Ante-Fatal Classes, anyone?

Before the birth of a first child, the prospective parents are usually more than keen to do the best for their anticipated baby. This will involve discussing options about where the birth should best take place, what “style” of birthing is preferred, and a lot of learning about feeding, sleeping, nappies, and so on.  Of course, as all grandparents know and acknowledge with a wry smile, even new parents who think they know it all will find that the reality is different – more challenging but also, hopefully, more rewarding than expected. At the other end of life, by contrast, we are much less inclined to prepare in advance and to take responsibility for our own dying. That’s hardly surprising – a new life is a cause for celebration, while the ending of one, however long and fulfilled it has been, is invariably accompanied by sadness. I remember my intrepid aunt telling me about a trip she made with some Kurdish nomads in the 1960s. During one of their journeys, a pregnant woman slipped behind a rock to have her baby – and then without much pause rejoined the group.  That is an extreme example of birth as an entirely natural process. Recent decades have seen a resurgence of campaigning for natural childbirth in this country, as a reaction to what have been seen as over-invasive and over-medicalised approaches. Dying is a natural process: but care at the end of life also frequently involves, as childbirth does, questions of when it is appropriate to provide medical intervention.  One of the difficulties that doctors and nurses often face is ignorance about dying amongst relatives and carers. When someone we love is in their last weeks and days, it is too late to start learning. For one thing, we are too involved emotionally, often very tired and uncertain. We can’t really take in easily what options the doctor might be suggesting. One of the aspects of dying that is little understood by most people, for instance, is the issue of apparent thirst and dehydration.  In an emotional article in The Guardian earlier this year, journalist Paul Daley described the experience of being with his dying father.  Daley wrote: “His death was terrible. As his organs shut down, he was denied water. He could no longer swallow…” From the rest of his description, it certainly sounds as though Daley’s father was not receiving good end of life care. But relatives at the bedside are often unaware of the changes in the human body in the last stages of life.  As a guidance leaflet for relatives from St Christopher’s Hospice says:  “It is normal for people who are dying from advanced cancer and other illnesses eventually to stop drinking and to stop feeling thirsty. As the body weakens and the systems start to work less well, there is less and less need for fluid.” Other guidance points out that artificial hydration can in fact hinder what happens naturally at death.  Water deprivation increases the body’s production of natural opiates that create a euphoric state and has been associated with a reduction in pain. The provision of intravenous hydration can have a negative impact on quality of life. Awareness of this aspect of dying, and of a number of others, could be hugely reassuring for families who can be left with an enduring sense of guilt or anger that “not enough was done” for the one they loved.  Of course, that’s not to say that end-of-life care is always provided properly – it isn’t. But learning about dying in advance could ensure that our public debates about, for instance, deep sedation or assisted dying are much better informed. Duncan