With the End in Mind: Dying, Death andWisdom in an Age of Denial by Kathryn Mannix
When John Keats was dying of TBin Rome, just 25 and far from family and home, he wrote a series of beautifullyjudged, empathetic letters of farewell that deal lightly (yet never falsely)with his physical suffering and his emotional anguish. From the shrinkingcircle of his life, from his frail body drowning in itself, he reached outwardstowards the friends he was leaving. In his final letter, he wrote of living a“posthumous existence”; his last phrase becomes his eloquent, courteous andself-effacing goodbye before he exits the stage on which he has had such asmall parcel of time: “I always made an awkward bow.” Dying as a performance,dying as an art and a practice, dying as something solemnly profound andsorrowful and at the same time as normal, natural; dying as physical and asspiritual; dying as the end of a whole world because, as OliverSacks wrote, when dying himself: “There is noone like anyone else, ever.”We live in our bodies and die in our bodies. In previouscenturies, death was familiar and not hidden behind institutional walls: beforethe 20th century, there would have been scarcely an adult who had not seentheir parents, some of their children, and their friends die. Moreover, therewas faith that it was not the end. People witnessed death, dealt with it,prepared for it, even embraced it (John Donne used to sleep in his owncoffin; Jeremy Taylor wrote his 17th-century manuals for the soul, Holy Living and Holy Dying,which became the preeminent works of the ars moriendi tradition;in TheTempest, Prospero consigns himself to an old age in which everythird thought will be of death). Now, although we live with the sense of ourown ending, we don’t really. We know we’re going to die, but we don’t know. Ourbody doesn’t know, except in dizzying moments of terror, until the sentence hasbeen uttered and the gallows are being built under the window. Even then, deathis often held at bay and life prolonged at all costs: the fragile anddisintegrating body is plugged into machines, pumped full of oxygen and bloodand drugs, its gallant heart restarted and kept going, no matter the pain, nomatter the hopelessness of the endeavour, no matter that at a certain pointthis isn’t living, just a slowed-down, drawn-out, painful and undignifieddying.
It has become easier to live longer, but harder to die well.Most people want to die at home; most die in hospital. Most want to be withfamily; often they are alone or with strangers. “Their death has been stolenfrom them,” writes Seamus O’Mahony in his bracing and unsentimental account ofdying, *The *Way We Die Now,which charts how something that used to be public and acknowledged, with acommon script, has become an aggressively medicalised and bureaucratic processplaced in the hands of experts; sometimes banal, sometimes farcical, sometimespainful or undignified. Modern, sanitised death becomes a dirty little secret,almost embarrassing: our language circles round it, we don’t like to name it,cross the road to avoid those recently touched by it, and shy away from thephysical, squeamish fact of it, so that the dead body is whisked away,frequently embalmed (for fear of its smell), cremated in “facilities” that areoften in industrial zones.
Have we lost our way with dying and with death?In the last few years, there has been a crowd of books by doctors, scientists,writers and people who are scrutinising their own departure that have sought toshow us different, kinder ways of ending: Atul Gawande, Oliver Sacks, HenryMarsh, Jenny Diski, Tom Lubbock, MarionCoutts, Paul Kalanithi, the luminous final poems of HelenDunmore… the list is long. Behind them all standsthe austere, magisterial work by Sherwin Nuland written in 1993, How We Die. Now Kathryn Mannix joins this distinguished group and hervoice, though quiet and calm, is distinctive. A palliative doctor (or“deathwife”), she spends her days with the terminally ill and their families,witnessing and supporting them at times of intense suffering, terror and loss.About a quarter of deaths are sudden and unexpected, but she usually sees theones that come slowly, over months or years, and while much of her work isdiagnostic and medical, one of her crucial tasks is to help those who are dyingand their families find ways of dealing with life’s final, great event.
With the End in Mind: Dying, Death and Wisdomin an Age of Denial is Mannix’s account of ways of dying, through a seriesof vivid stories, most of which disguise the protagonist, some of which arecomposite tales stitched together from several cases, and all of which areheart-wrenching testimonies to human courage and love. Her purpose is todescribe many forms of death – the young man with testicular cancer treated inthe room dubbed “the Lonely Ballroom”, the dying mother in the hospice whomanages to walk her daughter up the aisle, the 22-year-old with cysticfibrosis, the teenager with leukaemia – and to show how in each case, while adeath may be emotionally harrowing, it need not be intolerably painful; whileit may be tragic, it need not be ghastly or full of the chaos that accompaniestoo many ends.Like those romantic portraits of Florence Nightingale holdingher lamp aloft as she walked between beds of maimed and dying soldiers,Mannix’s aim is to shed a soft, clear light on a subject she feels is too oftenavoided. She wants us to think about what dying and death mean for others andfor ourselves and take the fear and recoil out of the subject. Mild, tender andconciliatory, she is punctiliously even-handed. If one story shows how denialis toxic and the truth needs to be gradually and gently revealed, in anothershe demonstrates the usefulness of denial; if one describes how precious timecan be won for a patient, another is an example of how prolonging life can becruel and death a necessary kindness. One person’s good death is not another’s– we all need to find our own way to take our bow and leave the stage.I agree with almost everything Mannix says; I would like her, orsomeone like her, to be my compassionate, wise doctor when I lie dying, easingme out when my time has come. Yet in her desire to show that death can be wellmanaged, she leaves out the mess, fear, pain and unpredictability of so muchdying – its scandal, its wildness and its impossibility. Not all passing can begentle and not everyone can be brought to acceptance in the face of their ownobliteration. However we dress it up and think about it, death remains blanklyungraspable and stark.
Animals perish; only humans die – because weare creatures who are aware of our own mortality. This awareness, which canfeel vertiginous, unendurable, is also what gives us selfhood, and life shapeand meaning. “Death destroys a man; the idea of death saves him,” wrote EMForster. It’s the great nothing; the everything, which makes us and unmakes us,and to which we all come in the end. Nothing is more certain; nothing morebewildering, strange, scandalous, downright impossible, forever true.
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