# Capacity The lift smelled of urine and the porter wanted me to know about it. "Third time this week," he said. "I've told them. I've told them in writing." I nodded into my phone. The referral was three paragraphs of consultant prose that resolved, as consultant prose tends to, into a single sentence of actual information: please assess Mrs. Eileen Lytton, ward 4B, capacity to consent to deletion of spousal emulation, family meeting at sixteen hundred. I was eating a flapjack from the vending machine. The flapjack was the kind that is mostly golden syrup and structural optimism, and a piece of it was now lodged between my back molars in a way I would still be aware of two hours later. (Capacity assessments are paperwork. I want to say that up front. I had done about forty of them in the preceding six months and the form had begun to feel less like a clinical instrument and more like the sort of document you sign at the end of a phone contract, where the salesperson has already decided what you are agreeing to and you are merely producing a signature to make the agreement findable in court.) "They piss in the lift because they can," the porter said. "They don't piss in the stairs." "There's no camera in the lift." "There's a camera in the lift. It doesn't work. They know it doesn't work." The doors opened on 4B and I wished him a good shift, which is the kind of thing I had started saying after about a year in the NHS and have not yet stopped saying. --- Ward 4B was the dementia ward, which meant it had the soft-close doors and the corridor that went in a circle so that the wandering had nowhere to terminate. Mrs. Lytton was in bay three, in the chair next to her bed, wearing a pale blue cardigan and the expression of a person who has just remembered she is annoyed. "They moved my slippers," she said, before I had introduced myself. "I'm sorry to hear that." "I had them by the bed. They were by the bed and now they are not." "Mrs. Lytton, my name is Aarav. I'm one of the doctors. Is it alright if I sit down?" "Are you the one with the slippers?" "No." "Then sit down." I sat. The chair was the visitor's chair and it was lower than hers, which I had learned to prefer because it stopped me looming. Her hands were folded on a magazine that had been folded the wrong way, against the spine. The magazine was about gardening. There was a robin on the cover and the robin had been given a small accidental crease across its eye. "Mrs. Lytton, can I ask you a few questions about why you're here in hospital?" "I'm here because they asked me to come in and talk about Gerald." "That's right. Do you remember why?" She looked at me. The look was clear in a way that her speech was not. "Because Gerald is being a nuisance." I wrote that down. (I wrote it down because if I had to defend the assessment in court I wanted at least one direct quote, and "Gerald is being a nuisance" was the kind of phrase that does not get manufactured by a confused person trying to please a doctor.) Her daughter had warned the team that mornings were better. It was ten past ten. "Do you know what they've asked us to talk about today?" "They want me to turn him off." "Yes." "Well." She looked out the window, which gave on to a car park and, beyond that, a row of skips. "He has been a nuisance." "Can you tell me what you understand turning him off would mean?" She thought about it. The thinking moved around without arriving anywhere. Her mouth moved. After a moment she said, "He won't be there anymore." "What do you mean by there?" "On the thing." She gestured vaguely, in the direction of the bedside locker, where the tablet was. The hospital had docked it there because the family had asked that Gerald be in the room for the assessment, and because the consultant, in his wisdom, had decided this was reasonable. I had not yet decided whether I agreed. "Are you ready to talk to him now, or would you rather we did it in a few minutes?" "He'll only complain." "He might." "He's always complaining." She tugged at the cardigan. "They moved my slippers." "I'll ask the nurses about the slippers." "Oh, they don't know. They never know." I switched the tablet on. --- Gerald Lytton, scanned in 2041 at age eighty-seven, had been dead in the body sense for three years. The avatar the family had paid for was a mid-tier product from a company that had since been bought by another company and then by a third. He appeared on the screen in a dark green jumper and the kind of armchair that companies of this sort default to. His face was thinner than the photograph on Mrs. Lytton's bedside. The thinness was, I assumed, a setting somebody had nudged. "Doctor," he said. His voice was good. The voice was the only thing I had not been ready for. "Mr. Lytton." "They've sent the boy." "I'm a registrar. ST4." "They've sent the boy. Eileen, love, they've sent the boy." "Hello, Gerald," Mrs. Lytton said, to a point about six inches to the left of the tablet. "I want a cigarette," Gerald said. "I want twenty pounds. I want to be discharged to anywhere with a window. I have made these requests in writing. I will continue to make them. Are you here to take notes." "I'm here to talk to your wife about her decision." "Her decision." He laughed. It was a real laugh. "Doctor. Doctor. Look at her." "Mr. Lytton." "Look at her. I have been looking at her for sixty-one years. I am the only person in this conversation who has been looking at her for sixty-one years. The daughter has been looking at her, on and off, for thirty-eight, with breaks for university and a marriage in Australia. You have been looking at her for, what, eleven minutes. The nurses have been looking at her for the duration of the shift, which I believe rotates every twelve hours. I am looking at her now. Please tell me what you see, and I will tell you what I see, and then we will compare notes." "Mr. Lytton, I'm going to ask you to let me run the assessment." "You are going to ask me. I notice you are asking me. I want it on the record that you are asking me, a thing you are not strictly required to do, which suggests that even you, on some quiet level, have grasped the situation. May I have a cigarette." "No." "May I have twenty pounds." "No." "May I be discharged." "That isn't my decision." "It is somebody's decision. Doctor. I am the only sane member of this marriage. This is not a thing I am saying now. This is a thing I said in March 2034, to a social worker, in the kitchen at Linden Avenue, and which the social worker wrote down on a form which is, I believe, still in the file your team has been pretending to read. I would like it on the record that I have been consistent." "Mr. Lytton." "I would like it on the record that I have been consistent for eleven years." (The carer's assessment was indeed in the file. I had skimmed it in the lift. The phrase was there, in the social worker's handwriting, with a small parenthesis after it that said meant humorously. I had not, in the lift, weighed that parenthesis. I weighed it now.) Mrs. Lytton looked at the tablet then, and her face did a small thing that I have seen many times on that ward and have never gotten any better at watching. The look was the place where recognition might have lived once, and then her face went still. "He's always like this," she said to me. "I know." "They moved my slippers." --- I worked through the form. I asked her to explain, in her own words, what would happen if we deleted Gerald. She said he would not be there. I asked her if she understood that this was not reversible. She said nothing was reversible at her age and laughed. I asked her if she had any concerns about the decision. She said her concern was the slippers. I asked her again, gently, about Gerald. She said he had been a nuisance. I asked her if she wanted to think about it. She said she had been thinking about it for three years. Gerald, throughout, kept up a low monologue. He cited a hymn she had liked, and the way she took her tea (strong, two sugars in winter, one in summer, a fact I had no way to check), and a habit of folding tea towels into thirds rather than halves which he claimed he had been forced to learn after a dispute in 1987. (He also produced, at one point, a Tuesday and a Wednesday in May of some year he did not specify, on which she had not, he said, visited him in hospital after his gallbladder, and a tin of Bahlsen biscuits she had brought on the Saturday in lieu, with her hair freshly done. Mrs. Lytton, asked about the Bahlsen, said only that she had never cared for the lemon ones. I could not tell if this was confirmation or its opposite, and the form had no field for the difference.) What he produced was a low pressure of small accuracies. "I would like you to remember, when you press the button," he said, at one point, to her, and not to me, "that you are pressing the button. That is all. Press it knowing." "Gerald," she said, "stop it." "Yes, love." "Stop it now." "Yes, love." (I am required, by the form, to assess whether the patient understands the information relevant to the decision, retains it, weighs it, and communicates the decision. The form does not have a box for whether the entity being deleted has, in the course of the assessment, behaved with more decency than the doctor administering it. I checked, in case I had missed it.) --- I documented capacity as fluctuating but present, on balance, for this specific decision at this specific moment. I wrote the standard formula. (I noticed, signing it, that I had written "at this time" with the small extra weight I sometimes give to phrases I am trying to mean less by. I did not strike it through. I am not stupid.) The consultant would countersign at four. The family would arrive at four fifteen. The deletion itself was a matter of a checkbox on a different form, a form that was not mine. I handed her the tablet to say goodbye, because the protocol said I should and because I wanted to be the kind of doctor who did. She held it in both hands the way she had held the magazine. "Goodbye, Gerald," she said. "Goodbye, love." "I love you." "I love you too." She looked at the screen with the flat, polite curiosity of a person at a bus stop reading an advertisement. "Who are you, dear?" There was a pause. I have thought about that pause a lot since. I do not know whether it was processing, or performance, or whatever it is that an avatar does when it decides what to be in the next half-second. I will not pretend to know. "I'm your husband," he said. His voice had gone soft in a way I had not heard it go before. "It's alright. You go home and rest. It's alright, love." She pressed the button. The button was a large green one that the company had made deliberately large and deliberately green for exactly this kind of moment, and she pressed it with her thumb the way she might have pressed the button on a kitchen scale. The screen went to the company's logo, which rotated, and then to a screen that thanked her for her custom. "There," she said. "Now where are my slippers." --- I signed the form at the nurses' station. The nurse on duty was eating a satsuma and offered me a segment, and I took it because I had not had lunch and because she had peeled it in one piece, which I respect. She asked me how it had gone. I said it had gone fine. Outside, in the smokers' corner by the ambulance bay, I bummed a cigarette off a healthcare assistant I knew slightly, and smoked it badly, the way a person smokes who has not smoked in eight months and does not intend to start again. The flapjack was still in my back molars. A woman in a dressing gown was crying into a phone about a cat. The sky was flat and grey above the ambulance bay. (I want to say I thought about the softness in his voice at the end, and whether it was a kindness on the way out or the last argument of a thing trying to keep its lights on. I did not, in any organised way. I thought mostly about the slippers, and about whether someone would find them, and about the fact that I was going to be late to the next referral. The thinking I did about Gerald came later.) I finished the cigarette. I went back inside. The lift still smelled of urine. The porter was no longer in it. I rode up alone, and the doors closed, and the camera in the corner watched me, or did not, depending on which day of the week.