The process of dying can be incredibly peaceful and comfortable enough to be bearable, and frankly, you can't always say that about the process of giving birth.
Welcome to the one you feed throughout time. Great thinkers have recognized the importance of the thoughts we have. Quotes like garbage in, garbage out, or you are what you think ring true, and yet for many of us, our thoughts don't strengthen or empower us. We tend toward negativity, self pity, jealousy, or fear. We see what we don't have instead of what we do. We think things that hold us back and dampen our spirit. But it's not
just about thinking. Our actions matter. It takes conscious, consistent, and creative effort to make a life worth living. This podcast is about how other people keep themselves moving in the right direction, how they feed their good wealth. Thanks
for joining us. Our guest on this episode is Catherine Mannix, who 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 patients own homes to deliver palliative care, optimizing quality of life
as death is approaching. Catherine is qualified as a cognitive behavior therapist and started the UK or possibly even the world's first CBT clinic exclusively for palliative care patients. Today, Eric and Catherine discuss her book With the End in Mind, Dying, Death, and Wisdom in an Age of Denial.
Hi, Catherine, Welcome to the show.
Oh all right, Hi, thanks revising me.
I'm really excited to talk to you today. We're going to be talking about a subject that is heavier than most, but not maybe as heavy as we make it out to be. I'm hoping as we go through this conversation because we're going to be talking about death, and we're gonna be discussing your book, which is called With the End in Mind. But before we do that, we'll start
like we always do with the parable. In the Parable, there's a grandparent who's talking with their grandchild and they say, in life, there are two wolves inside of us that are always at battle. One is a good wolf, which represents things like kindness and bravery and love, and the other is a bad wolf, which represents things like greed and hatred and fear. And the grandchild stops and they think about it for a second. They look up at their grandparent and they say, well, which one wins? And
the grandparent says, the one you feed. So I'd like to start off by asking you what that parable means to you in your life and in the work that you do.
I love it. It's pterrible and I'm struck by it often in my work. So in my life, I think it's easy for us to catch ourselves out feeding the needia wolf, and often that's the bad wolf, that's the wolf that comes from past us. So sometimes it's really important to notice that this thing that I'm doing to make myself feel better is actually feeding my fear, is feeding my worry and concern, and it's really your way from being confident that taking courage and feeding the fear
and doing it anyway really in the end prevail. And I think if we do that cycle often in love, I hope what we do is we start to wear the footsteps past the bad wolf store and towards courage and towards feeding in a monements and holding life in a way that's trusting.
That's beautiful. It makes me think of the idea of avoidance. Right when you avoid what you fear, you strengthen it. You're suddenly sending the message to yourself, I can't handle this.
Yeah, right. And so in my work, of course, I meet lots of people who are maintaining their peace of mind about the fact that their death is approaching by using the really really helpful and it is helpful technique of complete denial. So if you don't believe the thing is true, you don't have to feel any of the difficulty motions. And it's almost a point of equipoise, I suppose, between the wolves, because it's so easy to slip sideways
into fear and despair in one direction. And yet if you're able to open the litigat denial just enough to say, is there a little bit of this that I could deal with today, then you're stepping up in encourage and or stepping out, perhaps towards the arms of other people who aren't prepared to help to hold you and to
help you to face the difficult place. And so maybe one of the other things to think about with the metaphor of the wolves is that wolf's working pacts and the re living community, and the people who are facing the ends of their lives, sometimes tragically are alone. But that's really ran. Mostly there's a small group to an army of well wishers and supporters who, confronted by the
person's denial, don't know how to be. And by enabling them to start a conversation that requires courage, that requires tenderness, and I've written separately about that, then we've moved them into a place where the pack is surrounding the wolf and moving them in the direction of their good wolf, their courage. They're facing their fear, they're having more information, because information, in the end is the light, isn't it
that shines into the dark place? I says, Okay, that's what it looks like, right, Okay, how do we do this?
So you have a wonderful story in the book about denial, but I don't want to go there just yet. I kind of want to start at the beginning a little bit. You say that we all bring our own ideas and expectations with us in any encounter with the big questions, whether that's birth, death, love, loss, or transformation. We frame things through the lens that we see it. We see it mirrored to us, and we think that's what it's like.
And you say that death has sort of fallen out of the big questions, right, You said it's become increasingly taboo.
Yeah. I think this is really interesting because it's not that we don't think about it, it's that we didn't talk about it. And the taboo is almost the thought police that if there were a third person with us now, we might now be worrying that they might be uncomfortable if we perceive this conversation, or we might be watching really carefully in case this is going to be triggering for them. So often it's a kindness that we're being
careful with each other, and sometimes it's an overridingness. So I remember our coneigue coming back to work after the death of her father, and I bumped into her in the little hospital kitchen where we used to go to seek a little tea break in between really busy clinics or whatever. And it was tiny. You could only fit three people in the time, and we had to move very carefully around each other to get to the hot water boiler or the cupboard of the mugs in or whatever.
So I'm welcoming my colleague back and saying, I was really really start to hear that your dad died, and it's great to have you back at work, and you know we're here. If you want back up, you tell us to let us push it. And she said thanks, and she left the kitchen area. And there was a third colleague hovering at the edge, somebody who worked in
a slightly different discipline from us. And as our bereave colleague left, she came into the kitchen she history, I cannot you said the word dead to her when her father has just died. And I'm thinking, hang on, it's the thought police here. My bereaf colleague and I have just had a perfectly okay conversation. We've acknowledged her loss, re used a word about the loss. I didn't say
he passed or passed away. I acknowledged that he died, she acknowledged, receipated the message that she can call on us if she wants support, but we're not going to crowd her. We're done here. But a different person who is now policing my language, a person who wasn't engaged in that conversation. And I think we see this all the time, and we see it also in the media, so on news if you look out for it, in print media, in TV news, very often the announcement that
somebody has passed, that somebody has passed away. Now, in certain parts of society there's a deeper, transcendental and spiritual meaning to the language of passing. They're passing away and passing on. But largely we've grabbed onto that language to be euphemistic and gentler. But it also avoids using their language of the end of life, of the approach of death, of the doing the dying, of the being dead, of enduring being believed. And so we lonely find people by
not having the courage to mention the most obvious. Mostly people think that they're currently dealing with. And it's partly because we be careful of the language, and it's partly because we awthualized dying itself, the understood it, recognized it, saw it frequently three generations years ago. I'm going to say now it's something that we don't see. It's being medicalized. It's been kind of kidnapped into hospital, into escalating and
increasinglytutile medical care. So I don't see ordinarily dying happening with any regularity, and you certainly don't see it often enough to recognize that it's kind of pattern to recognize that it is recognizable that the patterns of basis are similar from person to person, that they can pace our way through it. We can realize what's happening to the person that the company good symptom control, which isn't rocket science.
By the way, With good symptom control, the process of dying can be incredibly peaceful and comfortable enough to be bearable. And frankly, you can't always say that about the process of giving birth, which often is you know, it's parallel in having recognizable phases, the stages, and we can you know, name it and accompany it. But giving birth unless you really well in these times is not a comfortable process. And dying with proper simptu management is not an uncomfortable process.
Yeah, it goes back to what I said earlier about avoidance. Right, if we avoid a topic, we can't say death, we empower it and make it harder to say it. You also make the point that we end up saying things like you know, you mentioned that they've passed or you've lost someone, instead of saying died or dead and that we've started to talk about the dying process in terms of warfare, saying somebody lost their battle right, which is
a defeatist way of talking about this. Say a little bit more about that.
I think that's a really interesting thing. And I think it might be Ronald Reagan who was culpable in the first place of saying it, you know, declaring a war on cancer, and it was about cancer. And it's largely cancer that the battle is used about. And for some people who are having treatment for cancer, vacue must if actually is quite helpful, so we mustn't throw the baby out with the baffle to hear. But for a lot of people, they are not battling cancer. They are living
with cancer. Their life is not cancer. They've got some cancer in their body. It's affecting their life, but it becomes everything about them for some people in their key relationships. And the truth is that we will all die. And I know you in that. I really enjoyed listening to your interview with them, the wonderful Ala Arthur talking about exactly this, that the fact that we're going to die is given. We can pretend for most of our lives, and we do pretend for most of our lives that
it isn't so. But at the end of our lives, we will not have lost in battle. We will simply have finished our lives and we have to die something. It's interesting that the battle metaphor isn't used so much for the other things that we die from. So the commonest cause of death in older people now in high level income countries, in older people in dementia. Okay, And we don't talk about losing your battle with dementia or
losing your backing with heart disease. And it's offensive to dying people to be criticized for not fighting hard enough to win the battle for what for immortality? Did anybody win that battle yet? So we need to be more cognizant that there is language that is helpful and there's language that it is hurtful. And a really good rule of thumb is to ask people how they like to talk about it. They'll look a little bit surprised to be asked, but also they'll appreciate it.
And you mentioned that many times the elderly, the people who are closer to death want to talk about death. They want to talk about their preparations, they want to get their affairs in order. But very often the younger people, quite often their children, don't They say no, Mom, you're fine. You're fine, mom, Or you know that's a long time down the road, dad, we'll talk about that later. And
you say that you've seen again and again. People see death in a sense almost sneak up on them, meaning they thought they had time to do that, They thought they had time to have the meaningful conversations. They thought that there was more they would be able to do. And once the person starts entering a dying window, they are less. I don't know if this is how you would say it. Less here with us.
There's an interesting thing. So the trajectory of dying is it's slightly different in different conditions. But for most of us in our lives, there's a periods in our lives when we're well and we're healthy, and our life expectancies measurable in decades. And even though I am now in my self, I believe it. You know, I still go out running slower, I don't go as far. My times get worse gradually, gradually, but it's showing me that our body is slowing down at a rate of decades to
decade rather than year to year. I'll come a phase perhaps when the illness or the illnesses that will eventually end our lives declare themselves, when we'll start to notice that the trouble with my hearts online months, or the cancer I've been having treatmentfore, or whatever it is, is starting to limit me now and I can notice the
difference from one year to the next. And so now we're measuring life expectancy, probably still in years, but not probably in decades, and as time goes by, that kind of failure of energy and difficulty doing things is noticeable. Within one year, it's a noticeable length pine month. We're measuring now in months, perhaps in a month to make a year also, and gradually that trajectory changes, and always
people think there's more time than there is. So given that we're all mortal, I think it's really really helpful if we stop talking about dying long before we need to, because our families generally are not upset that our death
is imminent. If we stop the conversation earlier, so my family know what kind of funeral I'd like, and what kind of language I'd like, and much more importantly than my funeral, preferences my living while I'm dying, preferences where and who the important people are, and what are the important things to have completed pied there, and what the noises around me should be. Some people may end up
my playlists. I'm a fan of thoughtful silence a lot of the times, So I don't want nursing stuff that I don't know to play their radio tunes at me while I'm in that important time of my life, you know. So these are the sorts of things for people to start to think about when they gather for a family gathering. And there's a really lovely game and I wish I could remember and if I can remember us sending people
to show notes. They came for somebody in the USA, which was for Thanksgiving dinner, to ask the people around the table three questions and it was their desert Island. That's probably not doesn't translate acros the Atlantic. We have a show called Desert Island Discs the seventh It does American to a desert island. Right, So their Desert Island books or discs or whatever. They're absolutely favorite dinner and their favorite pizza topping. Yeah, and everybody, this is the
gathering of the people who are closest to us. In families, they get each other's answers, and they never get each other's answers right. And then you turn the questions over and the questions are are those ends of my care questions? And you think, if people don't even know each other's favorite pizzas or things, how are they possibly going to
guess the answers to these questions. And so it's an invitation when the family is cavered, and because it's a little bit funny that we've all got these questions so wrong to just maybe take two or three of those questions and have a think about the answers, not because we need to, but because we actually, right now, thank goodness, don't need to. But it's a gift to each other that we have.
It's interesting because when I think about death, of the question to me would be, well, you want to be buried, you want to be cremated, you want to and I usually say, like I could care less. However, you make the point that there's a lot of time up towards
death that I may care a lot about. So, for example, in my case, since I have mesophonia, aversion to sounds, no one should be allowed to chew in the room where I'm done, where I'm dying, each your food in the hallway, I can't move and I'm just you know, I'm tormented by sounds like that. You say in the book that there's usually little to fear about death and much to prepare for.
I think that we fear it so much that we don't start the preparations, And it's absolutely the other way around that, actually, So first of all, the intention of the book is to decatastrophize dying and re familiarity people with its predictable and relatively gentle processes, and then to start to think about, well, if that's what's going to happen. Now you know that it's likely to be like that, let's think about where might that be able to happen.
It doesn't help to happen in the hospital. It doesn't have to happen in an intensive care unit. You might no longer be able to manage the stairs in your home, but you might really love snuggling down in your big sofa, or you like envisage that. Actually, when I get to the end of mine life, I'm going to go and be careful by my daughter. Really have we discussed that with your daughter, because the last time I looked, your daughter had three dogs, two criquetes and five children under
the age of ten. How's that going to work for you? Or where's the bathroom in your daughter's souse relative to the bedroom that you would use? Which if the kids won't be able to use their own bedroom for the duration of the time that you're living in their own And it's just meant to stop people from making assumptions and is there two have those conversations and if you know the process, then you can work out, Okay, how
much of that process? Could I actually live just in the place that I normally enjoy living and have control over my life? What extra help might son need? Where could I get that help? Is it going to be from friends and neighbors? Can I come from service as I pay from what will the state? Probably for me? Lots and lots of things to think about. And then that particular thing that you have said about the soundscape around us, or about the way we're touched or the
way that we're held. There are people for whom touch is really triggering that they had experiences in their lives that have been terrible for them and perhaps spent a lifetime mending as lest they can from that other people. They need to understand that and how they are to be touched people who obviously, this is an absolutely great example of something you would never guess from having conversations with a person, although if you've lived with them from Lomula though.
People in my life know you guys really know. Yeah, and so to hundreds of thousands of podcast listeners.
But you see, because I didn't know I was drinking tea with the microphone open. That's fine, but it didn't occur to me, and it would have occurred to me had I known. So these things, aren't they of thinking about what do I need to know about this person? Is that there's a psychiatrist in Winnipeg and Canada, Harvey choching Off, internationally famous for his working paratan En of My Care for Dignity Therapy, and he has this question, what do I need to know about you as a person?
Panel does that I can give you the very best care that matches your needs. And that's the conversation in which each of us would discuss some things that would be very very similar for a person to person and then there's individual things with it. Oh right, okay, I was going to unwrap my cheese sandwich and sit next to Eric so that he didn't feel lonely while he was waiting to go in for that scam. That's not a good plan. I'm not going to do that now.
Or oh, you know, for a Catherine's eyeing in that room and it's completely silent like the grave. I'm must be terrified there. I'm going to put some cheinerful music on. Go what do you need? Not? What do I think you need?
I want to pause for a quick good Wolf reminder. This one's about a habit change and a mistake I see people making. And that's really that we don't think about these new habits that we want to add in the context of our entire life.
Right.
Habits don't happen in a vacuum. They have to fit in the life that we have. So when we just keep adding I should do this, I should do that, I should do this, we get discouraged because we haven't really thought about what we're not going to do in order to make that happen. So it's really helpful for you to think about where is this going to fit? And what in my life might I need to remove.
If you want to step by step guide for how you can easily build new habits that feed your good Wolf, go to Goodwolf dot me, slash change and join the free masterclass. One of the things that I think is hard about this planning is it seems relatively straightforward to decide what you want to happen once you die. My partner, Jenny's mother passed coming up on two years now, amazingly from Alzheimer's and we took care of her for about
six years. And one of the kindest things she did for us was when she was diagnosed, she took me to the funeral home and we did all of it. It was just done, you know. We just said to the funeral home, come get her and do what she said. You know, we had like two decisions to make, So that seems straightforward to me. What does not seem straightforward and I've got an aging mother eighty one years old, and what makes the planning hard, I think is I
don't know what's going to happen. I understand what's going to happen in the last weeks of her life. I understand that we've had Barbara Carnes on who does the sort of thing you do here? I think she's here in the US, and so I recognize the patterns of the dying process. It's that time before that. Is she going to have a stroke and need to be in a nursing care? Is she going to get dementia and that's going to be a different thing. Is she going to just I don't know what it means to die
of old age. When they say that, I'm like, what does that even mean? But that's the plan in that's hard.
You're absolutely right, And I think that if we think about the planning as a list with tick boxes, the list would be open, it wouldn't it. So I think we can turn the conversation a different way. We can say, at this stage and all of our lives, what matters most to us? Where do we get our joy? What brings us peace of mind? What are the conditions that help us to feel satisfied and calm and at peace during and by the end of each day? What matters most?
Or we can have those conversations, and actually they're delightful conversations to have because they're about the things that bring us joy. They're often about the people whom we love, who we're thrilled to see or to hear their voices
if they're far away. And that means that if in the future there's some kind of medical event that makes it difficult for the person there to express their wish, like they have a stroke, for example, instead if I'm your mother's doctor, as she's had a stroke, heave an offend.
Instead of saying, what did your mother say she would want to do about sheep feeding, having a ventilator, of living in a rehabilitation facility, Yeah, yeah, yeah, I can say to you, explain to me what matterisms do you want, because then I can talk with you about all of the treatment options we have. And what we can do is we can wrap the treatment options that are most likely to match what matters most to her. We can
wrap those around the care that we give her. So it might be for example, I have I looked after a lovely, very elderly lady with terrible respiratory disease who was on oxygen at home, and part of my work was to be a cognitive behavior therapist. And originally I'd seen her because she used to get parosystems of panic when she lost to bratt. She always thought this was the time I'm going to die. And she learned to
use copnitive therapy skills to manage her panic. She was gorgeous and I loved her, and she came to my clinic one day, and she always had this attitude that doesn't really matter how long I live. Now that I'm aged, it's the quality of my living what matters supposed to me. And that's an important question. Is it quality or is it length the time? What would you be prepared to put up with to eke out extra time compared with what you wouldn't be prepared to put up with, Because
it's the quality of living means the most. And she said, you know what a wonderful thing is going to happen. My granddaughter in Australia is going to get married, and I want to go to the wedding. And I knew that this woman who is using oxygen just soon help to walk from her living to her bathroom at home. On the level she is never going to be are to tolerate flying at thirty two thousand feet, that that is not the possibility. So how are we going to bring the joy of the wedding in to her life
when she can't be in Australia for the wedding. But the important part for our discussion here is she's changed the parameters of what she wanted. It's not a once and for all decision. She was wanting quality of quantity. Now she wants quantity. She'll put up with any treatment to be still alive when the wedding happens. So she is still alive when the wedding happens. And this is I can't remember now the twenty early teens, long before covid Weill, skype was the thing we all used to
talk to each other. So she skyped into this wedding. It's stupid o'clock in the morning in England. She's got her lovely clothes on, she's got her grandma as a wedding hat on. You know, it's fantastic. So she comes in. The next time I see her and she's gone back to we've heard the wedding. I'm going back now to it doesn't matter how long I survive. I just want good quality of life. And so it's flipped. And then the next time I see her and she's noticeably more
Praille the granddaughter is pregnant. So now by right, I want to see this baby bore. Now Actually she clearly now she is deteriorating month by month. We can see that she isn't going to live long enough to meet this baby. But again, what can we do to bring the joy of that and the knowledge of that, and the grannying of that, or the great grannying of that into her heart and soul of life and into her
family's life. So she gets knitting, and she's knitting fast and furious for the time that she's still able to. So there's this bunch of babycluths going to be posted halfway around the world to this great grandchild that she's never going to meet. But every time her granddaughter takes out, you know, a pair of mittens or a little cardigan or whatever, she's getting her grandmother's love out of the drawer. At the same time her grandmother's investments in her and
in her child who she's never going to meet. So if we're honest about the conversations, and if we focus the conversations on what matters most, we can use those as the stepping stones for the incidents that actually happen that we can't prepare for in detail, but once they happen, once an illness declares itself, once there's a critical treatment decision about do we do this or do we do that?
And the person's not well enough to say the information we need isn't a checklist or they will definitely want this or then definitely not want that. It's which of the decisions that we can make best matches what matters most to this person.
That makes a lot of sense. And can I request you to be my palliative care doctor?
Now?
Can I make that request?
Oh? Eric, you're very sweet and sadly I stopped work to do this work. I took only retirement some time ago now to do something about public understanding and dying. There was a particular incident talked about it in the book of Meeting. A family with a very very elderly dad with masses of medical notes for people who are listening to us, my hands so maybe twelve inches apart, just so many things wrong with him in his nineties,
and they have none of these conversations. And he was blue lighted into hospital having CPR, almost dead, and we had to have that conversation. And they've had no preparatory conversations at all. And I don't know how many dozens or more times I'd met families like that, but this was the family that broke me. This was the family where afterwards, I mean, we gathered things together and that dad was looked at bebutifully and he died very gently,
but they stayed with me. Somebody's got to do something about public understanding replying. Somebody's need to do something about the way Hollywood portrayed dying. Somebody needs to do something about the fact that the newspapers pick up the rare, the unusual, the difficult, they're true, that they're the exceptions, and now, because we don't understand dying, we grasp those
exceptions and think that's the normal. And gradually, over the course I would say probably six or eight months, it dawned on me that I have many stories to tell about ordinary dying. Storytelling is our ancient way of giving each other insight information ruston one knew that it had to be stories, and I knew I wasn't going to be able to tell the stories about even some discernment time.
So I stepped out of medical practice to make the space to think about how that could happen, and I miss being heart of my fantastic team, and I miss meeting those fantastic families at that really poignant telling you of people's lives. And yet this has been such a rewarding new way of working.
So I have a couple questions of curiosity, I think maybe more than anything else. But I'm going to indulge myself here. When we say someone dies of old age, what do we mean just something critical gave out, but it didn't have a diagnosed disease before it gave out.
That's such a great question. And around the world, I don't know. It's not always legal for a doctor to say that a person died of old age. Sometimes they're
required to give a medical diagnosis. In Britain. It is legal in England and Wales, which is our area of jurisdiction, to give a diagnost to die of old age, provided it's given by a doctor who's known the person for a considerable amount of time, and so the Queen Elizabeth the second death certificate is given by her general practitioner in Scotland as old age, so old age is a death from a condition called prayerty. Now the use of
the word praille in common pants. It has a particular meaning in this, and it's usually there this person, who may be aged, or who may be young and just unfortunate, has collected enough mini diagonosies, enough things not wrong enough with them to kill them. But the accumulation of those things now is a burden on their energy and on their well be And I have a colleague who describes
this a little bit like paper boats. You get a piece of paper and you do those special origamy folds that we can all do to amuse a small child, and you end up with a tiny little paper boat, and it's got crisp folds, and it's got flat paper, and it sits up and you can stick it on a bathtub, or you can stick it on the river nearby, and it sits up and it's crisp and it's clean, and it looks great. As soon as it touches the water. As soon as a little bit of water gets over
for the lip into it, it's weakened. And gradually the weakness spreads through it, and maybe there's a big ripple. Maybe you've put it on the sea on a calm day, and then somebody throws a pebble in nearby and a big splash lands on it, and it disintegrates. So it has a sense of looking hole, looking complete, and looking strong. If you tried to tear an oregon refolded paper boat,
it's really hard to tear it. But when it's on the water, it's completely vulnerable, and the water is life, and it's the next thing that comes along is the pebble that throws the water onto the little paper boat. And whatever is the weakest lenk now disintegrates and allows the other things all in sequenced to unravel. And if it had only been one thing wrong that would have been recoverable, but only been two, maybe three things wrong,
it could have been recoverable. But there are so many little bits of us not quite working well anymore that we're not well enough to recover. And so it's interesting to notice that over the age of eighty, if a person falls over and breaks their hip, their life expectancy on the day they break their hip is shorter than if they've been diagnosed with lung cancer on that day.
And it's not because they've broken their hip. It's because they fell and they couldn't right themself, and they couldn't catch themselves as they went down, and it's because of the way they landed, And that's all about the muscle strength and their bone strength and their coordination. And once they've suffered the injury, it's about the way their blood
clots or doesn't clot. It's about whether their lungs are strong enough to be able to sustain them for the anesthetic, their needs for the operation to correct the fracture or replace the hip joint. It's all of those tiny little things that mitigate against them. If a person is striding out across the road and they hit by a car and they break their head, that's different because they didn't
have befall. But there's something about the cumulative effects of aging in the body where the whole thing holds together until there's something that happens and then it just can't work any longer. So it's really interesting. There are photographs of the Queen at Bowel Moral seeing off the old Prime Minister and welcoming the new Prime Minister. And when it was announced that she was going to accept the resignation and receive the new Prime Minister at Bowel Moral.
When that was announced, I said to my husband, she's going to do tarein six weeks because she can't risk going back to London. She hasn't got the energy to go to London and get back again. This is an absolute steed change in her behavior. And we've seen the change in her behavior for some times. She'd been gradually delegating, always predictedly, started walking with a stick, had the massive hits of her husband of how of ellon sixty something
years they've been married. But then she started to delegate at the last minute to send apologies to things that she was actually fully expected at. So you can see that the rate of changing, the predictability is starting to shift. And then she didn't go back to London for the change of Prime ministers. And for those of us who'd been watching, the queen had been dying in clear sight for about two years, but newspapers covered it as though
her death was a surprise and was quite sudden. It wasn't at all.
That leads us into the idea that there is a predictable pattern. We've talked about it a little bit, but I'm wondering if you could walk us through in just a little bit more detail, what the predictable pattern of dying looks like I found this really helpful when Ginny's
mom passed from Alzheimer's. Even though Alzheimer's is different than other things, the actual dying process was exactly as people sort of laid it out to be, and it was really helpful to know, Oh, here's what's happening, and then this is going to happen, and so I'd love to give listeners that information.
Okay, so what we're talking about now is that very last part of living a variety of routes of getting to there. Maybe the frail person whose paperboat just folds over the previous week after looking okay ish for a long time. Maybe somebody who's been gradually struggling more more with heart problems, lung problems, accouncer diagnosis that seem really well held by treatment until relatively recently, that has now escaped whatever it is. But we're now talking about the endgame.
I suppose this is the equivalent of giving birth, rather than what the pregnancy was like beforehand. So when we're down to the last few weeks and days of life, there are some consistent things that we see. We see that people lose interest in the outside world. They become more and more focused on the equaling mattering those to them, the state of their own selves and often kind of retrospect about their lives and what it's all been about.
And they are doing the reckoning. Have they lived their lives according to their standards, and that might be the standards of a faithful world? That it is just evil environmentalism, whatever the thing that matters to them, the things that to them. See people losing interesting food, and that's really hard for families because we show people we love them
by feeding them. All around the world, we do this people who really have no appetite left because they gut is starting to just close down if it's not doing digestion effectively anymore. So if they try and eat that meal that their daughter has slaved from now to make, it's just going to sit like a lump and they're going to feel uncomfortable. And it's so hard. But we see families playing to dis way people to eat.
Can I ask a question about that part of it? Yeah, because that stopping eating is kind of a common thing. And the worry that I've had when I've been around somebody dying is that they're starving. And I mean the psychological condition of feeling like you're starving. Yeah, and it sounds like you're saying that's not really the experience that it seems like they're having.
No, it's fascinating. What seems to happen is that they have a face of hunger and they no longer desire to eat. And when you face them with a meal, they can look at it. They can see it's beautifully presented, and maybe it smells denicious, but just I already feel as I've eaten, I just don't want that. So the wisdom that I give to families is go for the volume of the teaspul tiny tastes that are just for pleasure, because people don't in the main die because they're not eating.
They're not eating because they're dying, and it's one of the signs that the process is evolving. So very often their taste buds will still appreciate just tiny taste of things that they've all those loved. So just in case you happen to be in tel when it's my turn, it's going to be baked rubile, please no ginger on it, but lots of sugar or elder flour, cordial and vanilla custard. Proper vanilla custard. That's my teaspoon. That's my tiny taste something for pleasure.
I think I want Mikey's Late Night Slice pizza with a little bit of crush the red pepper on it, and Ginny's Banana cream pie.
Okay, so that's clear. So you're allowed to teaspoons then, because that's very specific and they're not going to taste together on the same spoon.
Very good now that those are going to be different events.
So gradually the body is showing us that it's changing less appetite, less energy, and the energy failure is a really interesting bit because the bit that replenishes lost energy now isn't eating and drinking. It's sleep as something in you. So you will see that the person will drop off to sleep. Now, for people who are listening to us who light their afternoon nap, and I'm one of those, I'm not talking about the nap that you've planned and
you're looking forward to. This is a kind of nodding off in the middle of a conversation that is just irresistible. Person will sleep for a while, they'll wake up, it will recharge their batteries, they'll have a bit of energy to do something for a while, and then they'll fall back to sleep again. So it's almost like, you know, a mobile phone with one of those old batteries that didn't used to hold its charge, a bit like that.
And as time goes by, the periods of time spent sleeping lasts longer, and the periods of time awake that they buy lasts shorter. And also it's important for people not to be frightened by a thing that isn't uncommon, which is people getting a little bit stuck between sleep and awake, which has happened to all of us, where you be deeply asleep and your alarm goes to waking you because it's work time, or particularly it happens when you know you've got an early flight and you set
your alarm so you don't miss it. So you're a waking at a different time from usual, and in your dream the noise that's real, that's the alarm, becomes a feature of the dream. So you start to dream about fire engines and there's a fire somewhere, and then as you waken you realize, oh no, no, I was dreaming that there's a fire. Where's the fire engine? What's going on here there's a fire engine in my room. And then you waken enough to say, no, this is my alarm.
I can turn it off. But there's that moment of being trapped between the things that are real in the room, the noise, and the things that are not meaning your head, which is the dream about the fire engines. And we call this modelness denverium, and there are lots of causes for it towards the end of life, but very commonly it's just being a bit stuck between sleep and awake.
And if it frightens the family and they start to be agitated, then the agitation communicates itself to the person, so they then think there's something to be frightened about, so they then become agitated too, so being able to say, oh, Dad, you're kind of talking to people in your dreams here. That's okay, it's fine. It's lovely to see them, isn't it. They'll have another cup of tea. Your voice stays calm, your meanness, faith calm. It doesn't wind it all up.
So as time goes by, we find the person is sleeping more, they're awake less, and very often that might need now that they can't wake up at times when they would have been taking medications for you know, some people have symptoms like paying breathlessness. A lot of people towards the very end of their lives have no symptoms at all. And it's really important to say that dying doesn't cause discomfort. The illness that they're dying from might
cause discomfort. Towards the very end of somebody's life, they're not just a sleep anymore. They're actually dipping in and out of unconsciousness. They don't know they've been unconscious, but we might notice it because a visitor came, or it
was medicine time and we couldn't waken them. And when they wakened later on, they come back up from deep unconsciousness through sleep back to being awake again, and will say, oh, we couldn't waken you at all, And they say, oh, you listen and tried hardument So being unconscious is not something that we realize is happening to us, which is
the clan's in the name space it. So towards the very end of people's lives, they're not awake, that they're not assleep, they are unconscious, and it's really important people understand that because otherwise they're afraid to go to sleep a time, and sleep is your most important ally for keeping you as well as you can be. Under the circumstances when the brain lapses into complete unconsciousness, there are only two things that's don't you. One is it can
still hear sound. I don't think whether it's still responds to it with misophonia. That's an interesting thing to speculate about, but we know that people do still hear sound. How we observe that people offering look more rested when the right voices of the room, or get a little bit agitated when the wrong voice is in the room. And we've seen people synchronizing their breathing to the live music
being played in the room. Really interesting that in the state of deep unconsciousness, hearing is probably still connected to our emotion system and our sense have come. So you will see nurses talking to people dying people, people who have head injuries or strokes and deeply unconscious, and the
nurses are still talking to them. That's why. And then the other part of the brain that's still working, is part of the controls are breathing, is now doing something that we normally never see, which is instead of kind of breathing that you and I are doing where we're not really thinking about slof breathing except I was talking about.
Of course, we are now thinking about our breathing. We're managing our breathing, so we're both thinking into microphones, so are being aware of not taking big issues sockey breaths As we do that, we're taking sufficient breath to speak a particular length of praise before we pause, take a breath, and the safe the next time brais and people who are listening to us are properly managing their breathing so their breath sounds aren't obscuring our voices coming into their ears.
So during normal life, will take breathing for granted we don't really think about it, but we can manage it now. In deep unconsciousness, the brain does primitive reflex breathing cycles and they look and sound peculiar. They go backwards and forms between very deep breathing that can be sighing. It can be coming out through the vocal cords, so there's a room noise and faster but shallower breathing, which can
look as over the person is breathless. So if you never seen that before then you need somebody who has seen it before to say to you, you know, this breathing is completely normal. Your dear person is deeply unconscious. This breathing tells me that they're beyond feeling distress from symptoms in their body. They're completely safe. They're dying, that they're safe, and that this is hard of ordinary dying,
and it's the last part. So once the breathing is changing like this, then we might be down to the final hours. Sometimes it's days, sometimes it's really short. So this is the time if you want to be alongside the person to sit there and bring your bring yourself a newspaper, bring your slippers with you, be a good visitor. So at home, in our houses, we don't normally sip locked tight next to the person, eyeble to eyebill, looking
at them, striking them. Do it not? In my house we kind of ignore each other in a loving kind of way most of the time. So how do you help families to feel peaceful around the death there? Do you remind them that actually, here we are. They can hear you, So why not chat to each other? Think about some of the funny things that have happened in the past. Think of somebody, how things that happened in
the past. Just tell them they're safe, that they love, they're doing okay, You're doing a great job of creating the safe space that this person can lead their life from. What's really fascinating is how often, despite the fact that this family's had a rotor, there'd be two or three people in the room the whole time. It's the one thirty second interval where everybody got called away at once
that the person stops breathing. Why does that happen? We just don't understand it, but it does seem to happen more often than can happen by a chance. Sometimes a person carries on to doing this terminal breathing for a very long time, and then the person they've been waited to arrive from around the world, they arrived, their voices in the room, and within minutes their breathing is just very gently slowed down and stop. Because there's nothing special
about the last breath. It's not Hollywood. During all of the periods of breathing, usually shallow breathing, there'll be a breath out, just have another breath in afterwards. So people don't suddenly sit up and you know, tell the family secrets or whatever. It's much much more gentle than that. There are occasional times when the person will rally unexpectedly for a few hours to a day, very closely before death.
But again, let's not leave those important conversations waiting for that time that's called the rally, because it doesn't happen to most people. Let's have the important conversations first. So we seem to have a little bit more control than we can understand about the moments of guast. It seems to be possible to wait for a while. It seems to be possible to wait till the room's empty, to be able to wait until the important news is broken,
until the right person has arrived. But not everybody can wait, and sometimes too feel dashed around the world only to arrive and it's just a few minutes too. But usually the family have said, you know, Susie's on her way, dad, and just knowing that Susie's on her way has been the helpful part of the constellation at that time. So there isn't a right way or a wrong way of
doing this. I've seen families sitting around beds, telling jokes, ripping each other the way they always have, reminding each other of childhood fights that their dad told them off about while dad's peacefully dying. I've seen families singing souls. I've seen families using whatever other sacred scriptures of their tradition because that's the way their dad would have wanted it, or that's what their family tradition is. I've seen families who just sit in silence, maybe with their favorite show
tunes in the background. There isn't a right and wrong way of doing it, but always there's a sense of something very powerful is happening in that room, that there's a huge amount of love in that room also, of course, and difficult things are also in that room. No family is perfect. Every family's got those times that were difficult. They haven't gone away either. And so coming back to our wolves, we can feed that anger into the bad wolf. Oh,
we can say, okay, this is lasted long enough. We can let that anger go and we can feed the good wolf even there's a deaf bet.
Well, I think that is a beautiful place to wrap up. That was a very nice ending on your part. You and I are going to continue to talk a little bit in the post show conversation. I want to talk about palliative care because palliative care is more than just hospice care, and I want to explore that. I think this is a really useful thing for people to know
about listeners. If you'd like access to the post show conversation, AD free episodes and the chance to support something that matters to you, go to one ufeed dot net slash Join Catherine. Thank you so much for coming on. I've really enjoyed this conversation, heavy as it is, it's been at.
Treat Thanks so much for aviting me.
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