Review
Ageing
Assisted dying
Culture
5 min read

For love there is no charge

Out of mind old people are at the centre of Allelujah! Sian Brookes reviews the film adaptation of Alan Bennett’s play.

Sian Brookes is studying for a Doctorate at Aberdeen University. Her research focuses on developing a theological understanding of old age. She studied English and Theology at Cambridge University.

In a hall decorated for a celebration a person stands in front of a seated group, all have their arms raised in celebration.
Jazz hands at the hospital.
BBC Films.

Spoiler alert – this film review reveals significant elements of the plot. 

Allelujah! is not a film that shies away from the big issues. In fact, you would be hard pressed to find a big issue this comedy/political commentary/drama/part-thriller doesn’t at least make reference to (and yes, it spreads itself across all of these genres too). With such an eclectic approach it is difficult at times to keep up with the narrative, and the deeper meaning of the film. Based on the Alan Bennett play, the plot centres around The Bethlehem, a small northern hospital for geriatric patients, which is facing closure due to the Tory government’s efficiency drive. It focuses on two members of staff, Alma Gilpin, a stoic and matter-of-fact but seemingly excellent nurse who has served the hospital her entire career, and a younger Dr Valentine. Other protagonists include an ex-miner patient and his son, a management consultant who has “made it” to London and is currently advising the Health Secretary to close hospitals such as the one in question for the sake of government finances. 

Whether it’s politics or the personal, this film has it all. It deals with levelling up, the cultural and economic gap between the north and south, the challenges of budget cuts in the NHS, the problems of a national health service claiming to 'care' but with managers more preoccupied by Westminster’s economic priorities. It depicts families waiting for older relatives to die in order to grab their inheritance, the broken relationship between an ageing man and his son, and those all-important stories of the older patients’ lives well-lived. And yet as the story line develops, a plot twist emerges which comes to overshadow the entire film, and in the process speaks to what is perhaps the most poignant of the many discussions it raises. Nurse Gilpin, who, until now has appeared consistently caring and committed to her patients, has been quietly administering fatal beakers of milk and morphine to those who she deems to be on “her list” of those who most need relief from their situation. When confronted by the doctor she justifies her actions with a multifaceted answer based on the requirement to provide more beds to a broken healthcare system, but also insisting “I had ended someone’s suffering”.  

When Dr Valentine remarks, “I like old people” a visitor responds “not even old people like old people”.

The manner in which Nurse Gilpin goes about what is effectively enforced euthanasia, is deeply chilling. And yet her reasoning is not entirely foreign to us – to end suffering could be deemed a noble cause. In fact, the need to simply delete the reality of suffering, particularly the suffering of the old is one that perhaps is not so uncommon. Throughout Allelujah!,we are reminded of our tendency to run from, to detest, to reject the suffering of the elderly in our society. When Dr Valentine remarks, “I like old people” a visitor responds “not even old people like old people”. A teenage intern declares to a patient “I hope I never live to be your age”. At the same time, characters look back on the days “when the elderly weren’t farmed out”, and questions are asked of families “if they love them, why do they put them away?”. A very good question. Of course, care needs are often too great for families to endure, yet it is still important to ask why the suffering of the old has become a professionalised service, which most of us avoid at all costs. Perhaps the answer to this is that we don’t like to watch the old suffer, we don’t like to watch them die, because their suffering and their death remind us of our future selves, our future suffering, our future death. In our sanitised, anything-is-possible-with-medicine-and-science society, death and the suffering that comes with it, is something from which we flee at all costs. Instead of acknowledging and working with it, we would rather pretend it wasn’t there at all.  

And yet, even as we try to avoid it, suffering and death are both certain parts of all our futures. 100% of us will die. For Nurse Gilpin, the solution to this is to bring on death prematurely, to erase the pain, overcome the misery by offering a false hope – that it doesn’t need to exist at all. In direct contrast to this, in a film which is littered with Christian references (Allelujah, The Bethlehem), there is a different approach taken by a messiah-type figure who seems to get everything right. Dr Valentine is compassionate and understanding. He not only challenges the political systems which undermine those most at the margins of society, but also has the kind of bedside manner we would all hope for in a doctor. In a closing monologue Dr Valentine utters the words of the doctors in the NHS, “We will be here when you are old, and we would die for you, we are love itself and for love there is no charge”.  

It is this suffering with which is so compelling, this suffering with which is truly sacrificial.

Nurse Gilpin and Dr Valentine offer two fundamentally different approaches to end of life care. One hastens the end quickly, deletes the suffering as efficiently as possible in order to make way for those in less pain. The other sits with those who suffer, holds their hand, gently cares for the human person that is in front of them. Even more, and perhaps most significantly Dr Valentine does not only watch from afar, but is willing to suffer himself for the sake of those in pain - working tirelessly, giving himself over day after day, fighting on with little sleep for limited pay just to make things a little less painful. It is this suffering with which is so compelling, this suffering with which is truly sacrificial, this suffering with which speaks of something much greater than politics, efficiency or inheritance, this suffering with which is indeed “love itself”, completely free of charge.  This is the logic that Christians see in the ancient notion of the incarnation, celebrated every Christmas, of God with us. This is what our older people need, this is what we will all need when we grow old. Let us only hope that when we get there, we find the one who is willing to offer it.

Article
Ageing
Care
Change
Death & life
6 min read

A Tolkien poem helps a nurse understand the ravages of dementia

'Not all who wander are lost.'

Helen is a registered nurse and freelance writer, writing for audiences ranging from the general public to practitioners and scientists.

An elderly woman wearing headphone looks up and to the side with a big smile.
Playlist for Life

Not all who wander are lost.

Often written on a care home wall, on an inspirational poster, these words are usually set against a forest background, or compass, for added effect. They have also been used as the title of a conference paper discussing so-called smart trackers for people with dementia, whilst, Not all who wander need be lost is the title of a concise guide to navigating the heartbreaking challenges when a loved one is diagnosed with Alzheimer’s disease or other dementia.

As a care home nurse for more than ten years, I have seen residents wander - not lost but “walking with purpose”, as it is sometimes known in the caring community. “Nobody gets up and walks without a reason,” says Suzanne Mumford, Care UK's Head of Nursing, Care and Dementia; perhaps they are easing pain, or boredom, or looking for something that they can’t describe. I remember residents exploring, enquiring into self-made mysteries solvable only by themselves, examining everything from door handles to another resident’s buttons, even escaping with surprising speed. Walking with them, often in silence, can bring a sense of relief, comfort and companionship.  

What I didn’t know was that this is a quotation from a poem by JRR Tolkien, published in The Fellowship of the Ring seventy years ago. The actual line is - “Not all those who wander are lost”. 

All that is gold does not glitter, 
Not all those who wander are lost; 
The old that is strong does not wither, 
Deep roots are not reached by the frost. 
 
From the ashes a fire shall be woken, 
A light from the shadows shall spring; 
Renewed shall be blade that was broken, 
The crownless again shall be king.” 

We first hear this poem in Chapter Ten of Book One, as Frodo reads it in the postscript of a letter from Gandalf. As I read it, the imagery of being lost, withered, frost-bitten, in darkness, burned and broken, speaks something, in poetic picture language, of the ravages of dementia, the harrowing losses, the valley of tears. It brings to mind residents unaware of familiar objects or surroundings, looking straight through loved ones without a flicker of recognition, losing also language, continence, mobility and the ability to swallow. 

The TV presenter Fiona Philips recalled an agonising decline in her mother as she succumbed to Alzheimer’s, describing how, in the final stages, her mother “spent whole chunks of time just sitting and staring ahead, only able to give out a series of sounds”. Fiona herself now lives with dementia. “'It’s devastated my family and it’s the biggest health and social care challenge we face as a country,” she says. 

I once interviewed retired doctor Jennifer Bute, who lives with dementia. She talked of time travel (perceiving herself as living in a time from her past); disorientation to place and person; frightening hallucinations when old memories are seemingly ‘unlocked’; and ‘emotional unzipping’ when agitation and anxiety increase, often in the late afternoon or evening in something poorly understood as a symptom, known as ‘sundowning’. 

Yet there is something more to this poem – each of the pains has a promise – not all who wander are lost; the old that is strong does not wither; and, most poignantly, deep roots are not touched by the frost. In dementia, it is true that deep roots are untouched, that an enduring aspect of a person’s identity never truly withers, though it may be mostly unseen. Something remains. Oliver Sacks the famous neurologist emphasised that, even in the late stages of Alzheimer’s, the person is still ‘alive inside’ (the inspiring documentary with this title is recommended). In stunning real-life stories, he has shown how music appears to ‘call back the self’, awakening moods, memories and thoughts that had seemingly been lost. He refers to music’s extraordinary ‘neural robustness’ and describes one man, unable to tie his tie or find his way to the stage, yet able to perform a perfect piano solo. In one life-affirming, must-watch, tear-jerking video, gospel music was shown to enliven, calm, focus and engage a man simply known as Henry.    

Watch Henry

Singing can “provide islands of arousal and awareness like nothing else can”, according to Alicia Clair, Professor of Music Therapy. I’ve seen singing bring the person into the present for a passing moment, illuminating a face that seemed far away. One otherwise-silent lady completed the chorus of ‘Daisy, Daisy’ before descending into dementia again. Others have laughed, clapped, danced, embraced and even shed a silent tear during music therapy sessions, when music elicits memory. Doll therapy meanwhile has sometimes restored and revealed a sense of nurture, purpose, care and pride, with residents feeding their new friend before accepting their own food, folding its clothes and taking care of it cradled in their arms. Though it divides opinion, a doll can preserve dignity if it de-escalates agitation or engagement in physical or verbal abuse; a sense of dignity also comes from the person being able momentarily to give care rather than receive it. 

“From the ashes a fire shall be woken, A light from the shadows shall spring; Renewed shall be blade that was broken,” continues Tolkien's poem, and, though not the original intention, these powerful images of renewal and restoration paint a picture of something known as “paradoxical lucidity”, or unexpected cognitive lucidity and communication in some patients with severe dementia, especially around the time of death (though sometimes long before).  

Anecdotes are recorded of “unexpected, spontaneous, meaningful, and relevant communication or connectedness in a patient who is assumed to have permanently lost the capacity for coherent verbal or behavioral interaction due to a progressive and pathophysiologic dementing process”.  Some scientists are seeing them as a paradigm shift in the understanding and perhaps even treatment of dementia. I will never forget when a woman in the late stages of dementia, with little spoken language, was brought back to the nursing home weeks after hospital admission; she had been perilously ill. With bright eyes, she took my arm and, as if the mist had cleared for a moment, spoke warmest words of thanks to me for helping her on the day she collapsed. In another fleeting and irreproducible moment, a lady wished me happy birthday, before continuing her silent walk around the home. Witnessing such an event is ethically and emotionally transformative. 

The concept of remaining ‘alive inside’ even when abilities, language and memory are eroded by dementia is taken to the next level in Christianity, which teaches that life continues even after death itself. The Bible speaks of new life beyond the grave; the fire shall be woken, a light shall spring. And there will be a crown (and the gold will glitter). The Crown of Life is referred to, being bestowed upon "those who persevere under trials." Dementia is one of life’s severest trials; a cross to bear. In the 1912 hymn “The Old Rugged Cross”, another cross is spoken of, being the cross of Christ at his crucifixion. Clinging to that cross, living out a Christian life, the hymnwriter wrote of “exchanging the cross for a crown” at life’s end. After ashes, hope awaits the Christian. 

 

Playlist for Life is a charity encouraging people to create playlists for people living with dementia.