With the End in Mind: Dying, Death, and Wisdom in an Age of Denial

by Kathryn Mannix

Dr. Kathryn Mannix has studied and practiced palliative care for thirty years. In With the End in Mind , she shares beautifully crafted stories from a lifetime of caring for the dying, and makes a case for the therapeutic power of approaching death not with trepidation, but with openness, clarity, and understanding.

Weaving the details of her own experiences as a caregiver through stories of her patients, their families, and their distinctive lives, Dr. Mannix discusses the universal, but deeply personal, process of dying. With meditations on life, death, and the space between them, With the End in Mind describes the possibility of meeting death gently, with forethought and preparation, and shows the unexpected beauty, dignity, and profound humanity of life coming to an end.

Genres: Nonfiction, Death, Medicine, Psychology, Medical, Science, Memoir

352 pages, Hardcover

First published December 28, 2017

About the author

Kathryn Mannix has spent her medical career working with people who have incurable, advanced illnesses. Starting in cancer care and changing career to become a pioneer of the new discipline of palliative medicine, she has worked in teams in hospices, hospitals and in patients’ own homes to deliver palliative care, optimising quality of life even as death is approaching. Having qualified as a Cognitive Behaviour Therapist in 1993, she started the UK’s (possibly the world’s) first CBT clinic exclusively for palliative care patients, and devised ‘CBT First Aid’ training to enable palliative care colleagues to add new skills to their repertoire for helping patients.

Kathryn has worked with many thousands of dying people, and has found their ability to deal with illness and death both fascinating and inspirational. She believes that a better public awareness about what happens as we die would reduce fear and enable people to discuss their hopes and plans with the people who matter to them.

Reviews

[Rebecca · Rating 4 out of 5]

This is an excellent all-round guide to preparation for death. It’s based around relatable stories of the patients Mannix met in her decades working in the fields of cancer treatment and hospice care. She has a particular interest in combining CBT with palliative care to help the dying approach their remaining time with realism rather than pessimism. In many cases this involves talking patients and their loved ones through the steps of dying and explaining the patterns – decreased energy, increased time spent asleep, a change in breathing just before the end – as well as being clear about how suffering can be eased.

I read the first 20% on my Kindle and then skimmed the rest in a library copy. This was not because I wasn’t enjoying it, but because it was a two-week loan and I was conscious of needing to move on to other longlist books. It may also be because I have read quite a number of books with similar themes and scope – including Caitlin Doughty’s two books on death, Caring for the Dying by Henry Fersko-Weiss, Being Mortal by Atul Gawande, and Waiting for the Last Bus by Richard Holloway. Really this is the kind of book I would like to own a copy of and read steadily, just a chapter a week. Mannix’s introductions to each section and chapter, and the Pause for Thought pages at the end of each chapter, mean the book lends itself to being read as a handbook, perhaps in tandem with an ill relative.

The book is unique in giving a doctor’s perspective but telling the stories of patients and their families, so we see a whole range of emotions and attitudes: denial, anger, regret, fear and so on. Tears were never far from my eyes as I read about a head teacher with motor neurone disease; a pair of women with metastatic breast cancer who broke their hips and ended up as hospice roommates; a beautiful young woman who didn’t want to stop wearing her skinny jeans even though they were exacerbating her nerve pain, as then she’d feel like she’d given up; and a husband and wife who each thought the other didn’t know she was dying of cancer.

Mannix believes there’s something special about people who are approaching the end of their life. There’s wisdom, dignity, even holiness surrounding them. It’s clear she feels she’s been honored to work with the dying, and she’s helped to propagate a healthy approach to death. As her children told her when they visited her dying godmother, “you and Dad [a pathologist] have spent a lifetime preparing us for this. No one else at school ever talked about death. It was just a Thing in our house. And now look – it’s OK. We know what to expect. We don’t feel frightened. We can do it. This is what you wanted for us, not to be afraid.”

I would be happy to see this advance to the Wellcome Book Prize shortlist.

Favorite lines:

“‘So, how long has she got?’ I hate this question. It’s almost impossible to answer, yet people ask as though it’s a calculation of change from a pound. It’s not a number – it’s a direction of travel, a movement over time, a tiptoe journey towards a tipping point. I give my most honest, most direct answer: I don’t know exactly. But I can tell you how I estimate, and then we can guesstimate together.”

“we are privileged to accompany people through moments of enormous meaning and power; moments to be remembered and retold as family legends and, if we get the care right, to reassure and encourage future generations as they face these great events themselves.”

Originally published on my blog, Bookish Beck.

[Paul · Rating 5 out of 5]

To completely re-write the original quote that Benjamin Franklin made; there are three things that are certain in life; taxes, your computer crashing and death. The final of these inevitable events will happen to every single person on this planet at some point in the future. Even though it is one thing common to all life, it has reached the point where it is seen now as a taboo, something that we deliberately choose to ignore or rarely talk about when pushed. Death though is something that Dr Kathryn Mannix has faced throughout her career, and this book, With the End in Mind, is a collection of stories of the last moment of people from all walks of society.

Probably the most poignant stories are those about the children and teenagers who have barely got started at life before it is tragically taken away from them. She talks to patients that have rooms full of their family, dealing with the anger and unfairness of it all, we learn about a young man who does not have long to live, but was still considering suicide as he is so despondent that he will never leave a legacy, but he is one of the first in the country to carry a plan detailing what should happen should he become ill. The media attention raised awareness and they saw a huge rise in others wanting to do the same thing. People react to their terminal illnesses differently. One of her patients was a mother who still feels that she needs to keep up her glamorous appearance, but pouring herself into tight jeans was not helping with the pain; a few subtle changes helped immensely and allowed to be comfortable in the final days. Some of the hardest cases are those that have one close loved one who are not sure how they will cope alone.

It is said that your life flashes before your eyes just before you die. That is true, it's called Life. ― Terry Pratchett

All of the stories in this book are sad; people grieving the loss of their loved ones, but in amongst the tears there are moments of comfort and illumination on how to deal with death, all coupled together with the calm and considered advice from Mannix. What she is a big advocate of is communication, telling people what is wrong with you, getting them to ask sensitive questions, finding out if people want to be at home for their last moments, or have no real preference. There is a Pause for Thought moment at the end of each chapter where there are suggestions and practical details are discussed. This book is not going to be for everyone given the subject matter, but it is a step in the right direction to seeing death as an intrinsic part of life and coping with it in the best way for you. Can highly recommend this moving book and I think it should be essential reading for anyone who has any concerns about death

[Nigel · Rating 5 out of 5]

In brief - Best book of the year without question. A powerful and moving read.

In full
This is the story of some of Dr Kathryn Mannix's patients. She has written this because, as a palliative care specialist of 30 years, she has seen a lot of people dying. She is also aware of the lack of information about the process that is available to patients and their families. This attempts to redress the imbalance. As a by product of this we get to learn quite a bit about the author and her career too.

I have read a few books on the subject of dying over the past few years. They have all been of interest and informed me to some degree whether they illustrate personal stories or look at the bigger picture. The "personal stories" approach ones that I've read so far were those of one person's story. This book contains a lot of personal stories, all different in the same way that we are all different people. One commonality is the misunderstanding of the stages and process of death. The book has a very good introduction to the subject as a whole. There is also a "health warning" on medicines and this book that sets the tone very well.

Very early on in the book I realised why palliative care might suit Kathryn Mannix. Concern, empathy and interest are very evident. The writing seems to reflect what I imagine her personality to be - skilled, caring and empathetic. It is also highly readable. The names of her patients have been changed and there is nothing that will give away exactly who is being referred to.

If there are not signs of dampness around the eyes when reading this book I'd be frankly amazed. My eyes were frequently damp and some of the stories had tears rolling down my cheeks. I must emphasise that this was not in a bad way. This book may well not be for everyone however it tackles very difficult subjects with great gentleness. The people in these stories are remarkable people.

The book starts with Sabine's story and looks particularly at the process of dying and the need for honesty at such a time. I'll not go through the individual stories - Kathryn writes far better than I do. No two people reading them will react in the same way I imagine however I enjoyed (if I can say that about tales of death) them all and some were very special indeed. What I should say is that some are hard stories and "shocking to read" - you have been warned . However the writing is frequently poetic and has a gentle directness that for me made it an excellent read. The phrase a "survival guide to dying ' seems apt and is coupled with a gentle caring honesty.

I did find some stories ambush you - for me Mark's was one of those. It suddenly hit me quite hard. However this book is so well written that it can allow you tears - not of sadness but maybe of understanding and empathy as well as tears of laughter. I hadn't expected to laugh out loud reading this but I did. One passage even made me both laugh AND cry - not something I expected.

This book worked on more than one level for me. As well as the stories and the "guide to dying" it is a good insight into palliative care and hospices generally; on what they do or hope to do. Due to the issues involved in one story the book also looks briefly at the legalities and ethics involved in dealing with patients who are approaching the end of life. At the end of each batch of stories there is a "pause for thought" section to allow people to consider their own positions. At the end of the book there is a good resources section.

In many ways it was a privilege to be able to read this book. It managed to be both personal & general and profound & trivial however it was almost always powerful and always deeply human and humane. I really would hope that this book would be widely read and not simply by those directly interested from a medical perspective - as the author tells us we will all die one day.

Note - I received an advance digital copy of this book from the publisher in exchange for a fair review

http://viewson.org.uk/non-fiction/end... 

[Alice · Rating 4 out of 5]

Surprisingly peaceful and comforting. Well worth reading.

[Jay Green · Rating 5 out of 5]

I very rarely give a book five stars, but this was so moving, eloquent, informative, poignant, and beautifully crafted that anything less felt unfair. I would recommend this book to anyone and everyone, regardless of age, as an educational, moral, and preparatory text that will allow the reader to deal with their own death and those of loved ones more meaningfully and considerately. It is a book of kindness, an act of kindness in its own right, that deserves a wide audience.

[Shirley Revill · Rating 5 out of 5]

I listened to this audiobook and I was very impressed with this book.
The book shares the stories of a palliative care doctor and the people she gets to know who are facing death.
Unfortunately in our society we seem to have become afraid of dying and being able to talk to people facing death.
This is a very well written memoir that will bring a great deal of comfort to so many people.
Well worth reading and very highly recommended.

[Laura · Rating 1 out of 5]

Kathryn Mannix's With the End in Mind: Dying, Death and Wisdom in an Age of Denial is written from her own experiences as a specialist in palliative care, and this proved, for me, both its strength and its downfall. The book is structured around a series of fictionalised case studies drawn from Mannix's own experiences, many of which are deeply affecting. I was particularly touched by the stories of Sally, a young woman dying from melanoma who refused to accept that her condition was terminal, and Holly, a mum of two teenagers dying from cancer of the cervix, who suffered from a last bout of restless energy before passing away. Mannix writes particularly well on the characteristic patterns of somebody who is entering a gradual decline. As the hospice leader she's working with on Holly's case describes it to Holly's daughters: 'Have you noticed that she stops breathing from time to time? That tells me that she is unconscious, very deeply relaxed... That is what the very end of life is like. Just very quiet and peaceful. I don't expect she will wake up again now.'

I find books of this kind difficult to review because the risk of sounding like you're passing a (totally unqualified) judgment on the writer's professional career. But ultimately I have to judge With the End in Mind as a book that Mannix has written, separating it from Mannix's personal achievements, and in this context, it fell very short. It's crucial to feel that you trust and respect the voice that is telling you such sensitive stories, but With the End in Mind left me feeling frustrated, angry and suspicious. This was for a number of interconnected reasons:

Unlike similar medical writers - Henry Marsh's Do No Harm and Atul Gawande's Being Mortal, Better and Complications come to mind - I felt that Mannix was keeping her professional distance, positioning the reader as her patient. Each section ends with a 'Pause for Thought' that I found simplistic and patronising, and unlike Marsh and Gawande, she writes virtually nothing at all about her own professional mistakes, although she says a little about other people's. In every story, she positions either herself or her palliative care colleagues as the all-knowing voice of reason, and after a while, this started to feel a bit sinister.

This was compounded by her discussion of euthanasia, a subject that is obviously very relevant in this context. While I am broadly pro-euthanasia, I wouldn't have minded if Mannix had directly challenged my views by offering up new evidence to support her obvious concerns about euthanasia options such as those offered in the Netherlands. Instead, I found her approach incredibly disingenuous. I almost stopped reading With the End in Mind after 'Please Release Me: B Side' where Mannix tells a story about one man's unpleasant experience in the Netherlands that is entirely based on hearsay, and I realised that a number of stories she had been telling in that section had been deliberately engineered to emphasise the benefits of palliative care as opposed to euthanasia. Again, I would have found this less troubling if Mannix had been upfront about it: instead, she claims that 'many of us in palliative care roles are exasperated by the trenchant, black-and-white opinions of the campaigners for either view [on euthanasia]' but makes her own views pretty clear when she says at the end of the chapter on the Netherlands that 'Once the euthanasia genie is out of the bottle, you must be careful what you wish for', echoing familiar 'slippery slope' arguments. All of this made me very uneasy and uncomfortable.

Finally, Mannix uses the metaphor of 'natural birth' throughout the book to promote her vision of a 'natural death'. She writes that 'both processes can proceed safely without intervention, as any wise midwife knows.' This infuriated me because of the damage, pain and suffering the language of 'natural birth' and the doctrine of little medical intervention has caused to women and their babies. Indeed, the Royal College of Midwives recently dropped campaigns for what they called 'normal birth' in recognition of this fact, although women are still denied the right to choose interventions like caesarians (in contravention of NICE guidelines on childbirth) as a consequence of this ideology. As the language of 'natural birth' is unfortunately quite common, I wouldn't see this as a significant problem for Mannix if she didn't repeatedly return to this metaphor across the course of her book. This, along with the problems I've noted above, left me doubting everything she said about birth and about death.

I received a free copy of this book from the publisher for review.

[Claire Fuller · Rating 3 out of 5]

I have mixed feelings about this book. Sometimes the stories almost moved me to tears, and I was interested to learn many things about dying and how it often follows a very recognisable pattern. But there are also things that irritated me and make me question elements of the narrative, which of course make me question it all. We are presented with case histories of patients facing the end of their life, how they cope (or don't), and what help Mannix and her team (and others) are able to provide via palliative care. In her introduction, Mannix states that in the book, 'the experience of several people is woven into a single individual's narrative, to allow specific aspects of the journey to be depicted'. And this is my first problem. The narratives feel generic; the people often feel generic, as though all their idiosyncrasies have been sanded down or air-brushed out. They were sometimes 'beautiful' or 'handsome', and none of them seem very real. And secondly, Mannix and all of the wider NHS staff that we meet along the way are nearly all calm and happy and lovely. I know a lot of NHS staff and they are lovely, but they are also often stressed, irritated by patients and managers, despairing of all they are expected to do in so little time for so little money. Clearly, this book isn't about that, but I would have liked the professionals to also have a little more personality too. Despite all that, the idea of this book; the spirit of it makes it worth reading.

[Bookphenomena (Micky) · Rating 3 out of 5]

2.5 stars

WITH THE END IN MIND is written for the public perspective and not professionals working with the grieving, in my opinion. It takes an anecdotal story approach to representing a variety of death, dying and grieving situations and conversations that many might find potentially helpful.

I tried to read it from a dual perspective, as a professional and academic in this field but also as a person inquisitive about their own death and those of my loved ones. However, I found as a professional it didn’t engage me. I do realise however, that I am not the reader this book is aimed at. Nevertheless, I am drawn to investigating books that might engage and aid people I work with searching for understanding and meaning around their loved ones death.

Readers will find stories about patients from different ages, stories of difficult conversations and a build in the narrative to questions a reader might have about what their own death might be like physiologically and psychologically. I felt more thought could have been given to questions such as resuscitation. The quick move from self-searching topics to stories wasn’t always a welcome shift in the narrative.

Overall, this book wasn't to my taste, but some readers will engage with the approach to this topic.

A copy of this book was provided by the publisher through netgalley in return for a honest review.

[Joachim Stoop · Rating 4 out of 5]

The book is as helpfull, wise and sensitive as everybody's been saying and I would've given it 5 stars, but...

It sounds kind of harsh, yet one out of forty chapters made me lower my general score with one star. It was a chapter about a dying person in Holland who felt he was pushed by his doctor into ending his life with euthanasia. Although anecdotal, this was presented by Mannix as the usual method in The Netherlands: doctors brainwashing patients into believing that their lives became too hard to bear and that there are better options than living and suffering to the painful end.
This is NOT the rule, but the exception. Generalising this one doctor into a nationwide trend is scientically and morally wrong. Doctors in The Netherlands (and in Belgium) do not see euthanasia as a default or standard procedure, but as a last resort. A last resort decision surrounded by strict laws with the highest regard for the patient's autonomy, family and close ones. A procedure with the patient's firm and repeated will to die and a team of specialists judging the demand. Nobody is pushing anybody and nobody takes anything lightly.

Mannix shows an incredible devotion and subtility towards human feelings and choices, but in this one chapter she generalizes one case and by doing so makes a faux pas. But overall I would still recommend this great book.

[Mrs. Danvers · Rating 5 out of 5]

This is wonderful. It is similar in many respects to Ira Byock's great work Dying Well. I have referred to that one a number of times when talking to people who were in fear of their death, and I can see how this one would be even more comforting. Mannix has a touch of rose-colored glasses, but I guess I don't mind in this context.

If you find Atul Gawande's Being Mortal: Medicine and What Matters in the End a worthy read, you should definitely look this one up.

[Rona · Rating 4 out of 5]

I was a bit startled by some of the negative reviews for this book which I read when I was half way through. I can’t agree with any of them as I thought it a well balanced, kind, considerate and helpful book which raises issues we really should be engaging with now.

They say that the Victorians were happy to talk about death, but not sex, and now we’ve reversed that as no conversation about sex seems too much, and yet we can’t even bring ourselves to use words like died/dead/death, only passed or lost or late.

My job means I deal with people coping with grief often, and I would dearly love to ease some of this ghastly suffering which comes from being utterly unprepared for death and grief, and having absolutely no language or map to navigate this one certainty in life.

So for dealing with this subject from the Palliative perspective, I salute you Kathryn! I also salute the brave and dignified men and women who’s stories you have sensitively jumbled and then shared with us.

[Laura · Rating 4 out of 5]

An emotional journey through one woman’s experience working in palliative medicine that challenges pre conceptions about the field while encouraging thoughts and discussions around our own mortality.

This book tells dozens of stories about people facing the end of their lives, and how best medical and nursing personnel work together to ensure their patient experiences a good death. Meanwhile, the author tells some of her own stories and encourages the reader to think about issues of their own.

I enjoyed this book and would recommend it to everyone, as it features something we all have in common. Death and dying should no longer be a taboo issue in modern society, we should all have discussions with our loved ones about what-ifs and what our own wishes are. The author is clearly dedicated to her area of expertise, although I feel she could have discussed issues such as organ donation which would have tied in nicely with the subject.

A must read for people working in medicine, nursing and the wider public.

[Bon Tom · Rating 5 out of 5]

I believe this is that kind of book which is only going to affirm you in your belief, whatever it is. Which, probably, in this case and with most people, is of bipolar nature.

If you are wired so that you think there's grandeur, learning, redemption, or whatever other "quality" in suffering except pointless pain, you are going to stand your ground and use this book to reinforce your rationalizations about why the pain (physical suffering) is unavoidable, even necessary part of human experience.

On the other hand, if your belief system can't reconcile the fact that we show mercy and euthanize a dog as soon as we notice first signs of pointless suffering, but use are "knowledge and expertise" to prolong that suffering as long as possible in our fellow humans, after reading all these testimonials of human beings falling apart alive, you're only going to be more mad and in wonder why we philosophize about euthanasia so much. Does it serve anyone but doctors and their sense of grandeur and omnipotence? Would they feel like admitting their limits and helplessness by allowing people to chose their end?

I'm the guy from the second group. I believe in adding life to my years, not vice versa if that means losing all the basic dignities and quality of human life. I believe in choice. I think I would chose to check out at some point before I lose capability of implementing the necessary "procedure" myself. And before I turn to ruin and sad memory in the minds of my loved ones. Man, watching your loved one suffering fucks you up for life, far more than "simple" fact of his of her death.

The very fact I have a choice would mean I might or might not actually make it. But I absolutely need to have it. Taking that choice from people is medieval.

[Rachel · Rating 4 out of 5]

The author's purpose in this book is to demystify dying and let people know that it doesn't have to be all that unpleasant. She is a doctor working in palliative care in England. She clearly describes the actual process of death by gradual illness to the people in her care, their families, and the reader. She also offers cognitive behavioral therapy (CBT) for the dying person, which sounds helpful. The book makes its points well through stories of people she has met in her work.

The people she talks about are diverse in age, ethnicity, and social class. They receive their care via England's national health program, so everyone qualifies for the same care. (She mentions that the rich can pay for more opulent settings, but can't get better care.) I don't know how easily available the care she writes about is in Great Britain, nor what percentage of people get that care. This makes the book not as relevant to us Americans, where palliative care is theoretically available to most people, but it helps to be in a higher economic class and/or have someone who can advocate for you.

I've been around several deaths where palliative care is in place. In my limited experience, a couple of deaths have fit her model, and a few others have involved more pain and discomfort than she describes but were otherwise similar. I've also seen a couple where I believe the people were in a nightmarish state even as they were in their final unconsciousness. Maybe if those people were under her care, things would have gone better, I don't know. Also, in the book, all the institutions and caregivers seem to behave consistently compassionately, which is not the case, at least here. So I do feel that this book is a bit more inspirational than most people's reality. And of course, it deals only with expected deaths, which we don't all get.

Even with that, the stories were well written, easy to read, and believable, as were her commentaries. I like her approach to her patients and families, and wish she could be my doctor when the time comes. I liked reading the book and recommend it to anyone interested in the subject.

[Carolinemawer · Rating 2 out of 5]

There are lots of moving stories in here, extremely well written - and I'm sure that this doctor has done a lot of good things.
But I often felt uncomfortable with what felt like a hierarchical doctor-knows-best approach:
- The idea of the 'Leader' when surely the patient and their family should be leading or at least in parallel with the doctors
- There were lots of peoples problems 'solved' here - rather than empowerment so that individuals and their families could be supported in choosing their own ways forward. Most outrageous was the agitated woman given medication to counteract the agitation some other medication had caused. Exhausted by all the running around (caused by the agitating medicine), the lady promptly died. The Leader (maybe it's a cult?) knew this was likely to happen - but didnt get informed consent from the woman or her family - who were then called in to witness how 'peaceful' their relative was.
- The story about assisted dying in the Netherlands felt like one-sided propaganda. Of course, if the man felt harassed, that's appalling. But this ignores the 'doctor-knows-best' use of medication described above - assisted is apparently OK if the Leader and the author decide to do it. It also ignores the significant number of individuals who are either rich enough to travel from the UK to Switzerland or not so rich but just as desperate - and so who throw themselves down stairs / try to poison / or suffocate themselves - all alone since they are concerned for their family with the current law.
Since the author is writing as someone working in palliative care, she also ignores / maybe doesnt know about the bits before patients get to palliative care. This 'transition' is extremely painful for patients, families, and doctors too. There's a myth that modern medicine is all powerful. This is of course ridiculous - there is a 100% death rate. But palliative care / hospice medicine seems to work according to another myth - that they are the ones to help with death. I think this is just as ridiculous. There are not enough hospice / palliative care staff to help with deaths now (the focus is still on cancer). With a tsunami of death coming soon as the baby-boomers die, there really wont be enough staff trained in this particular way.
The sub-title of the book talks about wisdom in a age of denial.
But the book seems to me to have more denial than wisdom.
Cicely Saunders made a great and gamechanging leap forward in thinking of hospice. But now we need something just as great and just a gamechanging - not just more of a 50 year old novelty.

[Robyn · Rating 5 out of 5]

Not a book I really wanted to have a reason for reading, but nonetheless one we all should. Clear-eyed accounts of Dr. Mannix’s career in palliative care and the many lessons learned.

[Lauren · Rating 5 out of 5]

A must read, such a profound and thoughtful reflection on what makes us human in life and in death

[Colleen Oakes · Rating 5 out of 5]

It is no surprise to me that this book is rated in the insane-high level of Goodreads - it’s a necessary, heartbreaking work of the gentlest of people, a woman who I want at my bedside when it’s my time.

I’ve been thinking about death a lot lately as the subject is likely to become one more familiar with me as my father is in the final stages of ALS. I can’t say enough about what a comfort this book was to me - it used knowledge and stories to take the fear away of what may come, and how to face those times with calm and reassurance, grace and finality.

I truly believe each person should read this book; the stories are heartbreaking but the lessons are forever.

[Jessie · Rating 4 out of 5]

With The End In Mind is Kathryn Mannix’s layman’s guide to death and dying. Mostly a reflection on her years as a palliative care medicine doctor, Mannix shares with readers what the process of death looks like, what is valuable to people at the end, and why honest conversations about the one true inevitable event in our lives yields so much less fear and such richer endings. I’m a sucker for qualitative snippets of the great transition, and the time before and after, because I am grateful for the privilege of doing death work in my work, and I know no truer teacher than the end of life, so I was a fan of this book. I think that the practical elements, particularly the reflection points, would make good conversation starters, even with yourself, if death looms large in your consciousness for any reason. This is a gentle book about dying, which is the nicest way to die probably, and I think that it’s a reassuring read if you’re considering the genre, considering doing work in the field, or considering your own mortality in soon days or in some future yet unknown. You won’t get the critical intersectional, or even graphically honest parts of death, but you will get a generalist middle of the road sense of what death and dying is told from a person who truly loves their work and sincerely takes the time to be immersed in it.

[Darryl · Rating 5 out of 5]

This outstanding book, which was shortlisted for this year's Wellcome Book Prize and was written by a palliative care physician in the UK, describes several remarkable people she cared for at the end of their lives, their families and other loved ones, and her experiences and lessons learned during her four decades in clinical practice. Dr Mannix demystifies and humanizes the experience of death for her patients, their families, and especially her readers, as people who have or very likely will care for a dying person, and will ultimately succumb to death themmselves. In addition to being an engaging and, dare I say, heartwarming read, it is also richly filled with lessons and advice for current or future use. With the End in Mind, similar to Atul Gawande's recent book Being Mortal, is an outstanding contribution to the topic of end of life care, and as such it is a book that would be of benefit to everyone.

[Gavin Whyte · Rating 5 out of 5]

Thoroughly enjoyed it. It’s written with such warmth, compassion, and integrity, and it contains just the right amount of humour. The narrative isn’t intrusive; it knows what’s important.

Yes, the book’s full of sad stories, and occasionally I swallowed a lump, but it’s a book about death and dying, and how people cope in/with their final moments, so it never was gonna be much of a hoot.

Many of us won’t read a book like this because we don’t want to look at death, think about death, speak about death, let alone read about Mr Grim and his rusty scythe. But when we find the courage to tap him on his shoulder, he may just help us feel more alive. He may just point to whatever or whoever, and say, gently, “It’s not gonna last, you know.”

And we’ll thank him because then we’ll know how to live.

[H.A. Leuschel · Rating 5 out of 5]

This was a book to take in slowly, chapter per chapter, intimate and tender story per intimate and beautifully written story. I shed tears as much as I felt wonder and awe for the people who accompany the dying. I must underline that this is not a sad book even though I felt sad and did put the book aside regularly to reflect on what I just read. Dying is made special in this book because it is given back its precious highly emotionally charged as well as matter of fact place in life.

Highly, highly recommended.

[Verity Hagen · Rating 5 out of 5]

4.5 ⭐️ Adam Kay mentioned this book in one of his footnotes in ‘Twas the Nightshift Before Christmas. It is written by Kathryn Mannix, a palliative care doctor, who shares a collection of stories about some of the patients she has cared for. She speaks about the importance of having honest conversations about death - particularly in a culture where death is a taboo topic - and how profound, gentle, and dignifying death can be

[Rod MacLeod · Rating 5 out of 5]

Brilliant, insightful, compassionate and wise. Kathryn has skilfully negotiated a territory that few have tried and she has done it with skill.
It should be required reading for everyone who cares for those who are dying in whatever role they have.
Thank you so much for your honesty and for taking what was possibly a great deal of time and effort in doing so.

[Gayle · Rating 5 out of 5]

Warning - do not read this book in public!! (Unless you like crying in public) However I would add this aside we should all read it!
An accessible and moving account of death and what to expect and what we all need to consider. It’s not morbid, but it is sad and moving but also hopeful and considerate. Can not recommend this highly enough!

[Julie · Rating 5 out of 5]

The primary thought on reading this book is that if you enjoyed Being Mortal by Atul Gawande then this very much feels like a companion read. One that I think that everyone should read and share with their loved ones.

Dr Kathryn Mannix is a palliative care Consultant and in this book she writes about her experiences of working with dying patients. She looks at the pattern of dying and what most people will experience as they die. Her insights into the support of the patient and the care of their families are demonstrate a level of care that we would all hope to experience, yet I feel is lacking in many peoples experiences.

She doesn't fill up the book with pages of medical jargon, but instead talks about many of the patients that she has met during the years and how her job helps them to deal with end of life care.

[Robert Day · Rating 4 out of 5]

Little stories that criticise how people die and, by implication, how they lived. If you like your little stories to have a happy ending, this ain't the book for you.

To be fair, it is stated somewhere in the book that it's not so much about dying as choosing what kinds of times we have while we're alive. Do we do things we can look back in satisfaction on, or things that we'll look back and regret when we're on our deathbed (other places to die are available).

That said - I think that you can write a book about how to live without referencing how you'll feel when you die.

Read this if you absolutely can't find a book that doesn't mention 'death' or 'dying' in its title. Avoid it otherwise.

[Jude Balit · Rating 5 out of 5]

This book is a beautiful collection of stories and reflections about dying, written by a palliative care doctor. I really liked her narrative style, which was sufficiently descriptive but always compassionate and with a touch of humour. I think this book is as much about how to interact with people who are facing death as it is about the different ways people face their own death.

[Martha · Rating 5 out of 5]

"I realise that it is a rare privilege to be present and to serve those who are approaching their unmaking. I was discovering that I was not afraid of death; rather, I was in awe of it, and of its impact on our lives."

Perfect for fans of When Breath Becomes Air, With the End in Mind is a collection of case studies about dying from Dr. Kathryn Mannix, a specialist in palliative care. Far from being melancholy (though I'll admit I shed a tear or two), this collection is a hopeful and comforting insight into what it means to reach the end of one's life and how we should reclaim the lost art of dying.

For someone who has not had much experience with the death of close friends or family, it was interesting to consider my own feelings on this subject. Fear? Denial? Both are there. I tried to recall conversations with anyone about my own death or the death of loved ones and could only remember odd snippets asking my parents and fiancé if they wanted to be cremated or buried; something I felt I had a responsibility to know. Nothing about the actual act of dying.

It is precisely this lack of conversation that Mannix is trying to change with this book. Despite all of the benefits the advances in medicine have brought us, we have only postponed the inevitable, and in doing so, lost the natural expectation and understanding of death.

I found Mannix's prose to be lyrical and soothing. Just like any good doctor, she meets your concerns from the off, with an early section about what to expect and how to read this book. Is it sad? Yes. Irene's husband was the first to make me cry and we meet him in the first chapter. Was it so sad that I couldn't continue? Not in the slightest. I felt like I was taking a natural journey, being introduced to a daunting subject by a wise and open teacher. Mannix incorporates stories of her own experience of the deaths of friends and family members, as well as how she and her husband tackled the issue of how and when to explain death to their children. At the end of each section is a "Pause for Thought" with open questions and conversation starters, designed to get us talking. This is not about Mannix and her career in palliative medicine, this is a deliberate challenge to do better in how we approach the end of our lives. A friend joked with me that this was not the most festive read I could have chosen for the Christmas period. Finishing it a couple of days before the end of December, I had a new sense that death could be more like the end of the year, taking stock of everything we've done and looking on to the next journey. Whether we believe in an afterlife or not, perhaps if we approached dying like we do New Year (the celebratory vibe more than the actual boozing), we might be less afraid of it.

"Enabling people to be architects of their own solution is key to respecting their own dignity. They are only in a new phase of life; they have not abdicated personhood."

Another challenge that the author lays down is in how we treat the elderly and terminally ill. The quiet respect Mannix and her colleagues give to their patients without question is a subtle defiance against a culture that writes people off once they cease to become 'useful'. In ignoring death, we also ignore those who are entering that last phase of their lives. One cannot help but wonder if a more open conversation about death would result in more consideration for the dying, and better investment in social care facilities that treat the elderly and unwell with the dignity and respect they are owed.

The fact that all of us will encounter death at some point in our lifetime is the reason why everyone should read this book. Just as everyone will have their own, unique experience, I think everyone will find something in this book that will speak to them. For me, recently engaged and planning a wedding, the cases where Mannix was treating patients who were afraid to leave their husbands or wives were particularly emotional for me, tapping into fears of committing my life to one person and losing them too soon. For another reader it could be the cases where patients were afraid to die in pain; for another, the patients afraid to live in an intolerable state, thanks to a degenerative illness. There is truly something for everyone here.

"It's your life that you are working on finishing well. It's a mighty piece of work. Give it the attention and the time you deserve."

5/5 stars for a profound and hopeful book about remembering the lost art of dying, and in doing so, remembering how to live.

Thank you to William Collins for providing me with a digital Advanced Readers Copy via NetGalley UK, in exchange for an honest review.