Interview
Culture
Life & Death
8 min read

Rediscovering 'ordinary dying'

On the eve of her Theos annual lecture on 'Death for Beginners', Robert Wright speaks to former palliative care consultant Kathryn Mannix about the need for everyone to re-engage with the process of dying. Part of the Seen & Unseen How to Die Well series.

Robert is a journalist at the Financial Times.

 

A woman stands in an autumnal-looking park, with her hands in her pockets
Katherine Mannix.

Shortly after the late Queen Elizabeth died, in September last year, Kathryn Mannix, a former palliative care doctor, decided to point out something that had been going unremarked. Mannix, who spent 30 years in various palliative care roles in the North of England until retiring in 2016, wrote on the social media platform then called Twitter that the world had watched the late monarch live through a process that she called “ordinary” dying. But, she added, the dying had gone “unspoken, un-named”. 

Mannix’s 12-post thread pointing out what the world had been watching was to prove one of the most successful steps yet in her long-running campaign to refamiliarise the world with how people die, the signs that someone is dying and how the process works. The thread has been viewed several million times. Among the replies to her post, according to Mannix, were several from people saying they recognised from it that relatives were going through the process and they should prepare. 

Mannix hopes that her efforts will ensure people learn to cope better with their own and others’ inevitable deaths in ways that work better both medically and emotionally. 

“The queen’s death was no surprise to those of us who have been watching that process that we recognise as ordinary dying,” Mannix says, in an interview over lunch in Newcastle, near her Northumbria home. 

“The person got into hospital to have treatment to stop them from dying. When they died, that was a medical failure. That was an embarrassment.” 

Mannix will take another substantial step in her campaign on November 1 when she delivers the annual lecture for the religious think-tank Theos on Dying for Beginners. The lecture will revisit the lessons of her thread about the queen and two successful books about dying: With the End in Mind, recounting the lessons of her career in palliative care, and Listen, about finding the words for end-of-life conversations. All of her work has stressed the unhelpful aspects of medical practitioners’ increasing involvement in deaths. Doctors’ increasing power to prevent death in many circumstances and delay it in others has made it, in her view, damagingly unfamiliar. 

However, Mannix insists that, while the November 1 lecture has been organised by a faith-based think-tank, her principles are applicable whether people understand their lives through a spiritual prism or via something else like family, politics or art. 

“There are a number of constructs that give people meaning,” Mannix says. 

At the heart of Mannix’s message is the idea that death was once a familiar process that people knew how to manage. She argues that the last century’s medical advances changed that. 

“I think we’ve forgotten because over the course of the twentieth century life expectancies nearly doubled,” Mannix says. 

She points to a range of factors behind the shift, from improved sanitation and vaccination programmes to the founding in the UK of the National Health Service and the introduction of antibiotics. 

She dates the shift of dying from home to hospital to the second half of the twentieth century. 

“It was almost like dying was kidnapped inside hospitals then,” she says. “The process itself got slightly distorted by the medical interventions like intensive care units, so the process became less recognisable.” 

The key change, according to Mannix, was that death became “the enemy”. 

“The person got into hospital to have treatment to stop them from dying,” she says. “When they died, that was a medical failure. That was an embarrassment.” 

“It’s hard to have a conversation with a person who has no pegs to hang that conversation on. The current population has no idea about dying.”

Doctors started to keep in hospital people who would prefer to be at home with their grandchildren, in case there was one more thing they might try that would save their lives, Mannix says. 

“We need to celebrate that medicine can do so much more than it used to be able to do,” Mannix says. “But we need to remember that those achievements are only postponing dying. We’ve not cured death.” 

Clinicians need to recognise the point in illnesses where death becomes inevitable and speak to patients about their priorities for their remaining time, she adds. 

“Survival at all costs might not be what is most important to them,” Mannix says. “There may be things that they wish to fulfil.” 

Mannix is clear that the UK at least remains a long way from learning the lessons that she is trying to teach. She was prompted to write her thread about Queen Elizabeth’s death partly by the ending to a news bulletin announcing that the monarch’s family were rushing to her bedside at Balmoral. Mannix says the newsreader finished the segment, hours before the death was announced, by saying “Get well soon, ma’am.” She describes it as “a dreadful example of our death-denying”. 

She is giving the annual Theos lecture as the group is in the midst of releasing a suite of resources designed to provoke greater debate around death and dying. They include a video where Mannix explains the dying process. The group’s research paper Ashes to Ashes, published in March, showed that many British people had similar priorities for their own deaths and those of loved ones as set out in Mannix’s work. They wanted to be free of pain or suffering, surrounded by family, probably at home, to be reconciled to people and to be prepared. 

According to Mannix, however, even her fellow medical professionals feel poorly equipped to begin conversations with patients or their families about impending death. Many people had contacted her after reading With the End in Mind saying that they were convinced of the need for frank conversations about death but had no idea how to start them. 

“The feedback from doctors and nurses was the same as from the general public – ‘I don’t know how to talk about this bit’,” Mannix says. “’Nobody taught us about this in training’.” 

It is also a challenge for medical professionals that patients and their families are typically resistant to conversations about death, she adds. 

“The doctor doesn’t want to be the bad guy or girl and constraints in the NHS are such they can’t find time for the length of conversation that’s likely,” Mannix says, adding that many doctors are also unfamiliar with exactly how the dying process tends to unfold. 

“They’re not taught about dying,” Mannix says of trainee clinicians. “They’re not taught to see good dying as a good medical outcome and it could be.” 

Those conversations are all the harder, she adds, because society as a whole has so little conception of the process of death. 

“It’s hard to have a conversation with a person who has no pegs to hang that conversation on,” Mannix says. “The current population has no idea about dying.” 

In wider society, meanwhile, she would like to see far more communities taking the opportunity to support the dying. 

The questions fundamentally end up being spiritual or philosophical ones, Mannix says. She declines to be drawn on her own spiritual practices but describes herself as “spiritually curious”. She similarly declines to outline her position on the debate about assisted dying, saying that expressing a view on that would be a distraction from her primary purpose of promoting discussion of the ordinary dying process. 

But she says questions about how to manage death, whether to prolong life and the balance between quality and length of life inevitably raise “societal questions”. 

“We all want to think about our life being worth something and about the purpose that we think is the purpose of being alive,” Mannix says. 

Mannix hopes her campaign will prompt religious leaders to think more carefully about how they support families and dying people. In particular, she would like priests to acknowledge to those they are supporting that faith will not always banish fear and that the faithful will sometimes feel abandoned by God in the face of death. She would like to see far more thorough training for clergy throughout their careers in how to have such conversations. 

She would also like to see more clergy learn more about the process of death, so that they can reassure families about what they are witnessing – for example, that apparent gasping from the dying person does not indicate pain. She expresses optimism about the growth of civil society organisations – some based around religious organisations – seeking to encourage a more open discussion of death and dying. She speaks particularly warmly of the Death Cafe movement – where people meet for cake and coffee to discuss death issues – and the End of Life doula movement. End of Life doulas seek to shepherd people through death the same way that birth doulas assist women in labour. 

Both of those movements have a key role to play in bringing about the revolution that Mannix would like to see in society’s understanding of death and its role in life. 

Asked what a balanced approach to the issue would look like, Mannix says it would be “very helpful” if people were told at the outset when they were diagnosed with a long term, potentially life-limiting condition that it could be so. 

“Currently, people understand that cancer can kill you,” Mannix says. “But there are many people walking around the country who have long-term lung diseases, kidney diseases, who just wonder why they never feel as well as they used to do.” 

In wider society, meanwhile, she would like to see far more communities taking the opportunity to support the dying. 

“A decision for the public would be to think of an organisation or society or a community that they belong to and how could they be agents of change in that community to explore the concept or ordinary dying,” Mannix says. 

Such communities can decide how best to prepare and make available support for other community members when they are dying. 

“Their dying will come one by one,” Mannix says. “We’ll all take our own turn.” 

 

While most tickets for Kathryn Mannix’s talk on November 1 have been taken, some more may become available at theosthinktank.co.uk. For those unable to attend, the lecture will be filmed and posted afterwards on the Theos website. 

 

Review
Culture
Music
1 min read

Beyoncé’s breaking barriers

Cowboy Carter sees the star crack her whip in the temple of the music industry.

Krish is a social entrepreneur partnering across civil society, faith communities, government and philanthropy, He founded The Sanctuary Foundation.

Side by side, two rodeo riders on horses trot toward the camera. One is Beyonce, the other a cowboy
Beyoncé at the Houston Rodeo.
Beyoncé.com

I sometimes wake up in a cold sweat with flashbacks of one terrible swimming lesson at school. I had accidentally forgotten to forget my kit, so was forced to face not only the freezing water, but the spouting of ignorant prejudice from my teacher.  

“Kandiah, you’re useless,” he said, as I heaved myself out of the pool at the end of the lesson. “Although I guess it’s not your fault you can’t float like the white children. Your bones are heavier. Look at the Olympics – you never see black and Asian swimmers, do you?” 

I opened and closed my mouth a few times, like the fish out of water I suppose I was, but inside I was seething.  

Being told I couldn’t do something made me all the more determined to do it. Back in I jumped.  

Last week, in another splash aimed at proving people wrong, Beyoncé’s magnificent album “Cowboy Carter” became the first album by a black woman to top the country charts. 

On her Instagram feed she said: “the criticisms I faced when I first entered this genre forced me to propel past the limitations that were put on me.” 

It was a brave move. Back in 2016, she had received heated and hate-filled reactions when she performed her song Daddy Issues at the 50th Country Music Association Awards with the country music group Chicks, formerly known as the Dixie Chicks. Many country music fans were outraged, calling it an act of cultural appropriation. One response on social media put it starkly: “SHE DOES NOT BELONG!!”.  

But as a Texan who had been brought up around country music, Beyoncé disagreed. She would spend the next five years planning her response. Cowboy Carter proves her country credentials beyond all doubt. It’s not only about the music. It also does three important things that show the world what can be done when faced with barriers of prejudice and ignorance. 

She honours the past

The album is clearly an act of tribute to trailblazing country artists before her. Beyoncé included notable guest appearances and feature tracks and took the unusual step of sending flowers to all who had inspired her.  

Beyoncé sent flowers to Mickey Guyton, the first black female artist to be nominated for a Grammy Award in the Country category. She also sent flowers to K. Michelle and featured Tanner Adell, Brittney Spencer and Reyna Roberts on the Cowboy Carter track Blackbird, a song that Paul McCartney wrote as a response to the case of the Little Rock Nine, a group of African-American schoolchildren initially barred from attending a previously racially segregated school in Arkansas. It took the direct intervention of then President Dwight Eisenhower in 1957 to make it possible for these children to attend their school. She also included guest appearances from country music royalty Dolly Parton and Linda Martell, who both introduce songs on the album. Dolly’s introduction to Beyoncé’s reworking of Jolene is particularly poignant: “Hey Queen B it’s Dolly P”.  

The song Jolene sticks faithfully to the guitar riff from the original, but the words and the tone of this song are completely different. Dolly’s original Jolene was begging another woman not to take her man from her. But Beyoncé will have none of that. She is full of threat and menace:

“I’m warnin’ you, don’t come for my man… don’t take the chance because you think you can.”  

As Beyoncé pays her dues to the greats that have gone before, she also offers a very different picture. She can recognise the past, and yet not be imprisoned by it. She can appreciate those who have laid the foundations for a new era, unbound by cruel stereotypes.  

She challenges the present 

We don’t have to look far to see the way that western society is splintering. It is becoming harder to find common ground, harder to move from one tribe to another.  Beyoncé’s album is political in that it is deliberately breaking down a wall and smashing a division. She refuses to accept that there are no-go areas for people of colour. The album feels like Beyoncé’s famous baseball bat from Lemonade, but this time it isn’t smashing cars, but preconceptions and prejudices instead. 

There’s anger in this record. The first song is “American Requiem” and includes the line:  

“They used to say I spoke ‘too country’./ And the reaction came,/ said I wasn’t country ’nough / If that ain’t country / I don’t know what is?” 

Full of confidence and rage she asks over a bed of country music guitar chords:  

“Can you hear me? / Can you stand me?”  

Beyoncé does not disguise the ironies. The fresh anger and challenge weaves into classic forms and tropes of country music. The artist that some wanted to exclude from the genre tops the charts. The pop icon becomes an iconoclast.  The smashing of divisions makes way for the building of something new.   

She opens a door for the future

It is within living memory of many that black people were prohibited from sitting at the front of a public bus or drinking from the same water fountain as white people. Beyoncé’s Cowboy Carter is not just a smash hit it is a smash down of the boundaries of genre that had excluded her and others. With this boundary smashed the opportunity is opened for others too.  

For example, there was a recent stand-out performance at the Grammy awards watched by millions around the world – the duet between the country star Luke Combs and Tracy Chapman. Luke, a young white man, is part of a new generation of country singers with a huge following. The legendary black artist Tracy Chapman recently turned 60. The joyful performance was particularly touching as the two of them looked genuinely delighted to be singing together. The video went viral and lead to a huge uplift in Chapman’s sales. The song Fast Car rocketed to the top of the charts some 36 years after it was first released.  
 
Cowboy Carter is Beyoncé using her voice and talent to push back against prejudice and push forward to a new era. She is cracking her whip in the temple of the music industry. She is driving out those who have commandeered the space that rightly belongs to those from any and all backgrounds.  She is righteously angry at the injustice. She is declaring that country music be reclaimed as a meeting place for all nations to enjoy.  

When Jesus unleashed the whip against the tables of the moneychangers in the temple who were excluding the non-Jews the space rightly belonged to, he fiercely declared: “My father’s house is to be a house of prayer for all the nations.” He was not only breaking the barriers of the past but ushering in a new future, a future where everyone could gather together before God on equal footing. Jesus would eventually die on a cross to ensure this free access to God was available to everyone - wherever they were from, whatever they had done and whatever they looked like.  

I welcome this album by Beyoncé in that spirit of challenging prejudices, breaking down barriers, and clearing the decks for a new future equally available to all.  

If only I could have whipped myself into shape, I believe I could have been the Cowboy Carter of the swimming world forty years ago.  

 

Beyoncé in her own words

“Ain’t got time to waste, I got art to make/ I got love to create on this holy night/ They won’t dim my light, all these years I fight.”  

16 Carriages 

“Say a prayer for what has been / We'll be the ones that purify our father's sins / American Requiem / Them old ideas (yeah) / Are buried here (yeah) / Amen (amen) 

 Amen