 What’s in it for me?

Discover the truth about dying – and why it’s less scary than you
might think. 
 There’s a general pattern to the experience of dying, and it’s surpassingly peaceful. 
 Sometimes, an energy burst or sudden death disrupts the general pattern.
 People with terminal illnesses can surprise themselves with their resilience.
 Terminally ill people should find coping strategies that work for them. 
 Cognitive behavioral therapy can help terminally ill people find their coping
strategies. 
 Cognitive behavioral therapy can also reawaken a sense of purpose. 
 Not talking about death can lead to communication problems.  
 Terminal people don’t stop living while they’re dying. 
 Final summary

What’s in it for me? Discover the truth about

dying – and why it’s less scary than you might
think. 
Before the mid-twentieth century, people usually died at home, surrounded by their family
members. But nowadays, they often die in hospitals or ambulances, surrounded by medical
personnel and machinery. 

As a result, most of us are unfamiliar with death and don’t know what to expect when
entering the final stage of life. Given our lack of familiarity with the subject, it’s easy to
imagine the worst – especially when TV shows and movies present a highly dramatized
representation of death.

Enter Dr. Kathryn Mannix. Few people are better suited to help educate and calm us when it
comes to death. She has worked in hospitals, hospices and in-home care settings since the
mid-1980s. Thus, she’s seen thousands of terminally ill patients die during her three-decade
medical career in end-of-life care. 

Drawing from this range of experience, these blinks will provide you with a variety of stories,
observations and lessons about death. 

In these blinks, you’ll learn  

 why dying is often a more peaceful experience than you might think it is; 
 how people find ways to cope with the worst aspects of dying; and
  why we don’t have to stop living just because we’re dying. 

There’s a general pattern to the experience of

dying, and it’s surpassingly peaceful. 
From cancer to Parkinson’s disease, terminal illnesses come in many different forms, but
there’s a general pattern to how most terminal patients die.

It begins with a gradual decline in energy, which starts slow and then speeds up over time. At
first, you might just feel a difference in your energy level from year to year. Then you’ll
notice a reduction from month to month, week to week and, finally, day to day. When you
reach that point, it’s a sign that the end is drawing near. 

But the end itself is something you won’t experience. That’s because the more you lose your
energy, the more you need to sleep, as your body tries to compensate for the loss. Eventually,
you’re asleep more than you’re awake each day, and while you’re sleeping, your mind dips
into unconsciousness for a period. These periods of unconsciousness become longer and
longer until finally, you’re unconscious all the time. As you reach the end of this final stage
of dying, your breathing rate becomes slower and slower, until it gently ceases. 

As a result, you don’t experience a surge of pain, a feeling of panic or a sense of life fading
away in the final moments of dying. In fact, you don’t experience anything at all. It’s not
even like falling asleep, where you can notice the transition from one state to the next.
Remember, your mind is unconscious at this point, so you don’t perceive what’s happening.
It just happens, and then it’s done. 

That’s the general pattern, in a nutshell. There are some exceptions, and we’ll look at them in
the next blink. But in the author’s professional experience, it’s helpful to know the general
pattern for a couple of reasons. 

First, it can be comforting to patients and their loved ones. It reassures them that the
experience of dying will probably be a lot less painful or dramatic than many of them fear it
will be. Second, it can give them time to prepare. If a patient has reached the point where his
energy is rapidly diminishing from one day to the next, he and his loved ones know it’s time
to start saying goodbye. 

Now, let’s look at some exceptions.

Sometimes, an energy burst or sudden death
disrupts the general pattern.
The general pattern of dying presents us with a fairly rosy picture of what happens in the final
days of a terminal illness. But there are some darker exceptions to the pattern. 

Sometimes, a terminally ill patient follows it for most of her illness – but then, right before
she dies, she experiences one last surge of energy. That might sound like a good thing, but it
can be a mixed blessing, as the story of Holly illustrates. 

A frail and slender mother of two teenagers in her late thirties, Holly was dying from late-
stage cervical cancer. In the week before Dr. Mannix met her at her home, Holly developed
terrible, debilitating nausea. She was given a medication to settle her stomach, and it worked. 

But it also had an unexpected side effect. Holly started to feel so energetic that she literally
couldn’t sit still or sleep. All day and night, she’d frantically pace around or dance to loud
music, keeping her family and neighbors awake. Dr. Mannix decided to give Holly another
medication to counteract her restlessness. While she didn’t want her to suffer from nausea,
she also didn’t want her to burn up her small supply of remaining energy. 

The medication solved the problem, but most of Holly’s energy was already spent by the time
she finally fell asleep. Indeed, she never woke up again, dying shortly afterward. But at least
she was able to die in peace, surrounded by her family on her deathbed. 

That’s in sharp contrast to the way that Alex died, which illustrates another notable exception
to the general pattern – a sudden, unanticipated death. 

Alex had cancer that began in his testis and then spread to his lungs, liver, kidneys and
abdominal cavity. His treatment was going well, and the cancer was in remission. But then,
all of a sudden, he had a massive hemorrhage that proved fatal. In a cruel twist of fate, the
hemorrhage was triggered by a rare condition caused by the very chemotherapy that helped
him to beat back his cancer. 

But even in this case, there’s a silver lining – as horrific as they can be, sudden and
unanticipated deaths only account for about 25 percent of all fatalities worldwide. And when
they happen, our minds usually lose consciousness before we’re aware of what’s happening.

People with terminal illnesses can surprise

themselves with their resilience.
When we’re forced to confront a challenge, we often discover that we’re stronger than we
thought. That’s especially true of a terminal illness, arguably the ultimate challenge that life
can throw our way. 

Even in the face of the most terrible diseases, people find themselves surprised by their own
resilience. Consider the case of Eric. He was a strong-willed school principal looking forward
to his retirement when he developed Motor Neurone Disease (MND) – also known as
Amyotrophic Lateral Sclerosis (ALS). The disease is always fatal. It destroys the neurons that
control the body’s voluntary muscles, leaving a person increasingly paralyzed, until they’re
unable to do anything for themselves. 

Eric was a fiercely independent, take-charge sort of guy. He was all about getting things done
by himself. So the prospect of paralysis was his worst nightmare. He hated the idea of
becoming a burden to his wife and seeming feeble in the eyes of his grandchildren. He hated
it so much that he planned to commit suicide before it happened. 

One spring morning, he got into his car, intending to drive somewhere to kill himself. But
when he reached for the gearshift, he found that he couldn’t move it. The paralysis was
beginning in his arms. After this episode, Eric resigned himself to living out the rest of his
days. He thought he would be totally helpless, and was sure it would be horrible. As it turned
out, he found ways to get things done and find happiness, despite his condition. 

For example, when he was in a wheelchair, he could no longer tend to his vegetable garden
with his own two hands. However, he could advise his wife and son while they tended it for
him – his directions ensured that they didn’t mistake parsnips for weeds. 

He also found ways of retaining his strong-willed, independent spirit and continuing to enjoy
the small pleasures of life. For him, one of those pleasures was eating the delicious meals
cooked by his wife. But in the latter stages of his illness, he was only supposed to receive
nourishment through a feeding tube. Nonetheless, Eric found that he could still eat tiny
amounts of food at mealtimes. He’d often suffer coughing spasms as a result of swallowing
them, but for him, the pleasure outweighed the pain. 

With coping strategies like this, Eric found ways to continue living through the summer and
winter of that year, which allowed him to spend one last beautiful Christmas with his family.

Terminally ill people should find coping

strategies that work for them. 
When it comes to coping with a terminal illness, there’s no one-size-fits-all solution.
Different coping strategies work for different people with different personalities. Unflinching
realism might be right for one person, but wrong for another. And then there’s the opposite
strategy – denial. 

Generally speaking, this is one of the simplest and most effective ways we deal with the
emotional effects of difficult situations. After all, if we don’t believe a problem is real, we
don’t have to deal with the emotional response it would otherwise trigger. 

But with a terminal illness, this strategy eventually runs into problems. It doesn’t matter if
you believe in the illness or not – it’s going to wreak havoc on your body anyway. And as
that havoc spreads, it’s increasingly difficult to ignore the reality of the illness.

But denial is not always an unhealthy coping strategy, and sometimes there’s more to it than
meets the eye. Consider the case of Sally – a young woman dying of widespread melanoma.
Her cancer had spread to her lungs, liver and groin, and the doctors believed she only had a
few weeks left to live. She was referred to a hospice where Dr. Mannix was working. 

Now, Sally was completely aware of the extent of her illness, and she knew full well what the
word “hospice” meant. But in every conversation she had with her family members and
medical personnel about her condition, she cheerfully insisted that she was going to “beat”
her cancer. She spoke about future plans, such as going on vacation and having children.
She’d even come up with names for them. 

Dr. Mannix’s initial inclination was to persuade Sally to face the cold hard truth – but then
Sally’s mother intervened. “Look,” she said, “deep down, Sally knows the truth. She just
doesn’t want to speak about it, because it’s too sad for her. By describing an imaginary
future, she’s keeping her mind focused on other things. It’s like a game of pretend, and we
need to help her play it.” 

Sally’s family and Dr. Mannix agreed. They decided there were much more important truths
for them to remind her of – like how much they loved her, appreciated her and treasured her
time here on Earth.

Cognitive behavioral therapy can help

terminally ill people find their coping
strategies. 
Terminally ill patients cope with their illnesses in a variety of ways. There's a single powerful
tool that can unlock these coping mechanisms – cognitive behavioral therapy, or CBT. 
CBT is a modern approach to psychotherapy that is all about getting a patient to identify and
change her patterns of thoughts, emotions and behaviors. In 1993, Dr. Mannix added CBT
training to her repertoire, and became a pioneer in bringing it to the field of end-of-life care. 

To see how CBT works in general, and how it applies to patients with terminal illnesses, let’s
start with the story of Mark. He was a 22-year-old-man with cystic fibrosis – a condition that
damages the digestive system, pancreas and lungs. As Mark’s lungs deteriorated, his
breathing became more difficult, and he started suffering from panic attacks.

By doing CBT with Dr. Mannix, Mark was able to identify the patterns of thoughts, emotions
and behaviors that were behind his panic attacks. Basically, whenever he noticed he was
experiencing shortness of breath, he would try to take deeper breaths to counteract it. He’d
find this to be impossible, which, in his mind, confirmed there was a problem. This prompted
his body to release the hormone adrenaline, which triggered stress symptoms, such as
pounding heart, dry mouth and shaking legs. 

His mind then interpreted these symptoms as signs of his imminent death. This prompted his
body to produce even more adrenaline, leading to a vicious cycle of ever-mounting levels of
adrenaline, symptoms of stress, thoughts of danger and emotions of fear. The result was a
panic attack. 

The trick was to alter his initial pattern of thought – changing it from “Oh no, I’m dying” to
“Ah, these are just symptoms of adrenaline. They’ll pass soon.” As Dr. Mannix reminded
him, the symptoms are not necessarily cause for alarm. It’s the same thing a person might feel
on his wedding day or during a sports game. By reinterpreting his initial symptoms of stress
in this way and stopping his vicious circles in their tracks, Mark was able to nip his panic
attacks in the bud. 

That’s just one example of CBT in action. But for terminally ill patients, the benefits can
extend well beyond symptom management, as we’ll see in the next blink.

Cognitive behavioral therapy can also

reawaken a sense of purpose. 
In the previous blink, we saw how CBT helped a terminally ill patient reverse a vicious cycle
that led to suffering. In this blink, we’re going to look at the opposite dynamic – how CBT
helped a patient embrace a virtuous cycle that led to happiness. 

It was the late 1980s, and a woman named Louisa was looking forward to her daughter
Penny’s big day. They were at an upscale clothing store, looking for a wedding dress. All of a
sudden, Louisa’s hip bone broke. 
Upon examining it, the doctors discovered even worse news – cancer. Specifically, it was
secondary cancer that originated from the breast cancer she thought she had beaten years ago.
Now it was in her hip bone, where it had been discovered too late. The cancer was now
incurable. But for Louisa, the worst news wasn’t that she was going to die. It was that she’d
be stuck in a hospital bed on her daughter’s wedding day.  

Louisa sank into a deep depression. She lost weight, became withdrawn and stopped
participating in daily activities at the hospital. She stopped maintaining her physical
appearance.

But then a colleague of Dr. Mannix intervened with CBT. As part of her therapy, Louisa was
encouraged to engage in mini-experiments to prove to herself that she was still capable of
doing things. For example, she started taking care of her appearance again. She got a
manicure and re-dyed her hair. 

This improved her mood a little, which enabled her to make a friend at the hospital – a
Nigerian woman named Millie, who was dying from the same cancer. With Millie’s
encouragement, Louisa started dreaming bigger. There was an experimental hip joint
replacement surgery that she qualified for. Previously, she’d been considered too depressed to
consent to the surgery – but now she could pursue it. Perhaps it would allow her to attend her
daughter’s wedding, after all, Millie suggested. 

Louisa signed up for the surgery, and it worked. Now she was filled with a newfound sense
of purpose. That is, supporting Penny as much as she could in preparation for her wedding.
The more she engaged in this task, the more her mood improved. This motivated her to
engage even more, leading to a positive feedback loop. 

With her rekindled spirit and new hip joint in place, Louisa attended her daughter’s wedding
in a wheelchair. Three months later, Louisa died. The next week, Millie died as well.

Not talking about death can lead to

communication problems.  
Death has become a taboo subject in modern times. Indeed, our discomfort with talking about
it can run so deep that we often end up engaging in conspiracies of silence, and avoid the
topic altogether. 

Unfortunately, these conspiracies of silence can lead to serious communication problems,

which can hamper health care decisions. Take this common scenario, for instance. An older
person wants to talk to his children about practicalities surrounding his death. But they rebuff
him every time he tries, saying it’s too morbid. 
That’s what happened with one of Dr. Mannix’s patients – an 82-year-old man named Gerry
who had advanced heart disease. When they needed to decide whether to leave him on life
support, Gerry’s children didn’t know what his wishes were. 

Conspiracies of silence can also prevent people from supporting each other as death
approaches. If ever there was a cautionary tale about this, it would be the story of Joe and
Nelly. When Dr. Mannix met them, they’d been in a loving marriage for 50 years. Previously,
they’d always been honest with each other and tackled life’s challenges as a team. But now,
they were both hiding a deep, dark secret from each other, and facing their greatest challenge
alone. 

Nelly knew she was dying from advanced ovarian cancer. Joe knew she was dying from it,
too. Somehow, neither of them knew that the other partner knew. They both wanted to shield
each other from the truth, thinking it was too terrible for the other to bear. 

As far as Joe knew, Nelly believed she was just suffering from a stomach disorder, and he
worked to maintain this fiction in all their conversations. Meanwhile, as far as Nelly knew,
Joe actually believed what he was saying, so she played along and maintained the same
fiction. As a result, each of them suffered in silence, trapped in self-imposed loneliness.
Neither of them could reach out to the other partner for support. 

Fortunately, Dr. Mannix was able to find a way to get them to confess their mutual secret.
This enabled them to carry their burden together in Nelly’s final days. 

Terminal people don’t stop living while

they’re dying. 
People with terminal illnesses aren’t just dying from those illnesses. They’re also living
through them. That’s how we can learn from the desires, emotions and struggles in the stories
we’ve been exploring.

Dying is a part of life – not just because it’s an unavoidable aspect of existence, but also
because it forms a distinct phase in most of our lives. Some people die sudden deaths, but for
most of us, there are whole weeks, months or years in which we live through the chapter of
our lives called “dying.” It might be the final chapter, but it’s as much a part of our life story
as any other. Indeed, the finality of it makes it all the more precious. It’s our last chance to do
the things we want to do. 

Some people use it as a time to develop new interests or return to old ones. At one hospice
where Dr. Mannix worked, a retired psychiatrist and retired hospital cleaner bonded over a
shared passion for jazz. The psychiatrist discovered it for the first time, while the hospital
cleaner returned to it after a long hiatus.  

Other people use it as a time to tie up loose ends. One of Dr. Mannix’s patients was a deep-
sea diver named Pete. He wanted to help his wife and kids as much as he could before he left
them, so he devoted one of the final weeks of his life to cleaning out the family’s messy
garage.  

Many people use this time to shape the legacy they’ll leave behind. This often takes a more
modest and personal form than the lofty-sounding word “legacy” might suggest. A girl
named Sylvie provides an especially poignant example of this. She was only 19 years old and
was dying of leukemia. As part of her legacy, she simply wanted to make a rocking chair
cushion for her mother. 

“This way,” she explained to Dr. Mannix, “it’ll be as if my mom can always sit down on my
knee, and we can rock in front of the stove together after I’m gone.” Sylvie’s life was cut
short, but her love continued.

Final summary
The key message in these blinks:

Dying is less scary than many of us think. While there are some notable exceptions,
most people die rather peacefully. Terminal illness poses a variety of challenges, but
people can summon tremendous resilience when coping with it. And they don’t have to
face those challenges alone. End-of-life care specialists can help them on their journeys,
using techniques such as cognitive behavioral therapy. People’s loved ones can also be a
great support, but this often requires overcoming the taboos surrounding death, which
can get in the way of open communication. 

Actionable advice: 

Start living your life with the end in mind.

For people with terminal illnesses, the knowledge that they are dying often triggers a radical
shift in their perspective on life. Many deeply personal and philosophical questions come to
the forefront. What are your values, and how can you live in accordance with them? Whom
do you feel grateful toward, and how can you show them that gratitude? How have you
wronged people, and how can you make amends? What do you feel bitter about, and how can
you let go? You don’t have to wait until your dying days to shift into this mindset. You can
do it right now. One way to start is to write a letter to a loved one in which you try to answer
some of these questions. 

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What to read next: Death's Summer Coat, by Brandy Schillace

You’ve just learned about how people deal with death in the modern world – but what about
the past? How did we arrive at our present-day ideas and practices? Author and historian
Brandy Schillace has uncovered some fascinating answers to these questions. They run the
gamut from Victorian Englanders who staged life-like photos of the recently deceased to a
Brazilian rainforest tribe that ate their flesh as part of a ceremonial mourning ritual. 

To learn more about these and other intriguing historical accounts, check out our blinks to
Death's Summer Coat, by Brandy Schillace.