Mannix, Kathryn. With The End In Mind: Dying, Death, and Wisdom In An Age of Denial. Little, Brown and Company, New York. 2018
Kathryn Mannix writes with honesty and tenderness as she relates the stories of her career as a palliative care physician in the UK. Mostly, they are other people’s stories, but they are her stories too as she has worked with each person living within limits continually redefined by their illness. As much as this is a book about people who are facing the end of life; it is also a book about living, and living well right up until the end. Having said that, it is not an easy book to read as Dr. Mannix brings each patient right to the heart of the reader. Even when you know you are reading about the end of life; even though you know the book is supposed to show us the possibilities of grace and joy within grief; and even though you know medicine has limits, you do what all humans do, hope for a miracle; pray that just this once the story will be about a cure.
But, in the end, there is no cure for our eventual death.
Each chapter begins with a brief paragraph that serves to introduce the story that will follow; for example, the section Naming Death has seven stories or chapters, and prior to telling each story we are given something to think about from the author. The chapter “Every Breath You Take (I’ll Be Watching You)” is introduced as follows:
“The process of dying is recognizable. There are clear stages, a predictable sequence of events. In the generations of humanity before dying was hijacked into hospitals, the process was common knowledge and had been seen many times by anyone who lived into their thirties or forties. Most communities relied on local wise women to support patient and family during and after a death, much as they did (and still do) during and after a birth. The art of dying has become a forgotten wisdom, but every deathbed is an opportunity to restore that wisdom to those who will live, to benefit from it as they face other deaths in the future, including their own. “page 145
So with the dying process in mind we get right into a story of waiting for a patient, Patricia, to die, and wondering if she will stay alive long enough for everyone, who is deemed significant to her, to arrive and gather around their beloved mother and grandmother.
“The art of dying has become a forgotten wisdom,” writes Dr. Mannix and we might wonder what wisdom around death looks like? She is not suggesting we have forgotten how to be brave or that we should face death heroically, but rather that most of us do not know the bodily process of dying, and this lack of knowledge keeps us from accompanying our loved ones. Many people simply turn away from death as if not acknowledging the dying of a loved one will protect them or somehow change the inevitable. As if hoping for a miracle and dealing with reality were impossible to hold together in one hand.
Dr. Mannix handles each end of life story with absolute care. You feel as though you are right alongside her listening to her patients with all her heart as she seeks to find the best way to make each end of life a life lived to the fullest. The people in each story grow in courage as they learn to live within an increasingly narrowing range of abilities, and, at the same time they experience a transcendence and freedom from their own limited definition of what it means to live a joyful life. While these stories are not easy to read; they do impart wisdom. By the end of the book, you find you are not so afraid; not so surprised that death comes; and more curious of the process.
While Dr. Mannix advises us to be honest about death — she has a chapter on how she talked about death with her own children — she does not advise callously confronting those who are unable to deal with a terminal illness. She, in fact, has a whole section on coping mechanisms and shares stories of persons who could never fully acknowledge they were going to die. What she teaches in this book is that the person who suffers takes the lead; sometimes knowing you are going to die does not need to be voiced. Perhaps it is a little voice inside of you, and you just cannot cope any other way than by denial; so you talk about beating cancer. Dr. Mannix asks, at the beginning of Never Letting Go, a chapter about Sally who copes by insisting, when all the evidence points to no cure, she will come out the victor, “Is complying with denial telling lies, or respecting the person’s choices?” It is complicated. How should one face death? In Sally’s case, she needed to think she could beat it so that she could endure it. The end of life is not the time for an intervention from concerned loved ones.
I read this book slowly, one or two chapters in a section at a time in order to give myself space to hold each story so that I could grieve for each person and for my own life that will someday end.