Navigating Conversations Around Dying Well with Dr Mark Donohoe

Navigating Conversations Around Dying Well with Dr Mark Donohoe

What does it mean to “die well?” How do we have these conversations with our loved ones and our patients?

This week we are joined once again by Dr Mark Donohoe who helps us tackle this difficult and moving topic. He and Andrew discuss how the modern medical approach to dying can be improved, how to help patients through a terminal diagnosis, why it’s important to have an end of life plan, and how we as natural healthcare practitioners can be a major part of the conversation between patients and the rest of their healthcare team in this area.

Covered in this episode

[00:57] Welcoming back Dr Mark Donohoe
[02:00] Introducing today’s topic: dying well
[02:47] Mark’s perspective on the modern medical approach to dying
[09:48] The role of natural health practitioners
[15:04] Opening up conversations around end of life wishes
[22:08] Broadening the conversation
[24:15] Helping patients through diagnosis
[34:11] Respecting different cultures and not imposing our own beliefs
[37:27] Bringing a different perspective as a natural health practitioner
[40:44] Thanking Mark and closing remarks

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook. Joining us again in the studio is Dr Mark Donohue who earned his medical degree from Sydney Uni in 1980. He worked in the hospital system for three years before opening his own general practice on the New South Wales, Central Coast. This is when patient groups such as farmers who could not afford to be sick presented with complex illnesses which had been left undiagnosed and untreated by his peers. Mark attests that this is when his real medical education began.

So he then delved into environmental medicine, nutritional medicine, and now lifestyle medicine with fellowships in each modality. Dr Donohue is renowned for unravelling complex illness caused by toxic exposures, creating the first low-exposure integrative hospital in Australia, and remains a staunch vanguard for patient advocacy and health.

Today, we're going to be discussing dying well. Welcome back to FX Medicine, Mark. How are you going?

Mark: Pleasure to be back.

Andrew: Now, we're discussing a very controversial topic, and indeed assisted dying is now legislated in Australia in one state, Victoria, with the first official case being recorded, Kerry Robertson, occurring in August 2019. So dying is one of the few things we know we will do - and that's a verb - in our life. So let's have a conversation about how we as integrative practitioners can help our patients to die well.

Now, I just want to make a statement here, and that is that I want to make sure we are not promoting assisted dying. We're talking today about how we can help those who are dying to have a better death.

Mark: Yes.

Andrew: So, Mark, over to you. What's your initial thoughts? Indeed, what's your history?

Mark: My history is like that of most doctors. I don't want to be too blasé about this, but doctors have killed patients out of mercy all the way through history, from Hippocrates to the present.

In my own history, I worked in a hospital in my early days as intern and resident. And it surprises everyone to hear this, but one of the worst and most difficult wards to work in was the respiratory ward where people had cancers, mesothelioma, chronic obstructive destructive lung disease. And there was no way back for them. These were people that were going to die breathless and desperate, and progressively so. And we all learnt the art of finding how a person wanted to die and how they could communicate to us - if they had time - that they wanted to die differently than just being kept in a hospital ward with drugs propping them up all the way.

So I, and I think all the doctors that I knew at that time, had to learn a very difficult art, and that is when there is no way back for this person, and you can be compassionate, and they can convey to you that they wish to die and that they wish to die having said goodbye to their family, having done all that they wish to do, and they wish to depart, how could we assist them.

And although we don't talk about it, John Ellard did in a book called "Killing Patients." We have a history of, "I will compassionately help you be free of suffering even if being free of suffering shortens your life or brings respiratory arrest." And we did that over and over. We don't talk about it because in the world today, everyone fears dying. It is the most natural act and the inevitable act of every person. We will all die.

The problem that I have with my medical profession is that we've set up a system where technology can prolong and prolong and prolong life beyond the point that the person, the family, the community needs to have that life prolonged at enormous cost with enormous pain and suffering. And we have failed to answer the question, "Should we?"

We can, and the problem that I see is dying used to be brutal, swift, and there were no questions about “Do we prolong life?” because life disintegrated very, very quickly and we were basically just holding people together long enough in the early part of the last century, and even into the '70s and '80s, we had limited tools to prolong one's life.

Now, dying is a long process that costs a lot of money, takes a lot of suffering, and prolongs the suffering rather than improving the quality of life. And at some point, we have to have that broad conversation about “How does this person wish to die?” That's the thing that we forget when we get into the high-technology, the hospitals, the drugs, the new anti-cancer drugs. We have almost infinite choices that can prolong life marginally, but at a cost to the life and the quality. And through my many years now, it's not that we have to actively go and kill people, but we need to listen and we need to hear the person.

Andrew: That's the thing, yeah.

Mark: And the person who is facing a fatal outcome and an inevitably fatal outcome, the enemy of medicine is not death. The enemy of medicine is suffering. And what we are, as doctors, obliged to do is not cause death but not to get in the way of death that is happening inevitably and to keep on obstructing a process that could be done better.

And I think what has happened in Victoria is at least it started that talk from happening. I think the legislation is so restrictive and so difficult that it almost makes it harder. But what it does do, is it opens the discussion to say, "When a person chooses to die in a particular way, do they have that choice? And are we obliged as doctors and practitioners to start talking about it in a whole different way?" Not the fear of dying and that we will hold death at bay, but that every practitioner involved in this person's care comes together in a discussion with the person with only one priority: to achieve that person's desired outcome, to know that person's desired way of dying, and to help them achieve that.

And that's a new medicine. That's not the medicine of fear of “we will do everything to prevent death” because we never can prevent death. We can only delay it, and that delay sometimes cost people their dignity. It costs them their family. It costs them their home. I think it's an interesting statistic that, for people with long-lasting fatal diseases, the last year of life can extract about 50% of their entire life savings without any observable or measurable difference in their duration of life, maybe a month or two, but a deterioration in the quality of life, not an improvement in it.

When I was a young intern, the people who were dying wanted their family with them. They wanted to have that conversation. They wanted the people who are with them to love them. Many of them wanted to return home, and we went home with them to be with their family. Now, new drugs mean, "Oh, you might get an extra few months. Even if that fails, we've got a backup drug. We've got a backup drug. We've got a backup drug." And there is a failure to listen to both the person and the other practitioners who were in that person's life. And I think that's where it becomes a kind of integrative medicine and natural healthcare side.

In the past, people died brutally, rapidly with pneumonia. It was all hands on deck to try and stop that death at that time. Now, people are dying in a much more prolonged way with more practitioners, many of whom spend a lot of time with the person—the psychologist, the naturopaths, the others who are involved in their care. And those people need to have their voices heard as well because, if you spent hours with a person as I do, you get to know what their aim is. And if you can communicate that aim to others in the chain of medical care, everybody can stop; it's just that we don't think of stopping.

If people get into that vortex of, "Oh, we've got a new drug. We may try this," we forget to listen to the person. And I think this conversation is the person's desires and the family's desires are part of medical decision-making, even though we've ignored them for a long period of time. Other practitioners are inputs to that, and we've got to start listening to everybody involved.

Andrew: Okay, so that's exactly what I want to talk about now, the role of natural health practitioners who are excluded from the normal medical model. So these conversations with the patients have to be done earlier. Now there's that awkward sort of time. How early do you plan your death? We have plans in place. I have a funeral plan. I have planned the Monty Python music which I would like played at my funeral.

Mark: Haven't we all? I mean, that's a basic requirement.

Andrew: Yeah, you know? These conversations, when is it appropriate for a naturopath? And I need to just tell our listeners outside of Australia that, in Australia, naturopaths are not part of the orthodox medical healthcare system. So there's that awkward relationship. However, patients rely on naturopaths, and I think it's very important that integrative practitioners can be a conduit to open up this conversation, to make sure that the wishes and the plans of the patients are known.

Mark: Yeah. Death is not a technical issue. It is a technical diagnosis. I mean, you still need a doctor to come and feel the pulse, make sure a person dies, fill in the forms. There is a medical technical side of dying. But the dying process is what every person in the world does and will go through. We can make a sense of, "Okay, I've got funeral arrangements," because that's practical. But how do I wish to die? Having the kind of living will or the advanced care directives is what more and more of my patients are doing.

It still is too medicalised because you still have, “You must have a fatal disease from which there is no possible return or cure.” And a lot of the conditions that we have now, the people fail slowly but tragically: Alzheimer’s and different forms of loss of the person, the person disappearing from life, and being propped up by expensive medical care all the way. That is not the traditional thing that people want to experience.

And given the choice, given time where they could have a think about “What is my dying going to be like?” is like having a birth plan for a mother who is planning to go, “I'm planning to go to hospital. I want you to do the following." Putting the details in place is extremely important. What the naturopaths, natural healthcare practitioners, acupuncturists, Chinese medicine, we all have a team of people these days. It's not usually in my world, just the doctor, who's having the inputs here. There are a team of people who, if they can get together, can conspire to provide a great death for a person.

Even well before the time that those decisions have to be made, the people that I see have enormous comfort from knowing that their rules of dying are written down, that they are going to be respected in their choices, and that they are not going to be sucked into that vortex of medical care. The most difficult decision here is usually the family, especially the children of an older person dying. There is an enormous sense of guilt that, if you don't give everything to your mum or your dad or your grandma or your grandad living an extra, God knows, weeks, months, maybe even a year, that if you haven't done that, that there is some failure of priorities. But the understanding and acceptance of death by the person dying is normally much, much better than everyone else's.

Andrew: And yet I'm reminded by a recent mum's story I read about a psychologist who was dying. His daughter was a linguist, and she's written books. I'll put all of these links by the way up on the FX Medicine website so that people can go there and learn more and have ammunition for conversations. But this psychologist said to his wife, "Enough." These were the last words basically, "Enough. I love you and enough." And it was the...

Mark: Difficult to talk about this.

Andrew: It was the resolve of this psychologist to choose his deep parting.

Mark: I think we also all feel the finality of dying, and what lies on the other side, what is the future, how does the family move on. And we all fear our own death, no matter what we say. There's a little bit of us that knows that we will die, but we are in the process of living and we see ourselves reflected in a person who's dying. What would this be for me? What will I be at that point?

We all want to be brave. None of us are. Deeply, we love living, and we love the people that we are surrounded by, and that's the point of a good death, is to be surrounded by those people, not to be surrounded by machines, and not to be surrounded by people who don't know us and who we don't know.

Andrew: You know, this is one of the things that I absolutely adore about Lise Alschuler. She very early opens up the conversation once a diagnosis becomes terminal, and she opens up that conversation about the wishes of the person. What are your wishes? And that has underlying currents about dying, and the fear of death. She turns around and she says, "Well, isn't that because you love life so much? So let's fulfil your wishes to the best of our abilities with your loved ones involved."

Mark: Lise is a special person. I mean, not just the skills of what you can do outside the medical mainstream and chemotherapy. What can you do that’s soft medicine that allows for a transition, rather than a falling off the cliff kind of effect? Talking about death is essential. If you can't talk about it, it becomes the fear that I mentioned.

It's the same as the legislation. Why is it so hard to get legislation across? Because to talk about it is to open up a wound and we have a mythology that somehow we can avoid death if we don't talk about it. It doesn't work. Lise is so good at opening up that conversation saying, "Here's what can work to ameliorate your problems. Here's what can work to prolong life safely and without high cost and without going broke along the way. And here's how you bring family into it."

The thing that we do understand is that dying well for most people involves being in the presence of loved ones around the time leading up to the time of dying, that medicine's interventions should be not invasive and almost abducting a person into a hospital but should be always pushing back towards “What can be done within the home, within the family,” where possible.

It's not always possible. You know, some people don't have kids. There is no family. Some people are dying young, and the parents still have to work to pay medical bills. But what is the optimum way that we can help this person transition? And the transition is a very different thing from the dying. The dying moment is in fact very simple. At that point of dying or at the minute of dying, breath stops, everybody cries. We're all hopefully present at that time. Sometimes not.

What we're aiming to do, I think, is to get the conversation out of near the point of death where it is so emotionally tearing, move it forward to a time where everyone is moving towards an acceptance of mum's, dad's, my child's choice. How do we experience that? How do we all go through dying? And how do we do it as a loving family or a loving group together?

The second thing is, what can the practitioners do? What do they bring to it? How do you stop the suffering? How do you allow for the pain to be relieved? How do you not institutionalise a person?

It's almost like, as a society, we've got used to dying invisibly. The person dies in a hospital, and when they die alone, it's not the same. In that respiratory ward, having the family nearby at that time of dying was unbelievably important for the person. That was their number one choice. And what we were doing was propping them up with Ventolin, propping them up with different types of adrenergic drugs. We were trying to keep them breathing, trying to keep them alive. And when that changes to trying to keep you conscious to the point where you can be with your family and then let go voluntarily, that's a very, very big difference.

Andrew: Having said that, there is that point where people hang on and it's often… the word appropriate is not appropriate, but it's often necessary for the person who is dying to be alone. And the kind health professional will say to the family, "How about you just go and get a sandwich?" Having said that, this is not the realm of naturopaths.

Mark: Dying alone and dying lonely are very different things, right?

Andrew: Yes, that’s exactly right.

Mark: Being able to die in peace with that kind of soul moment where the person passes, that can be with or without family because truthfully the person at that point has no recognition of what's around them. Dying lonely is a very, very different experience. Dying lonely where you crave the family, where you crave the contact, where you need the love, and not finding it, that's a very, very different thing to do.

But just realising how difficult this conversation is because each time I do that, I think of either my mother or patients that I've been with. And I think of, in a sense, a kind of beautiful moment but also that loss, the kind of permanent loss is a heartbreak. And that's not something that's in the medical curriculum. We don't talk about that heartbreak. We don't talk about the loss. We talk about the fight against death.

And that's why it's so hard to talk about this, that there is a permanence to the loss. You don't get the person coming back on the other side of death. There may be a recycling of life but nothing that we are sure about. And in those circumstances, the decision is final. And the decision for a person to say, "I'm ready to make my transition, goodbye," is a heartbreaking moment, including for the doctors and those around them at that time. It's a privilege to be there. It is a privilege to be with people at that time.

But letting go and then having a team to say, "Here's a way of comfort, of support, of family," is more than the medical model, the medical model of "we can do the following" is not doing dying. The person has to do the dying themselves, and we have to be there to support them.

And I know the people who have worked with patients of mine. I'm still a medical practitioner. I still have a job to coordinate that, but the healing of the naturopathic chiropractor, the healing of people who've spent time with the person is something we've never formalised. Everybody goes quiet, and it's important that everyone does not go quiet at that time, that everyone has their input, and that the plan is built with family, practitioners, carers, helpers, and hospital. That we don't exclude anybody, but we say, "Here's the point beyond which there is no recovery. Here's the point beyond which the person is keen not to lose their autonomy, not to lose their decision-making capacity, and they've written down or told us how they wish to die.” Our job to honour that is a very difficult job but it is still the job that we choose to do.

Andrew: Now there's also, I guess, the practical implications of the wishes of the person talking to you in a sole consultation, versus when you include or ask them do they want to include family or significant others to come into the room and have a conversation, or to voice their opinions separately and to be the conduit to the medical team.

Mark: Yeah. I think that's where a general practitioner, whether integrative or not, has always taken that role. The role of the conduit, the role of, "I hear you and I understand what you want," and then separating that into, "How do we go about doing it?" I think that is still going to be a doctor's role for some while. And I think that we need to take that responsibility. That's why we go through the medical training. We go through the autopsies. We try and understand what death and dying is all about. We're just not taught formally how to deal with it at an emotional level ourselves.

And when you set up the enemy of medicine is dying, then that gaze gives you great capacity for heroic rescue and getting people back to life. But they're not the people that were inevitably dying. They're the ones that you can save. And when you mistake that for... And now we have degenerative Alzheimer's which is destroying the person in front of us, the cancer is eating away at the body, and leaving them with less and less capacity every single day of their lives, that’s a whole different thing.

In the past, all we could do was step back and say, "What can you do now?" These days we're quite capable of coming up with 14 more drugs that will all extend life maybe a month, maybe two months but at a high cost and a high disability, a high adverse reaction rate.

Andrew: That's a really...

Mark: And that decision making is a tough one to make because you need to have oncologists onboard, and oncologists often just see cancer as the enemy, not the person, as the person to be served.

Andrew: So when talking about uncomfortable conversations with patients when the patient themselves has been delivered bad news, catastrophic news. They are going to die. Their treatment is now palliative, and they come up with a sentence like, "The doctor tells me I'm going to die."

I remember a nursing story that said the uncomfortableness of the practitioner, of this nurse, was the response... “No look, we'll take care of you as much as we can, and I'm sure we'll have you as right as rain,” and that sort of denial rather than the acceptance about, "I'm sorry. You've heard this bad news. Let's talk about that. What does that mean to you? You know, what emotions are conjured up in you?” and diving in there. And that comes back to how comfortable we are with the process of dying.

Mark: That's an area where education for doctors is needed desperately. Often the person, when they're delivered bad news, they can't hear it. All they hear is the word cancer, all they hear is the word dying, and they disappear. That's a point where practically you need someone who is their carer or loved one with them at the time. And it's often just as hard for both of them to hear those words.

So frequently you'll have a diagnosis that says, "Look, you've got a good chance of living," and they hear it as, "I'm going to die." Other times you're saying, "Look, you've got really no chance, and we should start preparing for death," and they hear it as, "That's a 50/50." There needs to be comfort on the part of the first practitioner who conveys that to be able to straightforward, to not gild the lily, and not to make it a black hole that they will plunge into, but to give them the opportunity to think of, "This is the next stage. Okay, where do I move from here?" not, "What is my diagnosis?"

The diagnosis honestly is irrelevant to the patient. The "what do I do next" is the most important next thing for them to start to move onto, and it can take a day, a week, a month. It can take a year for a person to be ready to think of "What do I do next? How do I wish this to play out?” And I think that's where training for doctors is a very, very useful idea. We get the training online because every doctor by the time they’ve work 30 years in practice has had hundreds, dozens - hundreds probably - of patients who have to face that question, but that's like trial and error.

Lots of doctors deliver news in a kind of almost dispassionate, scientific way and think that the job is done. That's not a job done. The person only now has words that they don't know the meaning of it, they don't know how it plays out.

My ideal world is, at the point that that diagnosis is made, which is a medical diagnosis that there is no way back from this point. And what we're doing is trying everything in our power to stop death, do we go down that path? Or do we accept that death is going to happen a little bit later or a little bit earlier and start to plan for the life that you live between now and the time you die. The life you live between now and the time you die is a thousand times more useful information—what you do, how you wish to live it, what family resources are there, what community resources, can you be in the home in comfort?

A good example in this is in the areas of cancer and Alzheimer's, exercise is critical to the best outcomes. If they're able to get up and move and walk around and able to move the body and have the muscles signalling that things are okay, that the quality of life goes up. How many institutions can organise that exercise when you've got people lying in a bed waiting to die? None of them.

Andrew: Yeah, and I've got to say, you just conjured up something that made my heart sing a couple of weeks ago, and that was a very short video of a very frail and elderly lady, patient, resident of a retirement village. And the staff had set up, a slippery slide, a water slippery slide on the front lawn basically. And they had her in a very cushioned, blow-up thing, and they were holding her and they were holding her and gently, if you like, but not rushing her, hurtling, but they were at a fun speed.

Mark: Yep,

Andrew: But nice, caring attitude down the slippery slide, and it was the best thing.

Mark: Yes, to be out in the sun, to be walking with family...

Andrew: Oh, my God.

Mark: ...to be in the water, to be immersed, to be living is way, way more important than finding “how do I scratch out an extra six weeks of life, buy very expensive drugs in an institution, and chemotherapy.” I am not denying chemotherapy, radiotherapy. You go and you get rid of your cancer and that is fine. And then so often we say, "Okay, cured." The person's not cured. Basically, they've just been through a bit of a torture of the medical side in order to try and achieve a cure, and more than half of those are not cured.

The steps of living and the steps of having the input from exercise physiologists, physiotherapists, naturopaths, chiropractors, osteopaths, everybody else, the team around a person provides comfort. It also provides comfort for a family who says, "What do I do next?" And if your only option is, "Well, she goes into the oncology ward and gets chemotherapy and radiotherapy," there's that loss of the person.

If you can say once that job is done, let's get back to life. The exercise is critical. The practitioners who can give positive care, who can relieve pain without the heavy drugs that will cause constipation and then take you down that path of being re-medicalised, that's the critical positive that Lise has talked about in her lectures of “What do you do to reestablish life so that you live well and die well.” And dying well, I mean, it sounds paradoxical but it's not.

Dying well is both, in wellness, you can still die. A critical thing can go wrong, you can still break, but you can be well in every other area apart from that. And well as in, with the way that I wish to die with my family around me. There are two wellness...

Andrew: And friends if that's the case.

Mark: That's right.

Andrew: And this is something I want to broach is that in the hospital setting, it's the family only that are around the person when they're dying. And it's sort of that sacrosanct moment, but it's almost a privacy law. Whereas, I mean, I want my friends there as well if they'll have me. They'll probably go, "Bye. What are you leaving me?" But I would expect that my close family are actually close to my friends, and I would hope that they're all included in my passing.

Mark: And that is the living until your time is up, right? Your time will be up at some point. The assisted dying is more the question of, "When can a doctor intervene to do something to hasten death?" And I think we've got to separate the two things there. The living well and dying well can happen without assisted dying, and the assisted dying is something that the medical profession that's grown up and realised its limitations can start to talk about with patients.

And so the assisted dying is, "What tools do we have to allow that transition to not be painful, desperate, short of breath?" What we used to do in the respiratory ward was provide the comfort, tell the family, move to a time that the person, in their most breathless moments could barely express, and then provide relief in the form of narcotics that we knew was going to suppress respiration to the point where they would no longer live, but it allowed people to say their goodbyes. If we left people to just die on our schedule, there was no goodbye because they could be in that ward for two years. And every breath they wish was their last, they could not stop from taking.

You raised a great point before. Every organism hangs on to life to the bitter end. It's not up in our brain. It's autopilot. We will breathe to our last possible breath. We will beat our heart to the last possible beat because that's how life survives all the rest of the time.

The ability of humans to choose their way of departing is restricted right at the moment. And the paradox is, when it comes to our pets, we do have that understanding of there is a point of suffering where the pet can be put down and that death is rapid and humane. We leave humans with inhumane deaths only because we are scared to have the talk about “What do we do?” and we're scared to actively go in and do anything that would hasten the dying of a person.

And we have created a whole new world in medicine where dying is a slow, long, laborious process. It's not rapid brutal. It's not the pneumonia that would take a person in five days and thin out the population. It is now slow because we are so good at medicine that we can prolong almost anything. We can stave off death for a while. And the next job is to say, "Should we? Should we not put our resources back into allowing people to choose their death, choose who it's with, and then assemble a team that can provide the best quality of life to the moment of that person's passing?"

Andrew: What about cultural aspects? Different cultures have different ways of dealing with death, and coping, and also demands.

Mark: They do. And the ability to be neutral about that, to not impose our own worldview on the passing of a person or the dying of a person… I have had situations where the person dying is absolutely convinced that they will be reincarnated. I have had circumstances of atheists absolutely certain that their atoms are meaningless and will go on into the distance. And yet death is meaningful for every person. It's not a question of “What's on the other side?” so much as “What does it mean to be leaving? What does it mean to be saying goodbye? What does it mean to be surrounded by people with love?”

So while we don't know what is on that other side, we should not be imposing a view ourselves. And so different cultural presentations have different families, for example, different groups of friends. The Caucasian Christian is not the same as the Buddhist. It's not the same as the Hindu. It's not the same as the agnostic or the true atheists. And so being open as a practitioner to the person's needs as opposed to my belief systems is a critical component. Trying to impose our beliefs on somebody else of, "Oh, you'll be back,” or "You'll go to heaven," or, "You will go to hell." That's saved for people such as ourselves, Andrew.

Andrew: Speak for yourself.

Mark: But imposing those doesn't help anywhere. It's just our fear of death that we're expressing, our fear of what's on that other side. The cultural respect is often what religion is best at. The saying goodbye can provide that comfort, that family, that unity, and the words and the meaning that are not implicit in medicine. Medicine is becoming much more a technology and much less an art form. And along the way, we run the risk of losing that very humanity that allowed people to come into the world with meaning and leave the world with meaning.

That assembling of the family, the culture, the church, if necessary, the assembling of all of those is for the person, not for us. And so as the practitioner, we assemble others who can help in that saying goodbye, that leaving, and not something to make us feel better about it at the other end of it.

And so you'll often have, in the groups that I've seen, atheists, and Buddhists, and Qigong, and things that are on that kind of line between, "Is it Christian enough? Is yoga Christian enough?" It's irrelevant. It's an assembly of the things that that person needs to kind of, almost like packing of the bags to say, "Okay, goodbye. Got the bits that I need here. I've got the comfort that I need here." And the people whose interactions don't have to fall within the guidelines of the Catholic church, or the Buddha, they can be a person's unique way of signing off and saying, "I'm out of here now. Goodbye. Thanks for the fish."

Andrew: Just one last quick question. I know you're different, but what would a doctor appreciate in receiving about patient's wishes from an integrative practitioner, a naturopath, a herbalist, a chiropractor, an acupuncturist?

Mark: What we doctors always appreciate is a different perspective, is what humanity a person can bring. It's not so much about, "This person needs vitamin C at a dosage of a certain amount." Sometimes that just induces a whole fight between the practitioners. But “I have listened to this person, and they have told me this. This is what's important to them," that is gold. That is information that often, as a GP, we're stuck between someone saying, "We must do chemo right out. We must go to the bitter end." We need the balance on the side from the integrative practitioner to say, "This person's desire is as follows. Can that be matched? Can we find some way to do it?"

So I think letter writing is far, far more important than anyone makes out. A simple note that says, "Here's what I found from this person and what they wish to go through, how they wish to pass, how they wish to experience dying well." That's gold to any practitioner. That humanity of another person having listened to them and conveying that back to the doctor allows the doctor to have, if you like, ammunition to say, "I will work with my patient because not just myself but other practitioners have found this about what this person's desired way of leaving is."And then we can pass that on and defend against unnecessary intervention.

It's not good medicine to go to the bitter end. In fact, that's often the worst possible medicine. It isolates, it destroys, and it can tear apart families and can send people broke. And we need to be able to have that line that says, "This far end, no further. This far the person wishes to go, but if we're going beyond that, what we're focusing on is not the technology but the humanity and bring people back to that humanity."And that's what natural healthcare practitioners are able to bring over and over again. So does the family. The family has to talk to the doctor and say, "I know what mum and dad want."

And finally, we should get into the healthcare directives, you know, the advanced care directives and the living wills. That's something that should be part of normal discussion at a time when the person is well and says, "Here's my views on how my life will end with me being well." And they're scary documents initially but they do give power to the person.

Just as you said right at the beginning of the funeral planning, dying planning is very, very important. And so the living will is your statement at a time that says, "I don't want to go down this path. I want to go down this path. I want to be with my family. I prefer to be at home. I don't want life-saving drugs administered when I have a terminal condition." Then write them all out, and then you put them in a drawer and they get revised in another five years' time and they get revised in another five years' time. And every practitioner can participate in that. We listen, we learn, we understand the person, and we contribute to their dying well.

Andrew: Dr Mark Donohue, there is no better way to end this interview than to thank you so much, and to give you my utmost admiration for your humanity when discussing this natural part of life. Thank you so much for joining us on FX Medicine today.

Mark: It's been difficult but it's been a pleasure. Thank you, Andrew.

Andrew: This is FX Medicine. I'm Andrew Whitfield-Cook.

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