With the End in Mind: Dying, Death and Wisdom in an Age of Denial. Kathryn Mannix

radiant. Andy, meanwhile, became increasingly gaunt and haunted-looking. I almost expected to see him with his own drip stand.

      And then Sally’s treatment was over. The research nurses saw her occasionally in the Professor’s clinic, and reported that she was well. We got a postcard from Greece (‘Hiya Poison Team. Said I’d do it so here we are. Can’t stand up on a wind-surfer but kayaking is brilliant!!! Keep up the great work. Sally’n’Andy xxx’). I lost touch with her progress when I went back to work at the hospice at the end of my research project, but I often thought of her when I met patients who coped with their misfortune by making little of it and thinking about how much worse things were for other people. Her denial had supported her through the ordeal of her treatment.

      Since then, two years have passed. Sally’s hospice referral took me by surprise, because I didn’t recognise her married name. The plastic surgery ward team had asked for advice about managing a young woman with widespread melanoma. There was some concern that she didn’t seem to realise how serious things were, and they wondered whether this was due to brain secondaries or to a psychological problem manifesting as denial. I was sent to assess her by the leader.

      On the plastic surgery ward, the doctor explained that their young patient had devastatingly widespread melanoma and a life expectancy of just a few weeks. Her groin was completely encased in the cancer, which was growing outwards through the surgical wound where removal of the affected lymph nodes had been attempted. Back-pressure from the groin tumour was causing her whole leg to swell. She had multiple lung nodules, getting bigger week by week on her X-rays, and also liver deposits that were almost certainly growing at a similar rate. ‘And yet,’ he sighed, ‘she seems not to hear any of this bad news when we tell her. She just tells us it’s an infection in her wound, and that chemotherapy will cure her. I’ve never come across anything like this. We just don’t know how to handle her.’ He invited me to walk down the ward with him, to be introduced to the patient.

      I saw that unforgettable hair shining across the hospital ward, and recognised her before she realised who I was. Her face was swollen by high-dose steroids for her headaches; she had a compression stocking on her right leg and the remaining four toes on that foot, swollen, shiny and disconcertingly purple, stuck out of the elasticated cuff. Pale and thin beside her sat Andy, disintegrating like Dorian Gray’s portrait while she beamed at me with an inner splendour despite her ruinous disease.

      ‘Well, doc! Long time, no see! What a surprise!’

      It is to me, too, I thought apprehensively.

      ‘Well, it’s been a busy time since I saw you last,’ she announced. ‘Look! Andy and I got married!’ She held up her left hand for me to inspect her engagement and wedding rings, a rather splendid interlocking arrangement of jewellery clearly made specifically for her. So you did achieve that plan. I was relieved that she had accomplished some of her dream in time.

      ‘Bit of a hiccup with the melanoma thing, though,’ she continued breezily. ‘I got a few lymph nodes in my groin and there’s a bit of melanoma in them, so I might need a little dose of chemotherapy. But there’s an infection in the wound. And you know’ – she grinned conspiratorially at me – ‘that they never give chemo when there’s a bug on board, so I’m waiting for the infection to clear first. It’s making my leg swell a bit. But I’ll beat this. You know I always do. Have you come to see me about the chemo?’

      She paused to draw breath. Andy looked at me with wide-eyed anxiety, and the ward doctor also watched my face, clearly wondering how I intended to tackle this situation.

      This was exactly the same coping style Sally had used of old: downplay the negatives, emphasise the tiniest positives, pretend it will all be fine, make plans for the future. She seemed unaware of her true situation, but a single glance at Andy told me that he was fully alert both to the devastation that was unfolding, and to his wife’s inability to contemplate it.

      What will happen if I say ‘Hospice?’ I wondered. Will she find an excuse? Will she be shocked? Will she dismiss me? Will all her denial come crashing down around her? How on earth do I play this?

      ‘Well, congratulations on your wedding,’ I began. ‘It seems like a lot has happened to both of us since we last met. You’ve got married, and I’ve changed careers …’

      ‘Aren’t you a doctor any more?’ she asked, surprised.

      ‘I’m a different sort of doctor now. Good old Professor Lewis is still trying to find the cure, and I hope he does, but in the meantime I’m trying to get to grips with tricky symptoms like headaches and nausea and breathlessness. Things that make people feel unwell.’

      ‘Well, I have ALL those symptoms!’ she almost squealed – perhaps disinhibited by her steroids, or by nervousness as I brushed too close to her own problems.

      ‘Then maybe I’m the right doctor for you just now,’ I said. Andy’s head nodded gently in agreement behind her; the ward doctor dashed away to answer his pager.