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What is dying? (panel discussion) — Transcript

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0:00welcome back so this is the last bit of
0:02what has otherwise been a very
0:05interesting day um so this just the
0:08panel discussion which is I suppose just
0:12an extended Q&A but the panelists this
0:16time are allowed to talk to each other
0:18as well so um
0:23extra
0:25um I'm gonna again cheek start us
0:31off with a question for everyone which
0:36is okay so we've talked about lot kind
0:40of somewhat vaguely about different
0:43concepts of
0:44dying right
0:47and
0:48uh potentially so my question is what
0:53exactly are they um it seems reasonable
0:59to say
1:01that all humans are mortal and so in
1:05some sense we're all dying and that is
1:09independent or like mind independent
1:11it's a fact out in the world you know
1:13it's dependent
1:15on things other than our practical
1:18concerns and interests and
1:21values but it
1:23seems equally plausible that there
1:26is a substantial difference between that
1:30sort of dying and the way in which
1:33someone with end stage heart failure is
1:39dying and I wonder what you think about
1:42that whether that sub that difference is
1:45just
1:46a
1:48practical concern that the difference is
1:51entirely grounded in our values concerns
1:55and essentially our minds or if there is
1:58genuinely some you know mind independent
2:01group of people who are
2:05dying but not the whole of do that me
2:09there are there subsets of people who
2:12are dying in significantly different
2:15ways from
2:17theal
2:25creatures
2:27Stephen yes do you think that there is a
2:30substantial difference between or the
2:33difference between the way in which
2:35we're all dying and the way in which
2:36someone with end stage tal cancer is
2:38dying is a kind of substant is a
2:41physical fact in the world
2:43difference or is it actually just a
2:47question of our practical concerns and
2:50values or is it you know I I think what
2:54you're referring to is the distinction
2:57between sence
3:00and eventually succumbing to the process
3:04of
3:05sence and all of the various other ways
3:08where by which your life could be
3:11ended um we know that um or organisms so
3:16to speak wear out with a with a couple
3:21of
3:23surprising uh exceptions like the Hydra
3:27uh that don't seem to siness uh but most
3:30organisms do including us
3:33and um because of that we even if we
3:40were extraordinarily careful not to get
3:43hit by a bus and so forth uh not to get
3:46the disease we'd still eventually die
3:50because of that
3:52inessence
3:53um and then there are multiple other
3:56ways of course like you mentioned heart
3:59attack
4:00uh but also various ways that um things
4:04like
4:06um um natural events can end a person's
4:10life I'm not sure what you were getting
4:12at with respect to values but that was
4:14my initial thought given your question
4:17yeah I mean I I'll put it to the rest of
4:19the panel in to what extent is someone
4:24with terminal cancer with how Days to
4:26Live dying in a m in a substantially
4:30different way from everybody
4:33else
4:34and so it's it's an it's an interesting
4:42distinction um I when I first said I was
4:45going to go into paliative medicine as a
4:48specialty a colleague um uh seemed a
4:51little bit surprised and um he's a renal
4:54physician and I said we're all paliative
4:57we just work on different time scales um
5:00and that's something that he sort of
5:02reflected a little bit on slightly uh
5:05flippant but sort of relates a little
5:07bit to your point it's interesting
5:09because if we are being pressed to um
5:14highlight what it is that causes that
5:16distinction it's hard but I also have an
5:20idea of if I'm called to come and review
5:22somebody who the current clinical team
5:24think is dying I have an idea of what
5:27that might look like and I have an idea
5:28of what to expect and I have an idea of
5:31what clinical situations I might be
5:34facing and needing to support in terms
5:36of physical symptoms in terms of their
5:38psychological needs in terms of their
5:40social needs so there is a pragmatically
5:43speaking there is a concept I think that
5:46I have an idea of what I would expect if
5:49I'm going to be reviewing somebody who
5:50is dying and maybe picking up on the ter
5:54that guy used this idea of is somebody
5:56dying or are they dying
6:02um I guess
6:04that people can die what it looks like
6:07to me looks different depending on what
6:09condition that they have whether that is
6:12on the whole different from because
6:15everybody in this room is going to
6:17probably die in one of those ways I
6:18wouldn't say it's substantially
6:20different I think the group that maybe I
6:23struggle with these either sudden death
6:25ones the suicides or the or the death
6:29row the ones that have been highlighted
6:31today by some of the philosophical talks
6:34what dying or when on their journey of
6:38life does dying starts I think that I
6:42grapple with more in terms of being a
6:45distinct experience than I guess the
6:48conditions that us as doctors generally
6:51see I don't know if that kind of speaks
6:54to a
6:55little yeah I'm saying okay so so you're
6:58p
7:00Searcher you want to do your research
7:03only on people who are
7:06dying why aren't you doing it on every M
7:10human like we're all di so so you're
7:13you're sub you're taking some kind of
7:16subgroup there and some pallative care
7:20research does mechanistic research
7:23like assuming that there's a
7:27biological reason for
7:31subcategorizing um and I'm just asking
7:35whether you whether or not you think
7:36that that's a valid thing to
7:39do I guess from so when you were saying
7:42that it made me think about how I was
7:44choosing who I was including in my
7:46current research and I'm looking at
7:48prognostic conversations with people
7:49with heart failure um and you
7:53know all the guidelines and it makes
7:55sense to me that sometimes you should be
7:58having conversations with what that
7:59person future might look like at any
8:01stage whether that's when they first had
8:03the diagnosis or further through their
8:04Journey after they've been hospitalized
8:06once twice three times or
8:08whatever and actually the dec decisions
8:10I've made and the cut offs that I've
8:12implied are purely practical I can't go
8:16around recording absolutely every
8:18conversation that's happening with
8:19somebody with heart failure so I've had
8:21to impose limits purely for practical
8:23reasons so I guess on that basis and
8:27your question is it just a practical
8:28distinction May maybe maybe it
8:33is so I think sometimes I think about is
8:36there a distinct population and I was
8:39thinking sometimes I use the phrase
8:40someone says are they dying and I'll say
8:43I don't think they're dying dying but
8:46they've lost the ability to sustain
8:48their own
8:49life so something about their
8:52physiological psychological makeup has
8:55moved the they're irreversibly unable to
8:57sustain their own living without EX
8:59external
9:01help and so maybe that feels like a mind
9:05independent property change so the vast
9:09of population can sustain their own life
9:11we can eat and drink and we can meet our
9:14own needs but then there's another
9:15cohort who now can't and so without
9:18artificial in the before modern medicine
9:21and before care they would have
9:24died that feels like a mind independent
9:27change in terms of no longer able to eat
9:30or drink for themselves so without
9:32external that's a change in their status
9:35so potentially there's something there
9:38and then I also think there is something
9:39in the very last hours of
9:42life that it's mind independently
9:45different uh maybe not two days out
9:48three days out like you were suggesting
9:49but in the very last
9:51hours it's the instant you walk into the
9:54room and you just
9:55know and you spent a few days going are
9:57they dying aren't they dying are they
9:59going to die today not sure and then you
10:01walk into a room and you're like it's
10:02going to be now it's going to be in the
10:04next and it's not or not everyone goes
10:06through that but sometimes you just walk
10:07in the room and you just know and maybe
10:10that's picking something up and it's I
10:11would say to families you won't know
10:13what I'm talking about if you're
10:14thinking are they going to die in short
10:17order they'll
10:19say if you're looking at them and you're
10:21not sure probably not but when you when
10:24they are you'll look at them and you'll
10:25know and the families will then come
10:27back later and say I didn't know what
10:28you were on about
10:29at the time but now after the death now
10:32I know what you were trying to tell us
10:34so whether that captures
10:36something a process two thoughts whether
10:40they cohere I don't know
10:42but thinking of things that might be
10:44independent of
10:47mind yeah
10:57let's you just said
11:01so then in a way differentiating between
11:04what I see is those three main groups so
11:07fully independent able to maintain their
11:09own life no longer able to sustain their
11:12own life and then dying
11:15dying seems like there's as various
11:19speakers have spoken about two main
11:22factors a temporal kind of time Factor
11:26but then also kind of a functionality
11:28Factor
11:29and do you think that at varying points
11:32along those different progressions from
11:35group to group to
11:36group the time and the functionality
11:39have varying contributors so do you
11:42think that transition from fully
11:45independent to no longer able to really
11:47sustain your own life is more of a
11:50functional change and then when you're
11:53dying dying it's more of a Time
11:57based Factor that's just my
11:59interpretation of of what you've just
12:01said and I just wonder whether that kind
12:03of feeds into your original question of
12:06is there a significant difference
12:08between the groups and how do we
12:10differentiate between those groups could
12:12it be that we come up with some ways of
12:14categorizing based off of
12:17temporality versus
12:24functionality I I think i' probably base
12:27it skewed heavily towards the fun
12:29functionality and something about an
12:31irreversible loss of that functionality
12:34I I'd want to build that in this is me
12:37thinking on the ho here I think temp the
12:40time side of things is time scales are
12:43different for different people and so
12:45possibly unreliable but yeah something
12:48about functionality it's a change in
12:50their
12:51function maybe that's how you
12:52differentiate the
12:54groups whether it's a useful
12:56differentiation is another question but
13:00and I I just to expand on that a little
13:03I think you've talked about time and and
13:06I think progressiveness is a is a
13:09concept of that as well some some
13:12illnesses some events will cause a
13:14sudden significant loss of function that
13:16then remains stable so for example a
13:19stroke that means a person can't swallow
13:21but can be fed through a Peg and
13:22therefore remains dependent on a level
13:25of medical intervention but actually
13:27then reaching a point of stability
13:29you wouldn't say that that person was
13:31dying so I think there is that context
13:34that that pattern of of where what is
13:36happening it is time dependent and there
13:38is a sense of of of a progressiveness
13:42again I'm thinking on the hoop a little
13:43but
13:44that's
13:46yeah um I wanted there's also isn't
13:50there a thing that um with most
13:53paliative patients you know what they're
13:54dying of I don't think we know what
13:56we're dying of yet but I want to ask
13:58completely different question if I could
14:00to Steve um about um relating your three
14:05your thinkers versus I'm going to get
14:07it's all wrong I'm not a philosopher um
14:09but the animal versus The Thinker um
14:12relating to brain death and our
14:15definitions of that because um I spend a
14:18lot of time sort of worrying about this
14:20and it feels to me in our definition of
14:23our sort of legal definition of death or
14:24our medical definition of death that we
14:26slightly mix up the groups and that we
14:29have two um we we talk about the uh
14:33permanent loss of the ability for
14:35Consciousness and the permanent loss of
14:36the ability to breathe as our two
14:38criteria and one of those the breathing
14:41one feels very animalism to me whereas
14:44the other one feels very think ISM and
14:45they're both I mean obviously on a
14:48ventilator we can keep them both or we
14:50can keep one of them going a long time
14:52but we we talk about the death of the
14:54person presumably referring to the
14:56thinker or the
14:57mind um
14:59but yet we keep this breathing thing in
15:02there which always feels a bit sort of
15:03random to me and a bit animalism that's
15:07terribly put but do you get what I
15:10mean yes I do yeah I I it was one of the
15:14things I was emphasizing that you know
15:16depending
15:17on whether you adopt the animalist view
15:21or one of the Thinker views death is
15:24just going
15:25to occur at under different
15:28circumstances at different times they're
15:30not necessarily necessarily going to
15:33coincide um take the case of you you
15:37mentioned brain death but start with the
15:39case of persistent
15:41vegetation uh that's a pretty clear case
15:44of an animal persisting not being
15:47dead
15:49um but on either version of The Thinker
15:55view the the person has ceased to exist
16:00if you accept my definition that means
16:03that a person has died or a mind has
16:07died um and you're now waiting for the
16:10animal to die and that seems pretty
16:14inescapable if you're if you adopt
16:17either one of the Thinker views if you
16:19adopt the animalist view you're just not
16:22going to believe in the
16:23existence of The Thinker as uh an
16:27essential object you're not going to
16:29accept that way of understanding uh any
16:33object it's just uh uh you reject it
16:36altogether so there's really for death
16:39to occur you have to wait for the animal
16:41to die so those come apart it's
16:45true I I'll leave it at
16:47that thank
16:53you um so I suppose I am reluctant to
16:59um subscribe to any concept of dying
17:02which relies heavily on functionality or
17:04the loss of functionality um because I
17:08worry that um some of that is is due to
17:12the inherent ableism in how we operate
17:15medicine and um and that it would
17:18exclude um a reliable concept of dying
17:22for PE for people whom uh their original
17:26level of function was not very good
17:29um I think that dying is a useful
17:32concept for people who have lifelong
17:35disabilities in the same way that it
17:36would would be for people who were you
17:39know who have seen a significant decline
17:41in their function and so my concern is
17:44that um is
17:46it whatever concept we want to use needs
17:50to incl needs to be inclusive of people
17:53who uh you know who are you know have
17:56medical complexity disabled um um
17:59learning to all these other things that
18:01mean that their their sort of the
18:03standard view of functionality may not
18:05be um may not be their kind of their
18:08their Baseline um because I still think
18:10it's helpful in those patients to have
18:13um a concept of dying I'm much more um
18:16I'm much more inclined towards dying as
18:19a kind of intuitive human uh relational
18:24kind of um uh experience that um that
18:28something that changes in the way that
18:30we have relationships with people when
18:33when they're dying dying um and um and
18:37that that is kind of a bit more uh and I
18:40and I think that that Taps into what you
18:42say about when you walk into a room and
18:44you know that someone is dying there's a
18:46there's a distinct change in the in the
18:48relationship that you have with them um
18:51so that would I guess yeah I I would be
18:54really cautious of anything that um
18:57looks at functionality as a
18:59key key part
19:01of di you know the diagnosis
19:08of so I yeah I'm minded to agree with
19:11you on that um I think for me so that
19:15that was an exercise in how you separate
19:18the general population with maybe the
19:20population of
19:22interests um but I agree with you around
19:25the worries around functionality and for
19:27me I think a definition of dying is
19:28always is going to be highly contextual
19:30I don't I think I'm going to struggle to
19:32come up with an a broad one time so and
19:36then so I think it will be highly
19:37contexted and I think it's worth say
19:40with that differentiation between the
19:41two populations it might be possible to
19:43do it but whether that's useful or fair
19:45or helpful in the social world we live
19:47in that's an that's a follow on
19:52question I would one of the things that
19:55you said that I would Echo one of the
19:57things that came out of today which was
19:59really interesting was um Professor
20:01Harris Keller's talk one of the things
20:03that resonated was about um how people
20:07interact with other people and and sort
20:10of some discussion of being able to
20:12partake in what has been their sort of
20:14normal life and how we interact with
20:16people um and I've been reflected with
20:19my politic care colleagues that one of
20:20the things that we find ourselves doing
20:22in politic care is trying to bring small
20:25normalities into people's lives um and
20:28we spend a lot time and effort on this
20:30um and I thought that that really
20:33distilled it down for me as to why we do
20:35that um simple things like helping a
20:38family organizer watching a film
20:40together with a pizza or in in the room
20:42just just those things that we spend so
20:44much time and effort on and and it to my
20:47mind speaks to
20:48that an element of that hope as well of
20:52retaining those little normal things um
20:55yeah
20:59we have a couple questions
21:02online so the first one is within a
21:05definition of dying is there's something
21:07around probability probability of dying
21:09in any month week day hour gradually
21:13increasing in life and in an accelerated
21:16way in a progressive medical
21:23condition and I guess that speaks to the
21:27presentation on prognosis that the
21:29probability is probably changing
21:32constantly and that there would seem to
21:36be some sort of threshold that would tip
21:38you over into I guess what the mass
21:41population would consider as dying or
21:43not but it's not clear what that
21:46threshold is and it's not necessarily
21:4850% um at all um increasing in
21:54life and whether that changes and like
21:56yeah um
21:58I guess that probability can go up and
22:00down depending on what condition you
22:01have because it's not always
22:11linear I um Andrew each another
22:14intensivist I quite like the relational
22:17concept if it it takes us back to one of
22:19the earlier
22:21presentations about talking about the
22:23loneliness of death and the loss the
22:26sense of alienation from the world world
22:28and a sort of I suppose a sense of
22:30disintegration in personhood being in
22:34anticipation of death maybe that's
22:36something you could recognize as a dying
22:38process um and it brings to mind a talk
22:42I attended at Putney the Royal National
22:45Hospital for neuro disability by their
22:46chaplain who showed us a series of Tomb
22:49photos of tombstones of patients who
22:52died in their institution and these were
22:53patients with prolonged disorders of
22:55Consciousness so in veget persistent
22:57vegetative state or conscious State um
23:01and most of those tombstones had two
23:03dates on them which I thought was really
23:04really interesting so the first date was
23:07the date of their initial accident and
23:09was often titled with something like you
23:13know lost to us on such and such a date
23:16and the second date was the date of
23:17their physical death organism death two
23:20or three years later when left this
23:22world on this date um so there's
23:26something about death and dying being
23:29related to what we mean by living um and
23:32again what we value in life I think that
23:36varies enormously between different
23:39people and their relatives as well
24:01find it interesting that people put that
24:04point um in terms of relations among
24:09persons whereas I think I would have uh
24:14conceptualized personhood in terms of
24:17self-awareness at least in the tradition
24:19of philosophy that's a pretty typical
24:21move goes going all the way back to John
24:23Lock
24:25actually um but that kind of an
24:27awareness also Al makes it possible to
24:29be aware of others and the interaction
24:33between and awareness of someone else's
24:37awareness of you um and the multiple
24:41ways that can be uh uh brought into play
24:46um but all that will go away if
24:48awareness is
24:50lost and there is that's all
24:54possible while leaving behind the animal
24:58um
24:58which makes it confusing right because
25:01if you consider the person part as a
25:04kind of death then you have to assume
25:08that there's another kind of a death
25:10that's not yet happened in the case of
25:12someone an individual who's a victim of
25:15persistent
25:19vegetation um yeah so there's a c
25:23there's a um something that struck me as
25:26a potential limitation of the relational
25:29interpersonal view of dying um is that
25:34it doesn't seem to be able to account
25:37for um situations where for instance um
25:41someone has cancer um and refuses to
25:46reveal it to anyone else around them and
25:49everyone just continues everyone in
25:51their lives continues to treat them
25:54exactly the same as if they did not have
25:56cancer and that might even be a motiv
25:58for that person to choose not to reveal
26:01that they have cancer um and then
26:05there's there interest there's an
26:06interesting moment that can happen where
26:09the person does eventually pass away and
26:11then the people in their lives look back
26:14and realize oh this person was
26:16dying um but we treated them exactly the
26:20same way as if they weren't and that
26:23this comes as a shock to the people who
26:25who find this out about the person um
26:27afterwards
26:29um so to me what this indicates is that
26:35uh we can't just use the
26:38interrelational view as at least it's
26:41very unintuitive to us in regular
26:44situations like the one that I just
26:46described that the
26:48interrelational view of dying captures
26:51every aspect of what we think dying is
26:54um and the other thing that it indicates
26:57to me um is that
26:59usually uh when when that inter
27:04interrelational aspect of when the
27:08relationship to between us and a dying
27:10person changes for instance what usually
27:14um is at the basis for that change for
27:17that shift in the relationship is
27:20something that's happening at the
27:21physical level physiological level of
27:24that person
27:27um so for instance uh someone who had
27:33cancer if they chose to reveal that to
27:36us um reveal this uh
27:39physiological um issue that they have um
27:43that might spark that might be the the
27:45reason for why um we we begin to you
27:50know shift our relationship towards this
27:52person and seems to explain why we in in
27:56a sense why we do have uh these sort of
28:00shifts in our relations with people when
28:03we discover that they are dying but that
28:06Discovery seems to happen um that
28:09Discovery seems to be of something that
28:11is at the physiological level and this
28:15is related to another point that I had
28:18thought about regarding um thinking of
28:21dying
28:23as uh as a loss of function I think I
28:28agree that um there are there are
28:31potential dangers and pitfalls of
28:34thinking of dying simply as a loss of
28:37function um however I also think that
28:40perhaps these pitfalls can be avoided if
28:43we complement the notion um of a loss of
28:49function with the idea of a progressive
28:53loss of function over
28:55time um and this seems intuitive because
29:00it seems to account for the fact that um
29:04it it account it explains why we're
29:06surprised in cases where we find out um
29:09when in cases where there is no change
29:11in the relational aspect but then we
29:14later find out that this person was in
29:15fact dying it accounts for the physical
29:18what's happening at the physiological
29:20level that um would explain our change
29:24of mind when we realize this person was
29:27in fact dying
29:28um without necessarily falling into the
29:32Trap of oh there is like a baseline or
29:35threshold of a proper function that once
29:39you fall below that then you're
29:40considered dying it's more of um there's
29:44this uh idea of a progressive loss of
29:48function over time that might be indexed
29:51to the Baseline being an individual's
29:55Baseline function um that they were sort
29:58of born with or sort of um were able to
30:00maintain over a reasonable um amount of
30:04time throughout their lives before um
30:08before they uh started dying
30:14dying does anyone want to respond to any
30:17of
30:22that I'll make a quick comment about
30:25functionalism um it seems to me that or
30:28sorry I should mean I I meant
30:31ableism I I think that that
30:35concern occurs due to worries about
30:40Injustice and treating discriminating
30:43against certain persons because of their
30:46differing abilities in ways that really
30:51are um
30:53unjustified um and I think that you can
30:56distinguish that whole
30:58worry um
31:01from setting out certain kinds of
31:04definitions that involve capacities and
31:08it does seem to me that in many cases
31:11when we Define key
31:13Notions capacities really are clearly
31:17determinative of whether the term
31:20applies and uh it's it's it's almost
31:23certainly going to work out in the case
31:25of dying and death
31:28um you can surely you can surely
31:32um well I guess I would argue that uh
31:35dying is the loss of certain kinds of
31:38capacities and that's that kind of a
31:41claim as far as I can tell uh it doesn't
31:44get you in any kind of danger of uh
31:50Injustice I'll leave it at
31:55that sorry everybody I need to leave
31:58it's been really interesting really
32:00enjoyed
32:00it um what we let Paul go we're going to
32:03listen eldine do you want to
32:06make a final comment I know I know
32:09you've been keen and hand in the corner
32:13obviously the speakers make the final
32:15final penultimate
32:19comment yeah I need to Cur my in a
32:23Granger yeah okay
32:26so I like I've said before I think it's
32:28helpful you know so Arin you kept asking
32:32about M Independence I mean set the side
32:35wores about mind Independence you know
32:37we can certainly ask about the biology
32:40of this in elephant dogs octopi all
32:44those places where you don't have to
32:45worry about complex social structures
32:47technological interventions etc etc and
32:51St is a helpful exercise and you
32:53probably still end up I I watched my dog
32:56die with with your diet versus dying
32:59dying like I remember my dogs was
33:02definitely in the
33:04last bit as opposed to the weeks before
33:08um but of course one thing that happens
33:10there is that you know organisms are
33:14self- stabilizing metabolic units and as
33:17such they sort of had tipping points and
33:20once that tipping points is
33:22reached uh it you know whatever it is it
33:25can't eat it can't hunt not Welling
33:28enough pretty quickly relative you know
33:31so you would see kinks in your curve and
33:35of course what we do and and you can
33:38just predict the kink like that was the
33:40elephant La elephant's last molar you
33:43know like it might otherwise be well but
33:46from that point it's just gonna Kink or
33:49Kink pretty quickly because one of the
33:51things we do as humans extraordinarily
33:53is
33:54we we we we reverse and smooth and that
33:59Kink but I think you can get that view
34:02of dying and dying dying and stuff from
34:04animals it's not going to get you that
34:06far for the case where we throw all of
34:11our heavy technology at it so that we
34:13get those curves of the the heart
34:15patient you know who goes like this and
34:18stuff like that on the social side I was
34:23wondering so once you go you put that
34:26aside and think more about dissoci when
34:28when do I go and just dying this this
34:30saying goodbye I'm you know you're not
34:32described as fighting for your life but
34:34as
34:36dying does the biology really matter all
34:38that much at all so suppose I'm going to
34:40do this annoying thing and philosophers
34:41called a thought experiment fill it in
34:43however you want but suppose that
34:44instead of getting there like oh sorry
34:46Asain you've got like stage hundreds
34:50breast cancers mesz anywhere I knew you
34:53felt fine but you're going to be dead
34:54somewhere the next three to six months
34:56you get
34:58oh sorry El there's an Intergalactic
35:00drone with your name on it and there's
35:03nothing we can do about it but you're
35:04going to be dead in the next three to
35:06six months right uh in terms of this the
35:12social role and the social adaptation
35:15like okay I don't have to seek paliative
35:17care in a hospice but I think in both
35:21cases I'm sort of radically shifted
35:23being a midlife
35:25person into the dying
35:28social role you know what am I going to
35:30do with the next three to six months how
35:31am I going to prepare my kids what do I
35:33want for my f all all of those kinds of
35:36things so I mean is that so that
35:40suggests that really if you're thinking
35:42about all of those
35:44aspects prognostication is
35:47relevant but the biology of dying what
35:52we share with animals and dogs and
35:55stuff maybe not very like like you said
35:58arjin often the social starts to float
36:00almost entirely free from the you know
36:04the biology started
36:07with yeah but we're now moving on
36:24here I mean okay so
36:30I think the question about whether or
36:32not there's a kind of biologically real
36:34subcategory biologically real
36:36subcategories of dying versus whether or
36:39not subcat or creating all of these
36:42different senses of dying is just a
36:44question of our practical concerns
36:48is kind of coming from
36:51this the literature which basically asks
36:55Physicians to use physical
36:58markers in order to know whether someone
37:02is dying dying or or dying or you know
37:09so and if if we are expected to use
37:13physical
37:14characteristics there's
37:16something about that which
37:19implies that at least those people think
37:21that there is a biologically real
37:24distinction to be made so
37:28I'm just kind of thinking you know there
37:31isn't a lot
37:33of how do how do we go about doing this
37:36right how do we go about answering the
37:37question what is dying and to some
37:39extent what we can do is we can look at
37:41what people do and then try and reverse
37:43engineer what they must think dying is
37:45in order to do that right so for people
37:49who um will only tell their patients
37:53that they're dying if they have a c
37:55they've reached a certain kind of life
37:57expectancy statistically or
37:59probabilistically then surely they must
38:01think that dying is
38:04a certain temporal proximity to death or
38:07a certain risk of death that you kind of
38:09reverse engineering the concept and
38:12similarly um from the guidelines which
38:14say these are the kind of physical
38:16characteristics that you need to look
38:17for and if you find all of them then you
38:19should you know refer these people to
38:21paliative care because they're probably
38:23going to die then the implication is
38:25that those people think that dying is
38:27some kind of
38:28physiological process and this is
38:30exactly what it looks
38:32like um
38:35and these seem to be kind of quite
38:39distinct
38:41things but what they have in common is
38:44that they all seem to come come out of a
38:48practical
38:50concern that in general in medicine we
38:54are not referring enough people to ped
38:59care right so a lot of the kind of
39:00questions around this and guidelines
39:02around they supposed to increase the
39:04number of people that are recognized as
39:09dying and so there's all of this kind of
39:12is this
39:13just a practical concern driving these
39:17this proliferation Concepts or is it a
39:21[Music]
39:23genuine you know objective thing that we
39:25we've just failed to recognize so far I
39:29think I don't know what you
39:35think I don't know if I've got anything
39:37wise to add
39:41um but I
39:44do I think you're right there is this
39:46concern that we're missing
39:48people clinically when we're working we
39:51miss the opportunity to tell somebody
39:53that they're dying or that there's a
39:54chance that they are dying and I guess
39:56we're all just Ling to find a way
40:00to assess that and just by the nature of
40:04us being external we have to be finding
40:07these things that we can observe and
40:10measure as I said I think from doing
40:13this day and really reflecting about it
40:15there definitely is something
40:17about knowing internally or this idea of
40:21what you said some people when they lose
40:25their status as a father or they can't
40:26work in the way that they do they enter
40:28this mindset of like I'm dying and other
40:31people are able to reframe themselves
40:33and find other meanings and they're more
40:36likely to talk in a way that they're
40:37still
40:39living and I think that's also that has
40:42kind of fed into some of the talks
40:45today is that it's this spectrum and at
40:48what point does living occur but that
40:50could be very different for different
40:51people just depending on how they're
40:53thinking about their own life and what
40:56they're able to give back to it and we
40:59kind of get sometimes caught up in are
41:00we prolonging life or are we prolonging
41:02dying and how do we use that language is
41:05it because we think dying is something
41:08different which I think we' which is
41:09what we're all grappling with
41:13today yeah I think
41:16it's it for me it's it with the PHD data
41:20behind me it's going to come back round
41:23to that question of what do we need the
41:24definition for
41:28what's it what does it allow us to do
41:31what what are we trying to justify with
41:34it um so it's going to be a contextual
41:37thing for me rather than a
41:40categorizing thing if it's to have
41:42utility but that's not to say that
41:44defining stuff has to have utility in
41:46itself
41:48um so yeah I think that's my sense and
41:52I'm also worried that I instead of
41:53defining dying I've just introduced the
41:56concept of dying dying
41:59and that's what people are going to take
42:02away I think that might be a good note
42:04to end on um so let's for those in the
42:08room let's carry on a you fancy a
42:11discussion and a drink on the Terrace
42:13outside the back suers at
42:15house say
42:18what okay and and then I'll okay but um
42:22for now let's thank our speakers let's
42:24thank Steve online and everyone who
42:25joined online
42:28speakers in the room

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