sets of notes initiated by a doctor or by a patient.

so we started to realize that we had a problem, and the problem is more serious because of this.

what we know is that obviously we are all going to die, but how we die is actually really important, obviously not just to us, but also to how that features in the lives of all the people who live on afterwards. how we die lives on in the minds of everybody who survives us, and the stress created in families by dying is enormous, and in fact you get seven times as much stress by dying in intensive care as by dying just about anywhere else, so dying in intensive care is not your top option if you've got a choice.

and, if that wasn't bad enough, of course, all of this is rapidly progressing towards the fact that many of you, in fact, about one in 10 of you at this point, will die in intensive care. in the u.s., it's one in five. in miami, it's three out of five people die in intensive care. so this is the sort of momentum that we've got at the moment.

the reason why this is all happening is due to this, and i do have to take you through what this is about. these are the four ways to go. so one of these will happen to all of us. the ones you may know most about are the ones that are becoming increasingly of historical interest: sudden death. it's quite likely in an audience this size this won't happen to anybody here. sudden death has become very rare. the death of little nell and cordelia and all that sort of stuff just doesn't happen anymore. the dying process of those with terminal illness that we've just seen occurs to younger people. by the time you've reached 80, this is unlikely to happen to you. only one in 10 people who are over 80 will die of cancer.

the big growth industry are these. what you die of is increasing organ failure, with your respiratory, cardiac, renal, whatever organs packing up. each of these would be an admission to an acute care hospital, at the end of which, or at some point during which, somebody says, enough is enough, and we stop.

and this one's the biggest growth industry of all, and at least six out of 10 of the people in this room will die in this form, which is the dwindling of capacity with increasing frailty, and frailty's an inevitable part of aging, and increasing frailty is in fact the main thing that people die of now, and the last few years, or the last year of your life is spent with a great deal of disability, unfortunately.

enjoying it so far? (laughs) (laughter) sorry, i just feel such a, i feel such a cassandra here. (laughter)

what can i say that's positive? what's positive is that this is happening at very great age, now. we are all, most of us, living to reach this point. you know, historically, we didn't do that. this is what happens to you when you live to be a great age, and unfortunately, increasing longevity does mean more old age, not more youth. i'm sorry to say that. (laughter) what we did, anyway, look, what we did, we didn't just take this lying down at john hunter hospital and elsewhere. we've started a whole series of projects to try and look about whether we could, in fact, involve people much more in the way that things happen to them. but we realized, of course, that we are dealing with cultural issues, and this is, i love this klimt painting, because the more you look at it, the more you kind of get the whole issue that's going on here, which is clearly the separation of death from the living, and the fear — like, if you actually look, there's one woman there who has her eyes open. she's the one he's looking at, and [she's] the one he's coming for. can you see that? she looks terrified. it's an amazing picture.

anyway, we had a major cultural issue. clearly, people didn't want us to talk about death, or, we thought that. so with loads of funding from the federal government and the local health service, we introduced a thing at john hunter called respecting patient choices. we trained hundreds of people to go to the wards and talk to people about the fact that they would die, and what would they prefer under those circumstances. they loved it. the families and the patients, they loved it. ninety-eight percent of people really thought this just should have been normal practice, and that this is how things should work. and when they expressed wishes, all of those wishes came true, as it were. we were able to make that happen for them. but then, when the funding ran out, we went back to look six months later, and everybody had stopped again, and nobody was having these conversations anymore. so that was really kind of heartbreaking for us, because we thought this was going to really take off. the cultural issue had reasserted itself.

so here's the pitch: i think it's important that we don't just get on this freeway to icu without thinking hard about whether or not that's where we all want to end up, particularly as we become older and increasingly frail and icu has less and less and less to offer us. there has to be a little side road off there for people who don't want to go on that track. and i have one small idea, and one big idea about what could happen.

and this is the small idea. the small idea is, let's all of us engage more with this in the way that jason has illustrated. why can't we have these kinds of conversations with our own elders and people who might be approaching this? there are a couple of things you can do. one of them is, you can, just ask this simple question. this question never fails. "in the event that you became too sick to speak for yourself, who would you like to speak for you?" that's a really important question to ask people, because giving people the control over who that is produces an amazing outcome. the second thing you can say is, "have you spoken to that person about the things that are important to you so that we've got a better idea of what it is we can do?" so that's the little idea.

the big idea, i think, is more political. i think we have to get onto this. i suggested we should have occupy death. (laughter) my wife said, "yeah, right, sit-ins in the mortuary. yeah, yeah. sure." (laughter) so that one didn't really run, but i was very struck by this. now, i'm an aging hippie. i don't know, i don't think i look like that anymore, but i had, two of my kids were born at home in the '80s when home birth was a big thing, and we baby boomers are used to taking charge of the situation, so if you just replace all these words of birth, i like "peace, love, natural death" as an option. i do think we have to get political and start to reclaim this process from the medicalized model in which it's going.

now, listen, that sounds like a pitch for euthanasia. i want to make it absolutely crystal clear to you all, i hate euthanasia. i think it's a sideshow. i don't think euthanasia matters. i actually think that, in places like oregon, where you can have physician-assisted suicide, you take a poisonous dose of stuff, only half a percent of people ever do that. i'm more interested in what happens to the 99.5 percent of people who don't want to do that. i think most people don't want to be dead, but i do think most people want to have some control over how their dying process proceeds. so i'm an opponent of euthanasia, but i do think we have to give people back some control. it deprives euthanasia of its oxygen supply. i think we should be looking at stopping the want for euthanasia, not for making it illegal or legal or worrying about it at all.

this is a quote from dame cicely saunders, whom i met when i was a medical student. she founded the hospice movement. and she said, "you matter because you are, and you matter to the last moment of your life." and i firmly believe that that's the message that we have to carry forward. thank you. (applause)

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