0:01

Ted Audio Collective. Hey

0:12

listeners, it's Ted Health and I'm Dr.

0:14

Shoshana Ungerleiter. In a

0:17

world fixated on prolonging life,

0:20

we often overlook the profound journey

0:22

of its final chapter. In

0:25

her TEDx New Castle talk, palliative

0:27

care physician Dr. Catherine Mannix

0:30

invites us all into a

0:32

crucial conversation about life, death,

0:36

and the poignant moments in between. Blending

0:39

empathy with expertise, she

0:42

explains how modern medicine has helped

0:44

us and failed us when

0:47

it comes to confronting death, and

0:49

she offers insights that reconnect us

0:51

with a long-lost wisdom. Then

0:54

join me after the talk for

0:57

my own personal story of

0:59

how one patient's death changed my

1:01

life forever, and led

1:03

me to found endorwellproject.org, a platform

1:06

dedicated to making end of life

1:09

a part of life. The The

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in all states and situations. Human

2:51

beings are

2:53

the only animals capable of

2:55

contemplating their own mortality.

2:58

And they've been doing that for

3:00

thousands of years. And

3:04

yet somehow in the

3:06

very recent past, we

3:08

have lost the practical wisdom

3:11

of what happens as people die.

3:16

I think that that's a problem. And

3:19

if you agree with me that it is a problem, then

3:22

we have to work out what we're

3:24

going to do about it. When

3:27

she was in her mid 20s

3:29

in the 1920s, my

3:31

grandmother was already deeply

3:34

familiar with the sequence of events that

3:36

happened to a human person as they were coming

3:38

to the end of their life. And

3:41

that's because as a woman, and it

3:43

was usually women's work, she was doing

3:46

what women had done for centuries. Looking

3:49

after people at the very end of their life

3:52

in their own beds, in their own homes,

3:54

supported by their own people. Because

3:57

hospital had nothing to offer once

3:59

a person dies. was so sick

4:01

that their death was imminent. And

4:05

yet, when I reached my mid-20s in

4:07

the 1980s, I

4:11

had none of her wisdom and

4:14

understanding and knowledge of dying. And that

4:16

was even though I'd just finished five

4:18

years at medical school. As

4:21

a newly qualified doctor, I'd spent five

4:23

years being trained to stop people

4:26

from dying. And

4:29

actually, if a death happened, it

4:32

was a thing that was seen as a medical

4:34

disaster. It was a thing that was

4:36

embarrassing. It was a thing of which we do

4:38

not speak. Why

4:43

the difference? And why within

4:46

just a couple of generations? Well,

4:49

think about what happened to medicine over the course

4:51

of the 20th century. It

4:54

was not worth going to hospital when you

4:56

were dying in the 1920s. But

4:59

by the 1960s, 70s, 80s, and onwards, think

5:03

of the fantastic progress that had

5:06

been made. So that people who

5:08

were so sick that they might

5:10

die, of course we took them

5:12

to hospital. Because there were antibiotics.

5:14

There were really clever anesthetics that

5:16

allowed surgeons to spend a long

5:19

time unpicking things during operations. There

5:21

were new and very sophisticated treatments

5:23

for cancers, for heart failure, for

5:25

kidney failure. There were intensive care

5:27

units. There was transplantation

5:29

of organs, some of that pioneered in

5:31

this very city. Medical

5:34

progress was astonishing. Taking

5:37

dying people to hospital very often

5:39

saved their lives. And that is

5:41

fantastic. And

5:47

yet, by taking dying people out of

5:49

home and putting them in hospital, we

5:52

changed our understanding of

5:55

the process. We

5:57

lost our ownership of the process

6:00

leave it to healthcare and

6:02

we forgot what dying looked

6:04

like. So

6:08

having been qualified for just over four

6:10

years, I find myself in

6:12

a new job. Having originally

6:14

intended a career in cancer medicine, I've

6:17

spent the last four years choosing to

6:19

train in the places where the most

6:21

sick people were. And

6:24

then I realized that actually what was really interesting

6:26

to me was the

6:29

detective journey of symptom management

6:31

and the emotional integration

6:34

of feeling well enough to live a little

6:36

bit during the very end of life. And

6:38

I went to work in a hospice. But

6:42

I'd been working in a big teaching hospital,

6:44

I'd learned a lot of medicine, I'd seen

6:46

a lot of dying. We

6:49

had a patient in the hospice. She

6:53

was a memorable woman for many reasons.

6:55

She had been a member

6:57

of the French resistance during

6:59

the second world war. She'd

7:01

married a British airman, she'd come to

7:04

live in England. She'd never lost

7:06

her French accent. She

7:09

had a cloud of

7:12

glorious white hair like a halo.

7:14

She had piercing brown eyes, the

7:16

kind of gaze that you feel

7:18

a person can see your soul.

7:21

She was self-contained, she was a

7:24

little bit aloof. In fact, she

7:26

was a little bit scary. One

7:29

day she told the nurse who was looking after her

7:32

that she was terrified of dying in agony.

7:36

Because if she were to die in agony, she

7:38

might despair in God. And if

7:40

she were to despair in God, as

7:42

a French Roman Catholic, her belief was

7:45

that that would be a mortal sin, so

7:48

she would not be able to go to heaven. And

7:50

heaven was the place she knew

7:52

her husband was waiting for her. This

7:55

was a profound existential

7:57

distress. And

7:59

my body was said, well, we need to go and

8:01

talk to her. You should come. You'll find this interesting.

8:05

I was 26. Do you remember 26? It's

8:08

that kind of age, the last age when you know that you

8:10

know everything. So

8:13

I went along wondering what I might learn, because I

8:15

thought I was quite good at pain control. That

8:19

conversation changed

8:21

my life. It

8:23

changed my career. And

8:26

it's brought me here. Sitting

8:28

on her bed with me on a little

8:31

hoodstool so I can see him and her

8:33

and the nurse sitting on the chair, he

8:36

said to her, I'm concerned

8:38

that you've got worries about

8:40

what might happen if you're dying. And she said,

8:42

yes. She knew him well. She trusted him. And

8:45

he said, I'm sorry to hear that. And I wondered whether

8:48

it might help you if

8:50

I described to you what usually happens as

8:52

a person is dying. And

8:55

I'm sitting on the stool of all knowledge thinking, well,

8:57

you can't tell her that. Because

9:00

I've seen lots of dying. And I know they're all different. And

9:05

she said, yes, please. And he said, well, I'll describe

9:07

what we usually see. And if it gets too much,

9:09

you tell me. Promise I'll

9:11

stop. The

9:14

thing that's really interesting, Sabine, is

9:17

that as people are dying, it doesn't really matter

9:19

what the illness is that they're dying from. The

9:22

pattern of events is very similar.

9:25

We see people becoming more and more tired.

9:28

It's harder and harder for them to find the

9:30

energy to do things. In

9:33

fact, they recharge their energy not so

9:35

much by eating and drinking, but by sleeping.

9:39

And as time goes by, what we see is that

9:41

people sleep more. And they're awake

9:43

less. And if they want to do

9:45

something important, they should take a snooze before it.

9:50

She nodded. And she got hold of his hand. As

9:54

time goes by, he said, we see people

9:56

are asleep for longer, they're awake for shorter.

10:00

something interesting we notice that they don't is,

10:02

maybe it's medicine time or there's a visitor,

10:04

we need to waken them. For

10:07

a period, we can't waken them. They're

10:10

not just asleep, they're

10:12

actually unconscious. And

10:14

when they waken, they tell us they've had

10:16

a lovely sleep. It turns out that human

10:18

beings don't recognize when we

10:20

become unconscious. And

10:24

so at the very end of somebody's life,

10:26

they're not just asleep,

10:28

they're actually deeply unconscious. And when the

10:30

brain is unconscious, the only part of

10:32

it that's still working is

10:35

the part that's working their breathing. By

10:37

now, she is sitting right up in bed.

10:40

She's got hold of one of his hands

10:42

and she's stroking it. She's

10:44

nodding at everything he says.

10:47

And in the meanwhile, I'm sitting on my

10:49

stool, horrified that he

10:51

seems to be describing dying to

10:54

a dying person. And that feels

10:56

to me to be really not

10:58

very okay. But

11:01

she is mesmerized. By

11:04

the time the brain is deeply unconscious, he's

11:06

saying to her now, the only bit that's

11:08

still working is the bit that drives the

11:10

breathing. And so breathing cycles

11:13

we don't normally see start

11:16

to happen, reflex, automatic breathing,

11:18

cycles from very deep breaths,

11:21

becoming shallower and shallower, and then going back

11:23

to the beginning again. Cycles

11:25

of fast breathing that gradually

11:27

become slower, maybe with

11:29

pauses, and then back

11:31

to the beginning again. The person can't

11:33

feel their throat. They don't notice if

11:36

they breathe out through their voice box.

11:38

Making a noise, families might think that

11:40

they're sighing or groaning or uncomfortable will

11:43

always check. And it's

11:45

part of this reflex breathing. Saliva

11:49

or mouth cleaning fluid won't irritate

11:51

their throat. It won't make them

11:53

cough or swallow. They Just

11:55

lie there with a little pool of fluid sometimes at

11:57

the back of their throat. It's not in the way.

12:00

Air is moving isn't as if their

12:02

lungs and it bottles through that little

12:04

ceylon. the fluid that families can mistakes

12:07

that for training old so kings and

12:09

one of the things that will disappear

12:11

if your nieces and nephews are here

12:13

is we will make sure we explain

12:16

to them. Was is happening

12:18

to you. She

12:22

stressing his hands she's not saying

12:24

she is absolutely teaching and everything

12:26

that he says. And

12:30

then he says and I think oh my

12:32

goodness. He's going to the last breath. And

12:36

then during, easily one of those

12:38

faces of slow freezing. They'll

12:41

be a breath out. That.

12:45

Just isn't Followed by another press

12:47

in. There is nothing

12:50

special about The Last Breath. It

12:52

so not like on the television.

12:55

Or in cinema. There's. No

12:57

rush of pain at the end. this

12:59

know sudden panic. There's no ceiling of

13:01

saving away. Sometimes we who work him

13:03

how he sipped have a my subsequently.

13:05

Delivered discovered this to be true

13:08

sometimes. We will walk into. The room

13:10

where family has been around. A

13:12

person who is in the act is

13:14

dying and will realize the person has

13:17

stopped breathing. And the

13:19

family hasn't noticed yet because

13:21

the Hollywood Sinhalese that they're

13:24

waiting for hasn't happened. She

13:32

got hold of both says his hands.

13:35

She. Shook them in has and then

13:37

she pulled his hands to have

13:39

space and she says them. And

13:44

then see sense to eyes. She

13:46

laid back on her pillows. I'm

13:49

just watched, relax, And

13:52

in her own inadmissible.

13:54

Until this way, she told us that we

13:56

were no longer required. A

14:01

my boss at me are you okay

14:04

I said yes and. The went to

14:06

the kitchens, blow my nose and dry

14:08

my eyes and sync up for. Tends.

14:13

To choose ideas exploding in

14:15

my brain that the same

14:17

time one is. How

14:20

have I never noticed that? That

14:24

says and he just explained

14:26

I have seen. Hundreds

14:28

of times but I was the most

14:31

junior doctor. It was my job to

14:33

stop the person dying remember So I

14:35

was so busy worrying about this process.

14:37

Oxygen levels on that person's polson, this

14:40

person's kidney function that it is come

14:42

back. And see that this

14:44

person. Going on here. We.

14:47

Can describe the process of ordinary

14:50

human delaying and it's as much

14:52

a process as the process is

14:54

giving. First is it has saved

14:56

his. We can recognize them, we

14:59

can pace ourselves, we can work

15:01

out where we are in it.

15:05

But. Even more fascinating.

15:08

Was that realization from what's

15:10

things have been? Swinson. That

15:13

we can describe ordinary

15:16

tying to with dying

15:18

person. And

15:20

it's signs, the lights of understanding

15:22

of information into that dark place

15:25

where all S. C is and

15:27

imagine a similar. At place. I've

15:32

gone on in my career and potty sucker

15:34

for have that conversation. Thousands of

15:36

times cancer signs I always have

15:38

to stop. I've

15:41

never. Been. Stuffed. But

15:44

what happens at the end? Is

15:47

that relaxation? that moment? Of.

15:50

Well that isn't what I was expecting. Followed

15:53

old and almost immediately by: Can you Tell

15:55

My Family That? Can You Tell My wife,

15:57

My husband, My kids? My. Parents. That's

16:00

not what we were expecting. I'm I

16:03

think we can do that. For

16:07

losing the with them. Really?

16:09

Messes. And we

16:11

can't leave it see palliative care

16:13

people or even medical people to

16:16

reclaim that last western one. Somebody

16:18

at a. Time. This is

16:20

a massive social public health

16:22

issue. And

16:24

I invite everybody his listening. To

16:27

step up. The reason

16:30

my grandmother understood about dying wish

16:32

that she'd seen it alongside people

16:34

he knew it to described her

16:36

as the process was happening, what

16:39

she was seeing so that she

16:41

would understand. And not be afraid.

16:44

And it requires all of us who

16:47

are mortals. All. Of

16:49

us who love other

16:51

immortals to step up

16:53

to say enough. says.

16:55

Is not a medical? defend

16:58

his the Socialists and it's

17:00

a deeply personal events. And

17:03

we can understand that. we can

17:05

describe it. We. Can console

17:07

each other. We

17:10

can accompany each other.

17:12

we can reclaim saying.

17:15

Census.

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This. Show is brought to buy swab.

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fear factor meals that com/ted health fifty to

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get fifty percent on. That

19:08

was Catherine. Mannix attacks Newcastle.

19:12

You know I'll never forget the

19:14

day I was still green for

19:16

medical school when I met a

19:19

peace since in the emergency. Room

19:21

We're going to call him

19:23

Mr. Jones. He

19:25

was an older man who'd been

19:28

a university professor, and he had

19:30

a life story that could sell

19:33

and novels. By. Be

19:35

here. He was frail

19:37

and scared. He

19:39

had lung cancer. His

19:41

family was huddled in the corner

19:44

nearby and I knew they were

19:46

all really scared. Heat.

19:48

Arrived in the emergency room with

19:50

severe shortness of breath. This.

19:53

Left him. Unable to

19:55

walk even short distances. So.

19:58

i looked at his labs and a suspect I

20:01

noticed that fluid had built up in

20:03

his lungs, which was a grim sign

20:06

for someone with his kind of cancer.

20:09

Mr. Jones was a kind man.

20:12

As we talked about his symptoms, this

20:15

really beautiful rapport developed between

20:17

us. I explained to

20:20

him that his condition had

20:22

gotten worse and that we

20:24

could make him feel better temporarily by

20:26

keeping him in the hospital. But

20:29

it was clear to me, his

20:31

cancer had advanced. I

20:34

took a step beyond the usual conversations

20:36

that I had with patients that night

20:39

and I ventured into some more personal

20:41

territory. I asked

20:43

him about his understanding of his

20:45

diagnosis and what he

20:47

envisioned for his future. Peers

20:51

started welling up in his eyes. He

20:54

said, I've had an incredible

20:57

life, a loving

20:59

family, and all I want is

21:01

to be at home with them. This

21:04

plea was simple but profound.

21:08

Can I please go home? All

21:10

I want is to be at home. And

21:13

as I talked to him, I realized

21:15

something crucial was missing from my medical

21:17

education. Sure, I

21:19

could read a chart, diagnose a disease,

21:22

but what about understanding Mr.

21:24

Jones, the person? He

21:27

wasn't just a case study. He was

21:29

a father, a husband, a

21:32

teacher. This

21:34

hit me hard. How

21:37

had I, and perhaps the medical

21:40

field in general, overlooked

21:42

this simple but profound

21:44

desire? This realization

21:46

for me was a gut pinch.

21:49

We're trained to fight diseases,

21:51

but sometimes the fight isn't

21:54

always what the patient wants.

21:57

Mr. Jones wanted to spend his final days

21:59

in peace. a home

22:01

not in the sterile environment of

22:04

a hospital room surrounded by strangers.

22:07

So with the help of a case manager

22:09

and a social worker, we were

22:11

able to get him home with

22:13

hospice care. And he passed away a

22:15

few days later in the place

22:18

that he loved most. As

22:21

I reflected on this experience, I

22:23

realized the importance of two key

22:25

elements in providing care that aligns

22:28

with patients' wishes. First,

22:31

having early conversations about their

22:34

hopes and values. It's

22:36

critical. It's about

22:38

understanding their life goals and not

22:40

just their medical needs. Second,

22:44

the role of palliative care

22:46

is invaluable. This care

22:48

goes beyond symptom management. It's

22:51

about nurturing the patient's mental,

22:53

their emotional, and spiritual

22:55

well-being, and recognizing

22:58

that extending life is

23:00

not the only priority. And

23:02

palliative care should ideally start at the

23:05

time of a diagnosis, years

23:07

upstream from the end of life. Patients

23:10

like Mr. Jones, who engage in

23:12

advanced care planning, meaning making

23:15

their wishes known around serious illness

23:17

and end of life, are

23:20

less likely to spend their last days in a

23:22

hospital or receive intensive care

23:24

that may not add value to their

23:26

remaining time. Palliative

23:28

care has consistently shown to improve

23:31

patients' quality of life, and in

23:33

some cases, early palliative

23:35

care can contribute to longer

23:38

lives. For

23:40

their families, being involved in these

23:42

kinds of discussions can also be

23:44

incredibly healing, reducing

23:47

emotional strain and uncertainty.

23:50

Unfortunately, there's a real lack of

23:52

training in medical school on how

23:54

to gently deliver bad news or

23:57

how to guide patients through end-of-life care.

24:00

According to the Journal of the American

24:02

Medical Association, nearly 70% of

24:05

doctors feel unprepared for these

24:08

conversations. My

24:10

experience caring for Mr. Jones

24:13

was a moment that reshaped

24:15

my entire approach to medicine.

24:19

I began to wonder, what

24:22

if our first question to patients wasn't

24:25

about their symptoms, but

24:27

about their lives? What

24:29

if we started with, what

24:31

matters most to you, instead

24:33

of, what's the matter with you?

24:37

I've come to believe that a

24:39

patient-centered approach isn't just beneficial, but

24:41

it's essential, especially

24:44

in end-of-life care. The

24:47

conversations we're not having, the

24:49

questions we're not asking, they're

24:51

not just oversights. They're

24:54

missed opportunities to provide care that

24:56

aligns with what our patients truly

24:59

need and want. But

25:02

here's the thing, it's not just

25:04

about changing how we talk to patients, it's

25:07

about changing how we view them. They're

25:10

not just bodies in beds, they're

25:13

people with stories, fears,

25:15

hopes, and dreams. Sometimes

25:18

our job isn't to extend their life at

25:20

all costs, but to make

25:22

their remaining time, however long

25:24

that may be, as meaningful as

25:26

possible. Mr.

25:28

Jones and so many patients since

25:30

then have taught me that

25:33

ensuring a good death is

25:35

as important as ensuring a good

25:37

life. Because at

25:39

the end of the day, how we

25:41

care for the dying says a lot

25:44

about how we care for the living. And

25:47

maybe, just maybe, in helping

25:49

our patients find peace in their final days,

25:52

we'll find a little more peace on our own. That's

26:00

it for today's episode. Thanks so much for listening. Ted

26:03

Health is a part of the TED Audio

26:05

Collective. I'd love to

26:07

hear your thoughts about the episode. Send

26:10

me a message on Instagram at

26:12

ShoshanaMD. This

26:14

episode was produced by me and

26:17

Costanza Gallardo, edited by

26:19

Alejandra Salazar and fact-checked by

26:21

Vanessa Garcia-Woodworth. Special

26:24

thanks to Maria Lajas, Farrah

26:26

de Grunge, David Biello,

26:28

Daniela Valarezo, and Michelle

26:30

Quint. I'm Dr. Shoshana

26:32

Ungerleider, and I'll talk to you again next week.

26:42

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