What to expect when someone important to you is dying

Since becoming an advocate for Dying Matters, I have had many conversations with strangers about death and dying. It isn't as morbid as it sounds. A good death can be a very uplifting event. In our family, Mom's death, although expected, changed our lives forever. Thankfully, we had good advice and great support and it made a very difficult day more bearable, to know that Mom had passed away peacefully in her own bed, at home, with no intervention. It is this simple act of kindness from a stranger, helping us through that day, that makes me want to share with other families.

I had a conversation with a professional acquaintance today. After our business was concluded we chatted for a while over coffee, and she told me that her mother has been diagnosed with breast cancer and her mother in law died recently, suddenly, from a brain haemorrhage. These two seemingly unconnected events have rocked her family and called into question whether it is better to die suddenly or to have time to plan for death.

Rather selfishly, I was very grateful for the few months my mother was given. We got to know each other again, and we made plans for the future, a future without Mom but with happiness. This was important for both of us.

I recall that several friends and family wanted to see Mom in her final days. As a family we asked them to keep their visits short and not to bring cakes. Mom didn't need much food, just a few sips of water and finally just sucking on a soft, wet toothbrush. People feel awkward around death and the dying and brought cakes regardless, because it made them feel better. We were grateful for their visits, but it wasn't helpful for Mom, especially when they left in floods of tears.

I do wonder how we would have felt if Mom had gone suddenly. It was, after all, medical intervention which saved her life, only to diagnose her with lung cancer within days of Christmas five years ago.

On the day Mom died, the community nurse pulled the sheet back and quietly pointed out the colour on Mom's foot. It was the first sign, she said, that the dying process had started. She spoke quietly, because hearing is the last sense to go and actually becomes quite acute before death. The tumours had taken Mom's sight, and her eyes were opaque, but she could hear us and feel our gentle touches. The nurse asked if we wanted Mom catheterised. We decided against it. She wasn't eating and only sucking on the toothbrush so we didn't feel there would be much need. A TENA pad would do.

Mom's foot was pale grey, with a very weak pulse. She couldn't speak, just a rasping gurgle came from her lips. My brother phoned from Australia and we held the phone to her ear while he said his goodbyes. Mom needed no pain relief that day - the pain receptors along with most other functions had already ceased their activity. Afterwards, I helped the nurse bathe Mom and change her into a lovely clean nightdress. I picked some flowers from the garden and placed them on her chest. Everything was very quiet. The oxygen machine had been turned off and we were lost in our own thoughts.

000

This was our experience. If you would like to know more, a new guide has been published by the National Council for Palliative Care. 'What to expect when someone important to you is dying' is available from shop.dyingmatters.org and costs £2.50.

Sea shell whispers

This lovely cowrie shell was collected on Durban beach a long time ago, when Granny was a girl. She treasured it. She gave away all her earthly belongings before she died. She was bed-ridden, on a high-care ward, dying from old age, metastatic bowel cancer, and had had several strokes. She was 89. 

The family gathered round, grateful for her life and laughter. We held her hand, she sucked a teaspoon of yogurt. Everything had been said. Her life was spent. So was her money. She had nothing left to give. And she was happy with that.

The oldest daughter clutched the crumpled papers. We spread them out and laughed. Granny had planned her funeral. Get the retired vicar. These are the hymns to sing. And afterwards, tea and cake in the church hall. But not Mrs So-So's cake, because she can't bake! Spread my ashes in the sea at Doonside.

What a joyous occasion Granny's funeral was. The cakes were especially delicious. I took her ashes into the sea at Doonside. The family sat on the rocks around the small inlet. The sea came in, and took her away. The seagulls mewed across the sky. Perfect.

The shell belonged to Mom after that. And now it belongs to me. It lives in my bathroom, slightly cracked, but intact. I hold it to my ear, and I can hear those waves. The generations of women who have treasured this shell. The sea shell whispers to me.

This is a post to celebrate Dying Matter Awareness Week 12-18 May 2014. Find out more here. Start a conversation.

Photography by Lesley Beeton

I'm not dead yet

Anniversaries focus the mind. Bring back memories. A talk radio discussion this morning reminded me how angry I was in the month before Mom died. How determined we were that Mom would not die in hospital.

Mom was admitted for treatment of fluid on her lungs. A side effect of the tumours and the chemotherapy, she was struggling for breath, but still very much alive. A simple chest drain would make her more comfortable and she could come home to be cared for by us.

The first drain wasn't monitored correctly and stopped draining before the fluid was cleared. But the ward was busy, so she was sent home to wait and see. With only weeks to live, it was most unsatisfactory. 

A week later, her breathing deteriorated during radiotherapy to her spine. Terrified, Mom was admitted again. She was terrified of dying alone, in hospital.

Days later, no chest drain, my mother lying in a hospital bed on oxygen, unable to talk, read, sleep, eat. It was awful. The nurses cast barely a glance in her direction. She wasn't helped to eat or drink. I complained daily to the nursing staff. The only doctor on the ward was a junior oncologist, with no respiratory experience. Then I made a complaint to the patient liaison service at the hospital. I wrote a strongly worded email to say that my Mother was not yet dead and deserved the dignity of having her respiratory condition alleviated to ease her pain and discomfort. And allow her to come home.

An hour later, she texted me to say that 'the great and the good' were at her bedside. The consultant respiratory physician and consultant oncologist had found the time to meet my Mother, together, and plan her treatment. Hooray! She was home the next day. And she died peacefully at home 6 weeks later. Mom was just 66 years old.

Death in a care home

I am an advocate for Dying Matters. I believe that when your loved one is nearing the end of their life, you and your family should be told about the choices for their care. It is not an easy conversation to have.

I recently heard about a family who were mourning the loss of their mother, just before Mothering Sunday. She was an old lady with dementia, living in a care home, with serious underlying medical problems. But she was well cared for and her family loved her and visited her several times a week.

When the family received a phone call late one night, they were understandably concerned. The GP had been called to the care home. It was not her usual doctor, but there should have been a chart and notes on her condition. Apparently there was not. The old lady was transferred to a nearby hospital, where the consultant said there was nothing he could do for her, and returned her to the care home.

Twelve hours later, having never regained consciousness, she passed away, with her family at her side.

Her family are questioning the decision made by the hospital consultant, to return their mother to the care home to die. They are questioning whether treatment should have been started, to prolong their mother's life. No doubt these questions will be answered and the family will be able to continue their grieving.

But, what if the care home staff had had the confidence to talk to the family, to talk them through the options. If the care home staff weren't qualified to do so, what about the GP? If the family had been able to understand that their mother had already begun her final journey, for death sometimes comes slowly to the frail, surely they would have been better equipped to deal with her passing.

Another family, left in tears for a loved one, grieving for things not said or done.

Close one door and another one opens

When Mom was diagnosed I was angry. So angry that her retirement had been ripped apart so cruelly. So angry that her life would be cut short and there was nothing we could do about it. Angry that my job doing something I loved, was so unrewarding and in such a toxic environment that I didn't tell anyone that my beloved mother was dying.

I struggled on for six months, juggling work and hospital appointments, crisis after chemotherapy crisis, as well as keeping house, being a friend and holding the family together. I know now that this is what families with cancer are dealing with on a daily basis, but at the time, I felt as though I was completely on my own. And in part, this prompted me to start the blog and write about my raw emotions as Mom suffered, and died from lung cancer.

When we knew that Mom's time was almost up, I gave notice and asked to be released early from my contract. It was a very difficult decision for me. I had worked so hard achieving my PhD, and had completed two pieces of work to be published in scientific journals. Despite being assured that my work would be supported in the future, I was devastated when it became clear that there was to be no future for me in science.

My last day of work was bitter-sweet as I said my goodbyes, knowing that I was not leaving to go on to bigger and better things, but rather to nurse my dying mother at home for the last weeks of her life. I have no regrets about my decision. It was the right thing to do. And I have rebuilt a career in writing, talking about end-of-life care options, promoting science, working hard to build a portfolio. I can honestly say that I have found my niche, and I love what I'm doing.

So it was a bit of a shock when I bumped into a senior colleague at the gym on Tuesday night. I haven't seen her 18 months, and for a split second I wasn't going to greet her. But I did say hello and she was surprised to see me. Of course, she asked what I'm doing now. As if she didn't know that she was in part responsible for closing the doors of mainstream research to me. I found myself talking down what I do, as if my value is less now because I'm no longer in academic science. And that really upset me.

I have resolved now to complete the writing of the manuscripts for the research I carried out, but instead of publishing in a scientific journal I will publish on my blog, in a way that everyone will be able to understand the context and contribution of the science to our lives. I hope that this will bring closure to that part of my life, and more opportunities in other areas.

I'm a member of the Dying Matters community.

I blog at talkhealth.

Funding cancer research or end-of-life care or both?

Prompted by two new tweeters in my timeline, I've written a comment about research funding and the difficulties faced by scientists in making choices about novel therapies for cancer. The post can be found on my science blog To science and beyond, but I wanted to mention it here, as it covers aspects of end-of-life care and dying matters, both of which are very important to me.

For more information and support to talk about dying, see Dying Matters. Living with Mom's cancer is a member of the Dying Matters community.

This post has also appeared on the talkhealth Blog.

Could all the money in the world find a cure for cancer?

I honestly think the short answer to that is no, but I would love to be proved wrong. 

Funding shortfall

There are any number of high-profile cancer research campaigns, all begging and pleading for funding. The UK medical research funding bodies are really stretched at the moment. Their funding was cut in the first round of austerity measures back in 2009. At the time, research scientists were warned that as much as 20% would be cut from research budgets, and that the remaining funding would be more focussed on translational research, that is, research which would yield applications in medicine, technology, engineering, for example. This meant that much basic science research into novel therapies was cut short. The EU-funded project I worked on for 4 years, looking at a novel gene implicated in cardiovascular disease risk, was cut off from the next funding round. The shortfall in funding vital research will have to be made up from private funding, legacies and public awareness campaigns. So I am always interested and supportive when I hear about anyone embarking on this sort of fundraising for projects near to their hearts. Because behind every campaign is a passion, a love, a loss. 

New campaigns

Two new campaigns have Twittered into my timeline. Two new lines of research into novel therapies for cancer. One is a campaign for more funding for immunotherapy by Ruth Stavric, the other is iCancer, campaigning for more funding for a cancer-busting virus. I have not read the preliminary research on which either of these campaigns is based, so I would urge cancer patients and their families to approach with caution. And in the UK (to my knowledge), these therapies are not available, apart from a small number of pilot study immunotherapy clinical trials. 

Cost

Yes, cost is an issue. The stats for cancer care are astonishing, and an ageing population will present with more cancers. The health authorities are already facing increased detection rates of cancer in patients over 65 years, across all cancers. There is no doubt that a widespread roll-out of novel therapies across the NHS is never going to happen. Indeed, it is rare, even for cancer care of patients who can pay for it privately, to deviate from the standard treatment at the moment. Pharmaceutical trials do go ahead, but the clinical criteria for entering many of these trials limit the number of patients who can enter the trial. There is also a vast minefield of medical ethics to consider, on top of constant monitoring, blood tests, scans and the like. Which goes some way to explaining the lag behind research discoveries.

A bit about the science

The science behind cancer is very complex. On a molecular level the initiator of a rogue cancer cell can vary from a genetic mutation to a break in a chromosome, or a response to an environmental stimulus (like a cold, or a chemical toxin). That is why a 'one size fits all' approach to cancer treatment is unlikely to be found. Breakthroughs in cancer research in the 1990s discovered the bcr1 gene, tamoxifen responsive breast cancer, the bcr-abl cluster in leukaemia, and clinicians have been successfully using this knowledge for a number of years. So it's a long term project. And best results across all cancers will most likely come from a number of approaches, some tailored to individual genetic make-up, some tailored to the individual immuno-regulation response, some using tried and tested chemotherapeutic agents, and some based on faith and alternative therapies. Many cancer patients will benefit from a multi-approach. Many will not.

Living with Mom's cancer

My Mom died of cancer last year. She was only 66 years old. She had small cell lung cancer, a very aggressive form of cancer. Without first stage palliative chemotherapy, she would have been dead within 4 months of her diagnosis. As it was, chemotherapy gave her another 5 months with us. She opted to stop chemo after 4 months because it made her too ill to spend time with her friends, family and grandchildren. And she died a dignified, peaceful death at home. You can read about Mom's story and our positive approach to Mom's cancer. Mom's cancer was complex, made up of different cell types. These small cells spread throughout Mom's lungs and into her spine and other organs. Nothing could have stopped the relentless march of those cells.

And I'm reminded at this time, of two other inspirational women. Ellie died earlier this year, having followed every line of treatment she could, to fight her breast cancer. Kris started CoppaFeel! to promote awareness of breast cancer in young women and is in part behind the new campaign of breast awareness. 

Dying matters

Despite their best efforts, oncologists cannot save every cancer patient. Whilst I applaud all efforts at new discoveries, fundraising and the brave people who take part in clinical trials, people still die from cancer. I would like to see more funding for end-of-life care. More funding to train more people to talk about dying. Because when cancer has run its course, your loved one deserves the best. A peaceful, pain-free death. 

For more information and support to talk about dying, see Dying Matters. Living with Mom's cancer is a member of the Dying Matters community.

A little book

A year ago I was contemplating life without Mom and looking after Dad. I felt sad, lonely, afraid, ill, tired. I started blogging more regularly until I had blogged all my feelings and thoughts and felt empty, ready to start again. I've had a little break from blogging to write a little book on dying matters. It is in review at the moment and I'm very proud that I've turned a negative into such a positive.

The book signals a shift from grief and bereavement to a more outward-looking blog and I hope that will be obvious from the post topics.

Thank you to everyone who supported me through the last year. Here's looking forward to new horizons.

Final chapter

This piece was submitted to Final Chapters, as part of Dying Matters Awareness Week in March 2012. I include it here, today, on the first anniversary of Mom's death, in tribute to Vivienne Mackinlay, wife, mother, granny, friend. Gone, but never forgotten.

Mom was dead before she was even diagnosed. The Russian roulette of small cell lung cancer had held a gun against her head, and pulled the trigger. By the time she knew what it was, and treatment started, she was already so ill we knew there was no hope. How do we go from here to find inspiration and a positive end to this story?

Mom’s story still stuns me when I tell people. Mom was sixty-six years old, enjoying her retirement. She was full of life and very active. A smoker in a past life, she had given up twelve years ago, but the damage had already been done. She and Dad were looking forward to spending Christmas with my brother and his young children in Australia. We put Mom’s feeling of being unwell down to her excitement and anxiety at making the long journey to Perth. Two days after she arrived in Australia, Mom collapsed and was taken to hospital. Two days after that, several blood tests, x-rays and a CT scan later, we had the dreaded diagnosis. I remember the feeling with numbness. The prognosis was six to eight months. That’s no time at all to prepare your self for dying. Our lives changed on that day.

Picture the scene

Britain was facing an unprecedented snowy winter. It started at the end of November and within days the airports were struggling. Mom was very anxious that their flight to Australia would be cancelled, so when she fell down the stairs, we all thought she was being a ‘flopsy bunny’. She fell three times in the days before her trip, but the GP was reluctant to stop her flying. So in spite of the weather, and with two black eyes, Mom and Dad set off on their trip to Perth.

Looking back now, I don't know how she did it, but within days of their arrival Mom felt so awful that blood tests were ordered and she was admitted to hospital with low sodium. On its own, this is potentially life threatening, but I had already been warned that this could be a sign of something really nasty. And it turned out to be extensive small cell lung cancer with paraneoplastic symptoms, such as low sodium.

Get your ducks in a row

That's what Mom always said. She was a wise woman, right to the end. And her clarity and comprehension of her situation helped us to help her. My wonderful husband was pro-active in getting Mom to decide where she wanted to die, and the GP helped us achieve this. I believe that this was absolutely the right way for Mom to go, but it took our family to raise the question with the doctor and push for the help we needed. But, it's still a taboo subject to ask someone how they want to die. It takes a lot of courage on both sides, and it's a topic I passionately believe in. I know it's a difficult conversation to initiate, and I wish I hadn't had to do it for Mom. I hope it doesn't happen to you, but if it does happen, be brave. It does make a difference, and getting things in order is very important for dying in peace.

Talking about grief

If I'm brutally honest about my grief, it's that I started grieving for Mom when we found out she was ill. I discovered the power of my mind, being able to separate myself from the horror of her situation, and still carry on with my own life. Going to work, being a wife, lover and friend. This detachment was my coping mechanism, my way of making sense of everything and ensuring that Mom and Dad had the very best treatment and support, whilst preparing for life without her.

Grief is a powerful emotion, even when you know it's coming, it punches you in the head, shakes you about and puts you down in another place. The straight lines of my ordered life were swept aside, a chaotic mess with no obvious way out. 

The doctors say that they won't treat grief with drugs, as in a significant bereavement it isn't always possible to know what is grief and what is clinical depression. So they play a waiting game. And in most cases it turns out OK.

I don't know exactly when things started to get better, but it was a slow process and now seven months since Mom died, I know I'm not grieving.

It's a different story for Dad though. His grief seems more intense now than it did at the time. His health is suffering, too. I think he may have shrunk a little, or perhaps it's just that I'm standing a little taller. I’m more grown up. More responsible. I don't want to, but someone has to and I have a duty of care to ensure that he is safe, well and not vulnerable. They don't tell you this when your Mum dies. They don't tell you what to do about Dad.

The positive power of people

Isn't it funny how some people have such positive insight? Throughout our experience of Mom's illness I have been amazed, delighted and encouraged by strangers. Sometimes, it's easier to tell a stranger how you really feel, perhaps we sub-consciously choose the people we talk to. 

I met someone recently who asked after Mom and was saddened to hear that she had died. This (almost) stranger told me that the loss of a parent is such a significant event that it is quite often life changing. She's right. I could never have gone back to my old job and sat in the same office with the people I never told about Mom's illness. I had to move on, look for new challenges, like a re-birth she said. Wow, what an important fifteen minutes that was.

Make time

I never realised how much I could do before Mom got ill. My comfortable life was snatched from under my feet and overnight, my time was not my own. And yet, I still had to go to work, do experiments, teach, be nice to people, be nice to my husband! And believe me, there were days when I was exasperated with people around me, days when I wanted to yell at them 'Don't you know my mother is dying of cancer?'

One day I burst into tears as I was driving to work, and thought 'This is ridiculous, you need to get some counseling!'. To which I answered 'I would, but I don't have time for counseling, now pull yourself together'.

The last year has made me think about priorities. There are clearly some things that are more important than others, we just have to keep a clear head, focus, and make a list! But above all, and I believe strongly in this, make time for loved ones. Its no good seeing somebody once a year at Christmas and presenting them with an extravagant gift that they don't want. Rather, make time during the year for a visit or a phone call. Keep in touch. None of us know when it will be too late.

Let’s talk about dying

I have been looking at cancer blogs and forums and have noticed something quite disappointing. They are filled (quite rightly) with inspirational survivor stories and battle cries, but are lacking in discussions on death and dying.

When I first started talking and writing about Mom's death from cancer I was amazed at how many people wanted to talk to me. Many had questions they had been too afraid to ask, too afraid of the answers. I had encouraging feedback too from a letter I published in the local newspaper, in praise of local end of life care services in our area.

I set about writing a blog, to document my own thoughts and to provide a forum for other families. The thing is, we still don't like to talk about death. And we sure as heck don't like to think about our own mortality. Cancer is a different disease for everyone but the one thing that all cancer patients have in common is confronting their mortality. And that is devastating.

So let's talk about dying, it helps us prepare and it can ease the pain of bereavement. Whilst there are incredible success stories in cancer treatment, many people still die from cancer. It would be wrong to avoid talking about death in order to not upset those brave and hopeful people going through treatment, but for many people there will come a time when the brave thing to do is to talk about dying.

Mom’s angels

Mom was not ready to die. Her type of lung cancer was caused by years of smoking as a young woman, growing up in the 50s and 60s, when smoking was considered stylish and cosmopolitan.

Mom's cancer took her life in nine short months. These were desperate times for us, but Mom did come to terms with her terminal illness. And because of that we were able to plan for her death. Mom opted to die at home and we were supported by several agencies and wonderful people, who we called 'Mom's angels'. Mom signed a do not attempt resuscitation order under her GP's guidance. The District Nurse team provided a hospital bed, commode, nursing and caring skills at home. It was explained to us the options for increasing Mom's pain relief as her death approached. This included the use of a syringe driver, simply an injection of pain relief given over 12 or 24 hours. Mom didn't want this and it was never used.

Mom was helped by an incredible hypnotherapist and towards the end of her life, she was clear about her wishes, wrote letters to everyone and planned her funeral. She was also calm and pain free. I had five beautiful weeks with Mom at the end of her life, so precious, and I am so grateful for that opportunity.

On the day Mom died, she had said her goodbyes and we had all given permission for her to go. I don't think she knew how bad her disease had become, but the cancer had grown out of her back, she had lost the use of her right arm and she could hardly see. She was conscious and could hear us but couldn't speak. Her clinical team wanted to give her pain relief through the syringe driver. Mom indicated NO! to us and died quietly within the hour.

Afterwards, we picked flowers from her garden and laid them on her body.

The point is that Mom confronted her fear of dying. And through the support of her GP and District Nursing team and hypnotherapy, Mom was a delight and a pleasure to care for. She enriched our lives. I urge families to ask for help. There is another way, and it can be beautiful and pain-free and dignified.

Time to say goodbye

I know that Mom hated her illness and was so frightened of her diagnosis. But as the months went on and Mom came to accept her situation, I felt so privileged to have the time together. Of course, nothing can ease the pain of bereavement but Mom's death was uncomplicated and peaceful, at home. We had said everything we needed to say.

For more information and support to talk about dying, see Dying Matters.

Your choice

Sometimes, when things get a bit tough, it is easy to forget that we have a choice. We have a choice about where and how we die. With a diagnosis of terminal illness, we are given plenty of time to consider our options, yet still, patients and their families are not offered the choice. The choice of whether to die at home, hospice or in hospital.

In our area, Surrey, I read that the authorities are letting terminally ill patients down at the end of their lives. They are not being offered a choice, clinicians are still reluctant to engage in these discussions. We were fortunate to know what we wanted, and who to ask to get it. And everyone was very obliging, but what if we hadn't known? What would Mom's death have been like then?

Surrey was in the lowest 20% of primary care givers in England for discussions between hospital care and peoples' preferences about where they want to die. And overall quality of end of life care was scored at just 40.5%, which I find shocking (reported in Surrey Advertiser  13 July 2012).

In response to the article, a spokesperson for Central Surrey Health wrote a letter to the editor (Surrey Advertiser 27 July 2012) saying that in the Epsom area in the last six months, district and community nursing teams had enabled 80% of patients to die in the place of their choice, usually at home. This is heartening and, in our experience, these nurses are fabulous at their jobs.

And then there was the sad letter from a concerned friend, who had lost someone special in hospital (Surrey Advertiser 13 July 2012). The patient had suffered a stroke and was critically ill. The clinical team had implemented the Liverpool Care Pathway, a series of clinical observations, actions and discussions with family, which ensures that the patient will have a dignified, comfortable death. There is no further intervention or treatment. The friend was so unhappy with this approach, and felt that the patient's illness should have been allowed to continue, with at the very least nourishment provided. Now, if only someone on the nursing or clinical team had taken the time to talk to the friend, her anguish could have been soothed and she could have been supportive.

I firmly support the right of everyone to have the choice. 

For more information and support to talk about dying, see Dying Matters.

If you have time, please pop over to #BlogFlash2012, where you will find the link to many other contributors to a creative writing challenge for August.

When your time is up

I am writing this today, the day after Tony Nicklinson died. I don't know his family, but I do understand how brave they are. To see your loved one suffer is so very hard to bear. We knew that Mom's struggle would be months, not years as in Tony's case. Still, our family was exhausted by our efforts to maintain her dignity and comfort at all times.

Mom knew when it was her time to go. Of course, she knew she had terminal cancer and treatment had been withdrawn. Her metabolism was slowing down, she needed little food and only small sips of water. Her eyesight was almost gone. Her right arm badly affected by the tumours growing in her chest. We drew each other close and talked about everything. It was a warm summer, and her beautiful garden was just a few tantalising steps from her bed.

Mom declined any medication which would sedate her in her last days. She accepted medication to help her breathe easier, but she wouldn't accept any increase in her pain medication. She didn't need it, as her body slowly, quietly went to sleep.

On that last Saturday morning in August, the nurses came to the house to prepare Dad for Mom's death. She was drifting in and out of consciousness, but when it was suggested that the morphine be increased she protested. Mom said her final good-byes and she died within an hour. Peaceful.

I have written about Mom's determination to die at home, with as little intervention as possible. We had all prepared for her death, we had talked at length about her wishes. We had done all the practical things. We had said our good-byes and given Mom permission to die when she was ready. In her own mind, she knew that her struggle was over. Her body took over and in its own time, began to shut down, bit by bit, until there was nothing left.

For more information and support to talk about dying, see Dying Matters.