IF SEX was the great taboo for the Victorians, for us, it is death — not only the one certainty in all our lives, but also the area that remains obstinately outside our control. As the author of this book dryly observes, “The death rate remains 100%.”
Not so long ago, death was part of life — not only biologically, but sociologically. It was normal for people to die at home, and tending to the body of a loved one followed naturally from that. The religious ritual of washing the dead survives in other faith communities: after the Christchurch massacre (News, 15 March), Muslim volunteers flew in from other countries to prepare the bodies for Islamic burial. We prefer to leave that “to the professionals”: morticians who can make a body presentable and who sanitise death for our edification.
The change is recent. In the second half of the 20th century, new technological and pharmaceutical developments offered, if not hope of cure, then “at least postponement of dying”. Instead of dying at home, surrounded by the people we love, patients are rushed into hospital for treatment. So, we die in clinical surroundings, “our loved ones separated from us by the machinery of life preservation”. The ways in which we die are unchanged, but we are no longer familiar with the process of dying, and we have lost, too, the vocabulary that goes with it.
Our expectations, Kathryn Mannix notes, are now shaped by the “sensationalised yet simultaneously trivialised versions of dying and death” which we see in the media, and we are consequently fearful not chiefly of death itself, but of the process of dying: “There is usually little to fear and much to prepare for.” Fear prevents us from making those preparations that could help us to ease the process.
She draws a helpful parallel with pregnancy and the preparations for birth: “Mainly, both processes can proceed safely without intervention, as any wise midwife knows. In fact, normal birth is probably more uncomfortable than normal dying, yet people have come to associate the idea of dying with pain and indignity that are rarely the case.” She laments the absence of “wise ‘midwives’ to talk us through the dying process”, observing that “in modern health-care, fewer doctors and nurses have opportunity to witness normal, uncomplicated dying as their practice increasingly entangles technology with terminal care.”
As a young trainee, Mannix was shocked by the candour with which her boss discussed the pattern of dying with a terminally ill patient — and even more startled by the effect of that conversation on the patient. She was struck by the realisation that it was “within [her] gift to offer that peace of mind to people at the ends of their lives”, hence this book. “It’s time to talk about dying. This is my way of promoting the conversation.”
The book comprises a collection of stories — of real people and events rather than case histories — grouped into sections, each of which ends with a “Pause for Thought” of practical questions to consider. In a calm and clear-sighted way, the author reintroduces us to the patterns of dying, and tackles issues of communication and legacy, relationships and priorities.
There is the story of the head teacher, used to being in charge, who is angry that he cannot have the help he wants to assist him to die. Before his eventual death in a hospice (after the remarkable hospice team have enabled him to celebrate Christmas with his family in November), he acknowledges that he was “angry with you because you’re part of the System that says no to assisting with dying. But you weren’t saying no to dying, you were saying yes to living.”
A devastating chapter describes a patient who was diagnosed with terminal cancer in the Netherlands, who experiences “an unintended and chilling consequence of an entirely humanitarian change in legislation”, and runs away “from that certain, controlled dying to live with the hope of uncertainty”.
A late chapter, “Transcendence”, looks at the transformation of world-view which comes with maturity: “A spiritual transformation, whether theistic or not”, it translates into the compassion and forgiveness that are so often evident in those facing death.
“In palliative care, we look after people who have reached a phase in their lives when they unconsciously radiate love . . . examples of what we can all become: beacons of compassion, living in the moment, looking backwards with gratitude and forgiveness, and focused on the simple things that really matter.”
But being prepared to die well is not limited to those in old age: easing the process for those who are far too young to die can, as Mannix demonstrates, help not only those who are dying, but also those who mourn them.
As its subtitle suggests, this profoundly hopeful book is as much about living as it is about dying. Death is revealed as “a mandated temporal boundary that makes time and relationships priceless”; palliative care as an insight into “the way people live when they know that they are dying”. It is a truism to say that we live in a death-denying society. If the tide has finally started to turn, it is at least partly because of this book.
Caroline Chartres is a contributing editor to the Church Times.
With the End in Mind: How to live and die well by Kathryn Mannix is published by William Collins at £9.99 (Church Times Bookshop £9); 978-0-00-821091-5.
WITH THE END IN MIND — SOME QUESTIONS
Did reading With the End in Mind make you think differently about the process of dying? How so?
In an increasingly secular and multicultural society, how do you think that we can communicate effectively with one another about the spiritual aspects of life and death?
Mannix writes that loneliness in old age is often a greater burden than ill health. Do you agree? How can we help with this problem?
Have you created, or been left, a memory box like those described by Mannix? What memory items from loved ones do you treasure most?
Mannix suggests that the last days of life often bring people to a “spiritual transformation” that leads to increased compassion and wisdom. Have you seen this happen yourself?
Which of the stories in With the End in Mind did you find most inspiring? Why?
Has the book encouraged you to speak more openly about death with loved ones? How might you approach these conversations?
Why does Mannix describe being a doctor as a “career in communication”?
Mannix suggests it can be easy to dispossess the elderly, noticing their physical problems and perhaps dismissing their wisdom. How can we better value the elderly?
Were there differences in the way in which younger people and older people approached death in this book? What were they?
IN OUR next reading-groups page, on 3 May, we will print extra information about our next book. This is Mrs Palfrey at the Claremont by Elizabeth Taylor. It is published by Virago Modern Classics at £8.99 (£8.10); 978-1-84408-321-3.
Laura Palfrey, recently widowed, is a new resident of the Claremont Hotel, where older ladies and gentlemen are living out their final years. She finds the community similar to that of her schooldays — with all the same intrigues, doublespeak, and social competition — and feels ashamed of her own lack of visitors. Fate intervenes when a fall during her daily walk introduces her to a young novelist, Ludo, who agrees to pose as her grandson. Mrs Palfrey at the Claremont is a nuanced portrait of old age, loneliness, and friendship. Published in 1971, it was shortlisted for the Booker Prize.
Elizabeth Taylor (1912-75) was a prolific English novelist and short-story writer. Educated at the Abbey School, Berkshire, she worked as a governess and librarian before her marriage in 1936. Her first novel, At Mrs Lippincote’s, was published in 1945, and was followed by 11 others. Described by Kingsley Amis as “one of the best English novelists” born in the 20th century, Taylor is often compared to Jane Austen; and, like Austen, is praised for her nuanced ability to describe the everyday life and relationships of the English upper-middle classes. Taylor died of cancer at the age of 63.
BOOKS FOR THE NEXT TWO MONTHS
June: The Salt Path by Raynor Winn
July: Aftershocks by A. N. Wilson