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

by Kathryn Mannix

Palliative care is not solely concerned with dying: excellent symptom management should be accessible to people of all diagnoses at any stage of their illness, when they require it.

allow the reader to ‘experience’ what happens when people are approaching the ends of their lives: how they cope; how they live; what matters most; how dying evolves; what a deathbed is like; how families react. It’s a tiny glimpse into a phenomenon that is happening somewhere around us every single day.

Similarly, discussing what to expect during dying, and understanding that the process is predictable and usually reasonably comfortable, is of comfort and support to dying people and those who love them.

Towards the very end of life energy levels are less day by day, and this is usually a signal that time is very short. Time to gather. Time to say any important things not yet said.

I recognised that these people were far better served by the hospice than they had been by the mainstream cancer services.

adjustment to sudden death is often harder than a bereavement when there has been a chance to say goodbye.

Bereaved people, even those who have witnessed the apparently peaceful death of a loved one, often need to tell their story repeatedly, and that is an important part of transferring the

experience they endured into a memory, instead of reliving it like a parallel reality every time they think about it.

If you regularly have upsetting memories of a difficult situation, whether it is a death or something else, and especially if the experience still feels as though it is happening again there and then, this suggests that your experience may be causing post-traumatic stress disorder (PTSD).

Denial is an effective psychological mechanism for dealing with distressing situations. By choosing not to believe the bad or dreaded thing is happening, a person can avoid distress completely.

People are not limited so much by their illness as by their attitude to it. The illness may present physical challenges, but the emotional challenge is often far more important.

Enabling people to be architects of their own solution

is key to respecting their dignity. They are only in a new phase of life; they have not abdicated personhood.

CBT helps people to understand and manage their terror, instead of feeling controlled and undermined by it.

I was mainly dealing with patients for whom no possible options for cure remained, and who knew that their only treatment options were aimed at improving their quality of life or possibly extending it by a short time.

Possibly 25 per cent of all deaths are sudden and unexpected, taking place too rapidly to allow time for any treatment.

We don’t understand it, but we recognise that sometimes people can only relax into death when they are alone.

Today, in ED, Lisl’s skills focused not on saving life at any cost, but on enabling goodbye. Sometimes, in the end, it’s all we have to offer.

Every family will find its own way to deal with the Facts of Life; we need to remember that the Facts of Death are just as important to acknowledge and discuss.

Bereavement is the process that moves us from the immediacy of loss and the associated grief, through a transition period of getting to know the world in a new way, to a state of being able to function well again.

Here is an important truth in action: by being able to sit with the deepest anguish and not shut it down, it is possible to enable people to explore their most distressing thoughts, process them, and even find more helpful ways to deal with them.

Sometimes the metaphor of leave-taking is the only way the approach of death can be discussed.

Knowing that there are plans for appropriate treatment, and also plans to avoid inappropriate or unwanted escalation, is a central part of planning end-of-life care.

Legacy is what we leave behind in the world, for good or ill.

The dying are often very aware of their legacy, and keen to ensure that their life ends in a way that does least harm to those they love.

As part of his CBT, Dan experiments with activity levels at home and discovers that the more he does, the less unhappy he feels.

autopsy offers answers that can benefit future patients, progress research, and comfort the bereaved.

The price of living longer is that we experience older age, with or without cognitive decline.

The second part of life is about transcendence to wisdom, and for many people this only develops over a long lifetime.

People approaching the end of life are grateful for the tiniest kindness. They appreciate the good intentions behind often gauche expressions of support.

These are just ordinary people, like the rest of us, but they are at an extraordinary place in their life journey, and all of us benefit from their compassion.

It is worth noting that, in the UK, hospices are mainly specialist units for management of complex physical, emotional, social or spiritual needs, and not merely end-of-life-care nursing homes.