I went in to see Isobel just before mid-day. She was asleep but woke up fairly quickly. Her speech was no better than yesterday, a lot worse than Wednesday. Isobel was sick during the night and again this morning. The nurses did not think the vomiting had resulted in the loss of a significant amount of dexamethasone steroid. Isobel's right arm was slightly more swollen, despite being well elevated on a pillow and a teddy bear.

Isobel's lunch arrived just after twelve. I fed her the first course, which was large, in about ten to fifteen minutes. She ate briskly with no problems swallowing and no coughing. We started on a beaker of thickened tea and had got about half way through it when Dawn from Ellenor arrived with the dietitian.

We had a long and detailed discussion. Isobel was only able to give a few yes/no answers to their questions so I gave an account of the past few days. It was agreed that Isobel was not at any significant risk of malnutrition at the moment, although we agreed a range of fruit flavoured balanced dessert mixtures will be supplied in place of other desserts, but Isobel can still have the occasional yogurt for dessert. This will make it less important to ensure Isobel eats all or most of her first course, as on bad days this takes a very long time and leaves her exhausted. I stressed how at the moment Isobel is spending almost all her waking hours some days being fed or having brief rests during the feeding process. Although we have not had serious disasters on the feeding front it was not a comfortable situation. I confirmed that Isobel had indicated that she was happy with the idea of the stomach tube being inserted, although while we were talking she had drifted off to sleep and could not comment herself. I thought that a nasal tube was likely to be less well tolerated. Dawn said that Isobel would be reviewed by the hospital on admission and it was possible, although unlikely, that they might conclude the procedure should not be performed. I accepted that this was a matter for the surgeon's professional judgement. The dietitian indicated that she considered the stomach tube appropriate.

We agreed that the future course of Isobel's illness was to some extent unpredictable as we did not know how the tumour growth was progressing or what parts of the brain were being destroyed. Regarding the effect of the steroid dose increase, I described the changes over the past few days. Dawn wondered whether an immediate increase from 12mg daily to 16mg daily should be made. We eventually agreed to allow a couple more days to see whether there would be a significant response to the last increase - although the steroids in January 2008 took effect in three days the full effect was not apparent for a week. Dawn will come in at 11am on Monday in order to further review the situation and the dose will be increased to 16mg daily unless there has been a significant improvement over the weekend. Regarding the vomiting, this may be due to stomach irritation from the steroids and a change in dosage of omazaprole (which protects the stomach lining from the steroids) may be required.

After Dawn and the dietitian had left, I let Isobel sleep on for a while. She did not finish the tea which had gone cold and is not a very appealing prospect when thickened in any case. I woke her at about 2pm and gave her a beaker of thickened blackcurrant squash which she drank steadily. Afterwards we sat and talked, although Isobel said only individual, rather unclear, words. I put the television on and we talked about the Olympic curling. Isobel fell asleep and I left at about a quarter to four.