingy lounge when I arrived. And that was the problem, Colin explained: Mary had been “right as rain” the previous day but now he couldn’t get her off the sofa. I asked her various questions, but she denied pain or any other symptoms. She just couldn’t move.
Although this wasn’t typical, I wondered about a stroke – her speech was halting and unclear, and her limbs were markedly stiff – but she firmly declined hospital admission. I set about getting urgent home care for them, and sent off a battery of investigations to try to get to the bottom of it.
Ultimately, the only condition that seemed to explain Mary’s presentation was Parkinson’s disease, in which the area of the brain responsible for executing voluntary movements, the substantia nigra, slowly degenerates. The problem was, Parkinson’s takes years to develop and Mary had succumbed overnight. The only time I’d come across such an acute onset was once, when a drug had caused Parkinson’s-like side effects. But Mary hadn’t been prescribed anything new for ages.
I cross-examined Colin in detail. It turned out his “right as rain” had been hideously misleading. Mary had been becoming ever less mobile for a long time, which they’d been putting down to old age. In the weeks before her final seizing-up, Colin had been having literally to manhandle her across the room. Trying to get her upstairs had involved putting her over his shoulder and shoving with Herculean determination. It was an eye-wateringly scary picture.
Mary soon improved with treatment – there are certain drugs that supplement the neurotransmitter dopamine, which becomes depleted with the degeneration of the substantia nigra. But the whole episode raised an altogether more delicate question: what to do when a patient or their carer seems to lack the kind of common sense that would prompt most people to seek professional help? We had to evaluate carefully Mary’s competence to make decisions about her care, and the degree to which Colin’s disregard for the medical profession might be exerting an undue influence. In the end, we had to move her to a nursing home. Some months later, Colin succumbed at home to a smoking-related cancer, declining all but the minimum help right to the end. His was an almost pathological stoicism, and I can imagine the disdain he would have felt for that bus-shelter advert. That was his right, but the tragedy was that, in the end, Mary had needed protection from his very particular brand of loving care.