Dr Doctor Heartly,

My apologies to you again for missing our reunion this year at Grizedale. You may be aware that my Rachel, Dr Jennings, passed away earlier this year and with the early retirement of Dr Wallis at the end of April, the practice has continued to function, just barely, with two men short. Indeed, I have relinquished my additional responsibilities with the Commission to some bright young upstart, though I may confess to you that taking the lead in the End of Life review had begun to strike a little too close to home with these advancing years.

It is however my End of Life that I wish to pass to you. Learning from the experience and concerns of the Liverpool Care Pathway, I have spent considerable time liaising with our colleagues in the district and have taken on board the views of patients, relatives and colleagues on the matter, and have assembled a comprehensive set of guidelines, and an implementation strategy that I trust you will find most useful, should you choose to proceed. The work is not ready for publication, but I would be honoured if you deemed fit to follow through to implementation, and published with your own conclusions.

Also enclosed, as I’m sure you’ll have noticed, is the fruit of my lifelong study into what I have come to term cognitive pre-mortem. As well you know, I have long been intrigued by the persistent family tales of those experiencing prior warning before their death. I know this defies logic, but every ward I have visited has such a story, and I have heard them all.

I can imagine your face as you read this, it defies all.reason and possibility you say, and you are right, but I want to give you a summary of my findings that will hopefully whet your appetite enough to, at the very least, open my journals, and not just consign them to the shelf.

Take the case of Mr Barnham, for example. Both he and his wife were patients of mine for over forty years. I confirmed all of Mrs Barnham’s pregnancies, watched their children grow from new born to becoming parents themselves, and of course, I watched Mr and Mrs Barnham retire, and recede into old age. It was I that diagnosed Mr Barnham’s heart condition and it was I that referred him for a pacemaker, giving him a full extra ten years to spend with his wife. But it was also I that should have spotted Mrs Barnham’s cancer, but I didn’t, and with the voracity so typical of these tumours, Mrs Barnham was dead, just a month after her husband’s own life extending procedure.

Mr Barnham never held me responsible, not so I would know it, and certainly not to the extent to which I hold myself, but he always maintained that had he known he was to lose his beloved, he would never have taken the procedure.

Ten years after that procedure, Mr Barnham came to the clinic for a routine appointment, he checked out well, but at the end of the appointment he confided in me.

‘Doctor’, he said, ‘I saw Millie this morning, while I was in the shower’.

Millie was Mr Barnham’s wife. He explained to me that he’d been taking his shower before coming to see me when he felt someone enter the bathroom. He pulled back the shower curtain and there she was, resting against the sink, large as life. He asked her if she was really her, and she told him yes, they chatted about things, the grandkids she’d missed, how he’d missed her, but she knew this already, she was never really far away.

This is all right up my street and I wanted to know more, but there wasn’t really anything else to tell. Mr Barnham had had a catch up chat with wife, like he had just returned from being away on business for a week or so. There was no terror, no creepy chains or spooky mist, but she did tell him that they would be together again soon. I always imagined if I’d been in that situation I would have panicked, but he was calm. It wasn’t a warning, it was a promise, and he seemed at peace. He left me with a skip in his step and a gleam in his eye.

That afternoon, the call came. The body was found resting in his arm chair by his daughter, and I went out to pronounce the death. He was indeed at peace, and his expression was blissful. He had spent the morning settling his accounts and left this world with his affairs in order.

This is just one account, there are many, and I know you have heard them from your own patients. I firmly believe that there is something in this and it’s conscious enough in the public psyche that it should be accepted in the media. Take Lou Beale or Jack Duckworth for example, but jokes aside I have so many of these examples, but I’ll give just two more.

This is the case of the ICU patient at Morecambe General. The particulars of the case are all recorded in both the history sheets in the patient record, and in my own journal, and the family have agreed to participate in further studies of this encounter should you deem to pursue it.

The patient in question, a young man in his late teens had a rather nasty meeting between a sheep and his motorcycle up on the Quernmoor Tops, which put him in a coma, but his condition only deteriorated further, eventually being placed on life support.

This family is well known to me also, being registered to my practice, and I called in to offer my support whenever I was passing ICU. It never did look good for the poor chap and it reached a point where the question of switching off the machine had been asked.

As you know, this is a decision that we all hope that we never have to make, and what happened next, I can at least validate myself.

It was late evening and following an over running project meeting, I was catching up on my emails in the ward manager’s office before going home when I caught sight of the back of a patient pass the office door and walk down the corridor. I didn’t think much of it at the time; it is after all a hospital. There are patients wandering around all the time; it was only once the patient had left the ward that I realised that something was amiss. It took a moment for me to register that on the intensive care ward, patients are not prone to getting up to stretch their legs.

I put my head out of the office door expecting to see who ever it was that had passed standing by the ward doors waiting to be let out by the attendant, but there was no one there.

Downstairs however, the patient’s mother, whom we will call Mrs Smith in the interests of information governance, was stood at the coffee machine by the reception desk staring through her options when she felt a hand on her shoulder. Expecting her eldest son to have caught up with her, she didn’t look up, but a voice said, Don’t cry mum.

She wept and told her son that she couldn’t do it, she couldn’t be the one that ended her son’s time here, the one that admitted all hope was lost. That she was giving up.
But the voice said that it was ok, that he didn’t mind.

Mrs Smith was furious her other son, Peter, could even think such a thing, and she turned to give her adult son a thick ear, but it wasn’t Peter, it was Paul stood there, in his hospital gown, but not a scratch on him.

She cried, asked him what he was doing out of bed, was he feeling better? But the answer was no. He had come to goodbye.

She was calm, she told me, very calm under the circumstances. It was later that she would freak out.

Paul told her that he would wait for everyone to arrive, but that he was ready to go now. Mrs Smith flung her arms around him, held him as tight as she could, and asked him to stay. She told me later that her son was soft to the touch, and had all the scents and feel of a baby, the way she always viewed both her sons. And then he was gone.

The next part I can corroborate as I was there. Mrs Smith pounded on the ICU doors, demanding to be let in, but as the reception desk was abandoned I used my own pass card to let her in. She dashed right past me and down the corridor, in to Paul’s room.

I followed her down.

In the room, the whole family was assembled and Mrs Smith had rested her head on her son’s chest, weeping, she told him everything she needed to say, everything that had to be said, and everything he’d always known to be true; and that he would never ever be forgotten.

Then he flat-lined: the DNR tag prevented the crash team invasion.

I stayed with family a while, eventually sitting down with Mrs Smith with a cup of tea in the office. She told me what had happened down stairs, and that she was at ease now that she’d had that one last goodbye, and how relieved she was that she didn’t need to pull the plug herself.

Now you know me, I’m a believer, but I also remain sceptical of each case I encounter. Morecambe General is a big hospital, if a patient had walked down the corridor, he should be on the security cameras right? I checked, and during that exact time, a circuit board had blown, knocking out every camera for three minutes. When they did come back over. It was all over.

There are lots of coincidences that I have found during this lifelong study of mine. Coincidence beyond reason, but coincidence nonetheless; it is almost as though the world itself conspires to maintain the shroud of uncertainty around the truth of our eventual fates, and all the evidence that I can provide, is ultimately anecdotal.

Despite my best efforts, it is here that the world continues to outwit me, but what that security recording did show me, is Mrs Smith dropping her arms, as if from a deep embrace with an unseen companion, and then she runs to the lift (The video file is in the notes too).

I know you too well to know that this alone is not enough to sway you, but I hope you will at least review the materials that I have sent as I fear I have run out of time myself; if there is any truth in the stories I have recounted to you, this will be my last correspondence. Despite the clear bill of health, I received this morning a visit from Rachel, beautiful as the day we met, and she told me, as the others have been told by their loved ones, that I will see her again quite soon.

Farewell my dear old friend,

Dr P Alexander