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Look, I had second thoughts, really,

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about whether I could talk about this

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to such a vital and alive audience as you guys.

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Then I remembered the quote from Gloria Steinem,

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which goes,

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"The truth will set you free,

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but first it will piss you off." (Laughter)

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So -- (Laughter)

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So with that in mind, I'm going to set about

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trying to do those things here,

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and talk about dying in the 21st century.

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Now the first thing that will piss you off, undoubtedly,

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is that all of us are, in fact, going to die

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in the 21st century.

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There will be no exceptions to that.

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There are, apparently, about one in eight of you

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who think you're immortal, on surveys, but --

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(Laughter)

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Unfortunately, that isn't going to happen.

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While I give this talk, in the next 10 minutes,

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a hundred million of my cells will die,

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and over the course of today, 2,000 of my brain cells

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will die and never come back,

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so you could argue that the dying process

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starts pretty early in the piece.

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Anyway, the second thing I want to say about dying in the

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21st century, apart from it's going to happen to everybody,

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is it's shaping up to be a bit of a train wreck

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for most of us,

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unless we do something to try and reclaim this process

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from the rather inexorable trajectory that it's currently on.

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So there you go. That's the truth.

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No doubt that will piss you off, and now let's see

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whether we can set you free. I don't promise anything.

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Now, as you heard in the intro, I work in intensive care,

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and I think I've kind of lived through the heyday

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of intensive care. It's been a ride, man.

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This has been fantastic.

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We have machines that go ping.

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There's many of them up there.

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And we have some wizard technology which I think

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has worked really well, and over the course of the time

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I've worked in intensive care, the death rate

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for males in Australia has halved,

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and intensive care has had something to do with that.

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Certainly, a lot of the technologies that we use

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have got something to do with that.

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So we have had tremendous success, and we kind of

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got caught up in our own success quite a bit,

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and we started using expressions like "lifesaving."

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I really apologize to everybody for doing that,

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because obviously, we don't.

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What we do is prolong people's lives,

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and delay death,

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and redirect death, but we can't, strictly speaking,

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save lives on any sort of permanent basis.

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And what's really happened over the period of time

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that I've been working in intensive care is that

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the people whose lives we started saving back in the '70s,

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'80s, and '90s, are now coming to die in the 21st century

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of diseases that we no longer have the answers to

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in quite the way we did then.

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So what's happening now is there's been a big shift

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in the way that people die,

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and most of what they're dying of now isn't as amenable

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to what we can do as what it used to be like

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when I was doing this in the '80s and '90s.

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So we kind of got a bit caught up with this,

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and we haven't really squared with you guys about

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what's really happening now, and it's about time we did.

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I kind of woke up to this bit in the late '90s

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when I met this guy.

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This guy is called Jim, Jim Smith, and he looked like this.

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I was called down to the ward to see him.

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His is the little hand.

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I was called down to the ward to see him

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by a respiratory physician.

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He said, "Look, there's a guy down here.

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He's got pneumonia,

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and he looks like he needs intensive care.

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His daughter's here and she wants everything possible

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to be done."

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Which is a familiar phrase to us.

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So I go down to the ward and see Jim,

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and his skin his translucent like this.

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You can see his bones through the skin.

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He's very, very thin,

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and he is, indeed, very sick with pneumonia,

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and he's too sick to talk to me,

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so I talk to his daughter Kathleen, and I say to her,

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"Did you and Jim ever talk about

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what you would want done

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if he ended up in this kind of situation?"

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And she looked at me and said, "No, of course not!"

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I thought, "Okay. Take this steady."

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And I got talking to her, and after a while, she said to me,

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"You know, we always thought there'd be time."

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Jim was 94. (Laughter)

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And I realized that something wasn't happening here.

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There wasn't this dialogue going on

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that I imagined was happening.

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So a group of us started doing survey work,

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and we looked at four and a half thousand nursing home

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residents in Newcastle, in the Newcastle area,

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and discovered that only one in a hundred of them

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had a plan about what to do when their hearts stopped beating.

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One in a hundred.

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And only one in 500 of them had plan about what to do

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if they became seriously ill.

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And I realized, of course, this dialogue

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is definitely not occurring in the public at large.

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Now, I work in acute care.

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This is John Hunter Hospital.

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And I thought, surely, we do better than that.

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So a colleague of mine from nursing called Lisa Shaw and I

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went through hundreds and hundreds of sets of notes

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in the medical records department

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looking at whether there was any sign at all

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that anybody had had any conversation about

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what might happen to them if the treatment they were

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receiving was unsuccessful to the point that they would die.

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And we didn't find a single record of any preference

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about goals, treatments or outcomes from any

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

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So we started to realize

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that we had a problem,

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and the problem is more serious because of this.

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What we know is that obviously we are all going to die,

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but how we die is actually really important,

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obviously not just to us, but also to how that

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features in the lives of all the people who live on afterwards.

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How we die lives on in the minds of everybody

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who survives us, and

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the stress created in families by dying is enormous,

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and in fact you get seven times as much stress by dying

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in intensive care as by dying just about anywhere else,

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so dying in intensive care is not your top option

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if you've got a choice.

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And, if that wasn't bad enough, of course,

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all of this is rapidly progressing towards the fact that

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many of you, in fact, about one in 10 of you at this point,

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will die in intensive care.

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In the U.S., it's one in five.

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In Miami, it's three out of five people die in intensive care.

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So this is the sort of momentum

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that we've got at the moment.

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The reason why this is all happening is due to this,

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and I do have to take you through what this is about.

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These are the four ways to go.

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So one of these will happen to all of us.

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The ones you may know most about are the ones

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that are becoming increasingly of historical interest:

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sudden death.

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It's quite likely in an audience this size

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this won't happen to anybody here.

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Sudden death has become very rare.

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The death of Little Nell and Cordelia and all that sort of stuff

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just doesn't happen anymore.

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The dying process of those with terminal illness

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that we've just seen

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occurs to younger people.

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By the time you've reached 80, this is unlikely to happen to you.

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Only one in 10 people who are over 80 will die of cancer.

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The big growth industry are these.

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What you die of is increasing organ failure,

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with your respiratory, cardiac, renal,

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whatever organs packing up. Each of these

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would be an admission to an acute care hospital,

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at the end of which, or at some point during which,

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somebody says, enough is enough, and we stop.

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And this one's the biggest growth industry of all,

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and at least six out of 10 of the people in this room

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will die in this form, which is

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the dwindling of capacity

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with increasing frailty,

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and frailty's an inevitable part of aging,

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and increasing frailty is in fact the main thing

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that people die of now,

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and the last few years, or the last year of your life

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is spent with a great deal of disability, unfortunately.

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Enjoying it so far? (Laughs)

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(Laughter)

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Sorry, I just feel such a, I feel such a Cassandra here.

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(Laughter)

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What can I say that's positive? What's positive is

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that this is happening at very great age, now.

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We are all, most of us, living to reach this point.

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You know, historically, we didn't do that.

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This is what happens to you

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when you live to be a great age,

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and unfortunately, increasing longevity does mean

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more old age, not more youth.

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I'm sorry to say that. (Laughter)

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What we did, anyway, look, what we did,

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we didn't just take this lying down

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at John Hunter Hospital and elsewhere.

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We've started a whole series of projects

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to try and look about whether we could, in fact, involve

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people much more in the way that things happen to them.

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But we realized, of course, that we are dealing

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with cultural issues,

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and this is, I love this Klimt painting,

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because the more you look at it, the more you kind of get

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the whole issue that's going on here,

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which is clearly the separation of death from the living,

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and the fear — Like, if you actually look,

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there's one woman there

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who has her eyes open.

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She's the one he's looking at,

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and [she's] the one he's coming for. Can you see that?

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She looks terrified.

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It's an amazing picture.

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Anyway, we had a major cultural issue.

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Clearly, people didn't want us to talk about death,

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or, we thought that.

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So with loads of funding from the Federal Government

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and the local Health Service, we introduced a thing

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at John Hunter called Respecting Patient Choices.

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We trained hundreds of people to go to the wards

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and talk to people about the fact that they would die,

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and what would they prefer under those circumstances.

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They loved it. The families and the patients, they loved it.

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Ninety-eight percent of people really thought

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this just should have been normal practice,

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and that this is how things should work.

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And when they expressed wishes,

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all of those wishes came true, as it were.

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We were able to make that happen for them.

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But then, when the funding ran out,

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we went back to look six months later,

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and everybody had stopped again,

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and nobody was having these conversations anymore.

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So that was really kind of heartbreaking for us,

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because we thought this was going to really take off.

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The cultural issue had reasserted itself.

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So here's the pitch:

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I think it's important that we don't just get on this freeway

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to ICU without thinking hard about whether or not

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that's where we all want to end up,

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particularly as we become older and increasingly frail

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and ICU has less and less and less to offer us.

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There has to be a little side road

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off there for people who don't want to go on that track.

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And I have one small idea,

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and one big idea about what could happen.

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And this is the small idea.

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The small idea is, let's all of us

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engage more with this in the way that Jason has illustrated.

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Why can't we have these kinds of conversations

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with our own elders

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and people who might be approaching this?

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There are a couple of things you can do.

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One of them is, you can,

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just ask this simple question. This question never fails.

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"In the event that you became too sick to speak for yourself,

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who would you like to speak for you?"

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That's a really important question to ask people,

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because giving people the control over who that is

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produces an amazing outcome.

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The second thing you can say is,

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"Have you spoken to that person

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about the things that are important to you

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so that we've got a better idea of what it is we can do?"

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So that's the little idea.

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The big idea, I think, is more political.

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I think we have to get onto this.

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I suggested we should have Occupy Death.

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(Laughter)

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My wife said, "Yeah, right, sit-ins in the mortuary.

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Yeah, yeah. Sure." (Laughter)

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So that one didn't really run,

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but I was very struck by this.

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Now, I'm an aging hippie.

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I don't know, I don't think I look like that anymore, but

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I had, two of my kids were born at home in the '80s

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when home birth was a big thing, and we baby boomers

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are used to taking charge of the situation,

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so if you just replace all these words of birth,

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I like "Peace, Love, Natural Death" as an option.

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I do think we have to get political

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and start to reclaim this process from

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the medicalized model in which it's going.

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Now, listen, that sounds like a pitch for euthanasia.

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I want to make it absolutely crystal clear to you all,

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I hate euthanasia. I think it's a sideshow.

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I don't think euthanasia matters.

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I actually think that,

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in places like Oregon,

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where you can have physician-assisted suicide,

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you take a poisonous dose of stuff,

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only half a percent of people ever do that.

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I'm more interested in what happens to the 99.5 percent

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of people who don't want to do that.

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I think most people don't want to be dead,

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but I do think most people want to have some control

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over how their dying process proceeds.

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So I'm an opponent of euthanasia,

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but I do think we have to give people back some control.

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It deprives euthanasia of its oxygen supply.

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I think we should be looking at stopping

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the want for euthanasia,

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not for making it illegal or legal or worrying about it at all.

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This is a quote from Dame Cicely Saunders,

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whom I met when I was a medical student.

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She founded the hospice movement.

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And she said, "You matter because you are,

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and you matter to the last moment of your life."

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And I firmly believe that

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that's the message that we have to carry forward.

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Thank you. (Applause)