It has nothing new to observe that in western society death and old age have been cleaned out of everyday view. Palliative care consultant Kathryn Mannix has seen enough death and dying to know that this is not a subject to shy away from. We will all face it at some point. She is doing her bit to help us prepare for dying, since the old acquaintance with death has disappeared. She does this with a series of fictionalised encounters with individuals and carers (and clinicians) she has met during her career, from when she was a medical student, through to being a consultant at a hospice, and performing a consulting role in palliative care in a major hospital. To say that these encounters are poignant and tear-jerking would be an understatement. I cried at some point during each of 30 episodes, and that is a lot of tears. But perhaps my readiness to cry when encountering the fact of normal human mortality merely reflects the result of our modern ability to remove death from our everyday thoughts. What is shocking and touches us personally will provoke strong emotions.
A repeated theme in the book is the need for families to talk and share their emotions when a family member is dying. There are several examples of when individuals are attempting to shield each other from bad news that they are both aware of but believe that the other cannot bear. Sometimes this involves partners, sometimes children or other family. The input from the palliative care team may be little more than facilitating this essential talking and listening together.
On other occasions the expert in palliative care is shockingly direct, explaining to individuals or carers and relatives what the process of dying is like. Kathryn Mannix was astounded when she first watched her senior engage in this detailed education with a dying lady, and even more surprised to see how reassured and relaxed the lady became when she understood the peaceful pattern that would evolve. “If you are well enough to feel you need a nap, then you are well enough to wake up again afterwards. Becoming unconscious doesn’t feel like falling asleep. You won’t even notice it happening.” The education comes in different forms throughout the book, delivered both for the individuals in the vignette and for us the readers. Each time it is different, in slightly different forms, for different individuals and their supporters. Each time Kathryn Mannix seems aware of the individuality, and notes the effect on the different professionals involved as well as the family.
In a couple of vignettes Kathryn is personally involved, as the bed-side watcher for her grandmother, and as supporting friend for a dying medical colleague she had known since student days. In these episodes Mannix notes the intensity of her feelings. At her grandmother’s bed-side she recognises the sensitivity to every change in the loved-one’s condition – movement, breathing, skin colour – an intense awareness that she has seen as a clinician in other watching family members, and so different from her clinician’s gaze.
The book’s conclusion is that discussing death and dying brings their reality into the daily exchanges, and helps us to appreciate and value the wonders of our relationships and of our life today. Which brings us back to the way death has been removed from our normal social interchanges in the western world. In remote rural societies death is still acknowledged in shared and public practices, as noted by Kevin Toolis in his memoir My Father’s Wake. For the vast majority of us who live in crowded industrial conurbations Kathryn Mannix has performed a valiant role in removing some modern taboos surrounding death. Her book has changed my life.
Kathryn Mannix (2017) With the end in mind: how to live and die well, London, William Collins
Kathryn Mannix (2018) ‘Dying is not as bad as you think’ (3:49) Radio 3 Ideas, https://www.bbc.com/ideas/videos/dying-is-not-as-bad-as-you-think/p062m0xt
Kathryn Mannix lecture for Hospice UK conference 2018
Kathryn Mannix talking for Wellcome book-prize short-list ceremony: