With the End in Mind: Dying, Death and Wisdom in an Age of Denial by Kathryn Mannix - review by Wendy Moore

Wendy Moore

Facing the Void

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


William Collins 341pp £16.99 order from our bookshop

When my husband’s father was admitted to hospital with lung cancer in 1974, his doctors made no attempt to tell his family that the condition was terminal. His death came as a complete shock to his wife and her two teenage children – my husband, then eighteen, and his younger sister. Five years ago, when my mother was diagnosed with cancer, the members of her medical team were unfailingly honest about her terminal condition and went out of their way to ensure that she died at home, peacefully, surrounded by her family.

Those intervening four decades have seen a wholesale transformation in the medical profession’s approach to death and dying. Most healthcare professionals today are fully committed to ensuring their patients’ final days are tranquil and pain-free. A ‘good death’ is now the order of the day.

As a consultant in palliative medicine with forty years’ experience, Kathryn Mannix has played a critical role in this gradual revolution. But she believes we need to go further. Mannix argues that we should all prepare for our own deaths by developing plans for our last days and opening conversations with our nearest and dearest about how we want to die. Her book – a kind of self-help manual for a good death – is not a comfortable read, though it makes a powerful case for openness.

As a society we have become less familiar with death and dying due to people living longer and the development of treatments for previously incurable diseases during the last seventy or so years, Mannix explains. Death, she says, has become ‘increasingly taboo’: we have lost the vocabulary to discuss the inevitable and the ‘art of dying has become a forgotten wisdom’.

Encouraging us to begin those conversations, Mannix describes real-life death scenes with matter-of-fact candour. Most deaths follow a predictable pattern, with a gradual descent into more frequent sleep, followed by unconsciousness and ever-slower breathing until it stops altogether. ‘In fact, normal birth is probably more uncomfortable than normal dying,’ she says. To illustrate her argument, she describes some thirty case studies drawn from her long career – ‘offering the reader my eyes and ears, my seat at the bedside’ – with empathy and humour.

These stories are poignant testimonies to the way professionals can work together with families to ensure the end of life is managed in the best possible way, though they are no less heart-rending for that. One patient, a retired head teacher, is anxious that his family will not be able to cope with his death too close to Christmas, so the hospice team brings Christmas forward to November and arranges a traditional dinner, complete with party hats and flaming pudding. Another, a young father with end-stage cancer, is given help to manage his symptoms so that he can take his sons on a final fishing trip. In other cases, hospice staff help patients to deal with their anxieties, talk to their families and arrange practicalities – from homing a reclusive man’s beloved cat to buying a wedding dress for a patient’s daughter. 

Reading these accounts, it is hard to avoid the conclusion that fate deals some people an unutterably rotten hand. There is little cheer in the story of a smiley teenage girl with leukaemia who sews a patchwork memory cushion to console her mother after she has gone, or of the young man who has had to prepare for his death since the age of twelve. Mannix closes the door when each patient dies, but the pain continues for those left behind.

Occasionally Mannix’s advice on preparing for death, which includes a template of a letter to write to loved ones, can seem a little patronising. As her stories eloquently demonstrate, everyone is different in death as in life – there is no template for dying. But with its combination of reassuring pragmatism and clear-sighted honesty, her book will make a valuable contribution to our understanding and acceptance of the certainty that awaits us all.

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