What to do about dying? – with Richard Smith and Libby Sallnow Episode 25 of the Health Foundation podcast

Jennifer Dixon: We don't like to think about death. Sometimes we can't avoid it. Someone we know personally dies, someone well known like the queen, events like the pandemic, natural or other disasters. The truth is, most of us prefer not to think about it, or plan for the inevitable. To many, death and dying just have no value and are relegated to the margins of our lives. But about half a million of us in Britain die each year, mostly in our 80s with half of us dying in our usual place of residents that is in our own bed. That's still half of us dying somewhere else, usually in hospital, although a tiny minority of us want that. We also receive a lot of medical care at the end of our lives and spend a lot of precious last time receiving it. About a quarter of us have three or more emergency admissions in our last year. Not to mention all those GP and outpatient visits, all the tests, and so on. The clinical staff caring for us might have little experience of death and the dying process. And palliative care is stretched or unavailable. Families and carers are not always confident or supported to help. What could be an enriching and meaningful phase of life can become over medicalised. But more than that, transactional and personal, costly, lacking humanity and feared. Now, we've all known about this for some time, but change has been slow. In January of this year, The Lancet published a five-year inquiry, a commission on the value of death looking at some of these questions. It was chaired by Dr Richard Smith, former editor of the BMJ. And he was joined by many commissioners including Dr Libby Sallnow, a palliative medicine consultant in the NHS and academic. And I'm really delighted to welcome them as guests today to discuss this thorny question, how we could die better in the UK. Or as the commission report title put it, how to bring death back into life. Welcome, both. I think the place to start is to ask a little bit about The Lancet Commission on Death and Dying. How did it come about, Richard? 

Richard Smith: Well, I must confess straight away that it has very ignoble origins. It drew out of a very drunken dinner that I had with Richard Horton, who is the editor of The Lancet and I've known for a very long time. And he's said, ‘Richard, you must do a commission.’ So I thought about it and I decided I would like to do one on death because I think we have, as a society and probably as a broader world, a very unhealthy relationship with death and dying. Almost everybody has a story of a bad death. And there are lots of people we know from evidence dying badly, often over treated at the end of life, increasing suffering. I mean these are, of course, the same problems that Cicely Saunders and the palliative care people identified years ago. But I think, unfortunately, palliative care has not been an adequate response. It has sort of turned death and dying into a specialty. So, whereas it was once the province of all health professionals, doctors, nurses, and even more of the community and priests, it's increasingly become a sort of medical issue. And also, I have to say that I thought the way that we relate to death and dying reflects broader problems with the healthcare system and social care system. 

Jennifer Dixon: And I think you say somewhere in your report that death and dying are relegated to the margins of life. And you wanted to bring death back into life. And, in doing so, you spent five years looking at a whole variety of aspects of death and dying. So I wondered whether you could just chart out for listeners what were the main elements of this huge project? 

Richard Smith: I mean, one of the things I should say straight away is that The Lancet has a policy that all of its commissions must have half of the members coming from low and middle income countries. And that actually, turned out to be very rich because when you think about this as a global problem, you get a very different picture in so far as in high income countries. And, unfortunately, increasingly in some low and middle income countries, lots of people are being over treated at the end of life. But at the same time, the majority of people in the world have very limited access to opiates at the end of life. And very limited access to any kind of even basic palliative care. So, you've got this paradox. And that's very central to the way we've thought. And we identified, of course, the nature of death has changed quite dramatically in the last 60 years. So the causes of death, I mean when the NHS began, people died from infectious disease and trauma. Now, most people are dying of noncommunicable disease. The commonest cause of death in women in this country is dementia. The length of dying, whereas death was often quite quick and sudden, it's become very long. The technology has moved on so that whereas when the NHS began, doctors really had very limited ability to keep people alive for longer. Now, they can. It's changed quite dramatically. But also importantly, death has sort of changed from being something that was primarily about families, communities, it was a cultural and spiritual thing to being a medical event. And I don't think this has worked well either for the community, or for health professionals. People often talk about death and dying being denied. But we don't think they're denied. There's lots of conversations about death and dying. But death has become very unfamiliar. You can find lots of people in their 40s and 50s in Britain who have never seen a dead body. It's sort of disappeared. The dying are taken into hospitals, or hospices, or care homes and then they're whisked away when they die. And also importantly, huge resources are spent on treating people in the last year of life. We did a lot of analysis on that. And we reckon that about 10% of the expenditure of health systems is spent on the 1% who die in that year. And I think that resources could be much better spent, certainly, from the point of view of the community but also from the point of view of the individuals.  

Jennifer Dixon: Yes, the kind of picture that's painted is that we're in some ghastly medicalised death system where there seems to be very little choice. 

Richard Smith: Recognising that death has value, I think, is very important in all of this. So death is needed for change and development. The whole of evolution is based on death. And without death, every birth would be a tragedy. And we're sort of hovering on the edge of that already. And the fact that we all die, that life is transient, I think binds us together. And also, very particularly sitting with the dying teaches us how to die. And, in a sense, we are given a gift. And lots of palliative care people can talk about that. But I think our big sort of breakthrough in a way was to recognize that these problems with death and dying, it's a systems problem. It's not down to doctors, or undertakers, or the public, or politicians. It's the whole system that needs to change. And I think a lot of the interventions that have been tried before have not thought about the whole system. So we argue that we need to rebalance care involving families and communities much more. And, of course, the reality is that they do most of the work anyway. And we'd like to see them importantly leading, not having to follow what health professionals are arguing. So health professionals, of course, are important but they would be supporters rather than the people leading it. And I think that shift in power needs to happen right across the health and care system from the services and the professionals to the community and families. 

Jennifer Dixon: Yes, the kind of picture that's painted is that we're in some ghastly medicalised death system where there seems to be very little choice. And your report sort of goes up well upstream to try to understand the factors that led us here, which could help lead us out. So you go into of spiritual aspects, cultural, historical aspects of death, which was really interesting. And it makes the report very, very comprehensive, not just a kind of medicalised report. Libby, I don't know whether you want to say something more about the other aspects of the report. 

Libby Sallnow: Yes, and I think as Richard just mentioned, our central contention was death is over medicalised. And that's kind of where we started. But, of course, with all these things as you begin on picking, you begin to realise that actually the problems don't start in an outpatient clinic, or in a hospital ward where discussions are being had around treatment options. They take place in a much broader system. And it was only really when we began going upstream and exploring these broader determinants that we began to actually understand the complexity that health and social care have a huge role to play, but actually so do the much broader societal points. And we're very used to talking about the social and structural determinants of health. And that's been a huge shift really in terms of understanding the contributions to health and to health outcomes in the broadest sense and the role of the social and structural within that. But somehow in death and dying, it's been seen almost just as a failure of public health interventions, as a failure of medical interventions rather than actually being understood as a part of health and wellbeing. And we really strongly try to shift that idea that actually death and dying are a part of health and wellbeing and not just their failure. And actually it's healthy to die. Death is a part of life, it's integral to life. And we have somehow lost that. And this doesn't sit just within hospitals, although we spend a great deal of time understanding what is the role healthcare playing within this, but actually how we go further upstream and learning from examples around the world, both historically and contemporary. 

Jennifer Dixon: Yes. And can we just take a detour into COVID because paradoxically, although death is closer because of COVID, it may also have hardened views that we have to redouble efforts to medicalise, to find solutions, to use science that's going to save us. 

Libby Sallnow: We thought at the beginning of the pandemic, we had one of our meetings of commissioners and we wondered whether it would actually make death seem more real. And bring a deeper understanding and reflection with so much death being discussed in the media and brought home personally to people. But, as the pandemic evolved and as more commentators discussed, it seemed actually that it was a success story of science over death. And continued these kinds of broader narratives that we see around immortality, increasing human life expectancy. And this idea that actually one day death will be defeated. And that is a very powerful narrative that actually underpins a lot of scientific research, funding calls, certainly healthcare. The idea that one day we will beat all these different diseases and then at some point beat death. And I think as a fundamental goal, we would question that. And at the beginning of the commission report, we went out to speak to a range of different people who were in charge, essentially, of understanding different budgets, and research and setting those agendas. And asked is the idea to cure every single disease, but what will we die of? And actually people, you might want to say something a bit about some of the responses we got. People didn't quite know where to go with that, but it is quite an implicit assumption. 

Jennifer Dixon: Yes. And, at the same time, in the pandemic we had the overwhelming thought that the scientific cavalry were coming over the horizon to save us all. We also had at the other end that the paradox was, as I think again you put in the report, that you have the ultimate site of a medicalised death with individuals separated from family and friends. Treated by people in hazmat suits dying alone in the circumstances nobody would want. So the two things were almost stark, weren't they? Those conflicting thoughts. 

Richard Smith: We also saw sort of communities mounting a response at the beginning of the pandemic, people connecting in ways that hadn't connected before. But unfortunately, that seems to have fizzled out perhaps, because it hasn't been adequately supported. I mean when we thought about the pandemic, we began to realise that the pandemic, the climate crisis, which I think is going to begin increasingly to dominate everything and the way we respond to death and dying, all have similar origins. We are denying that we are part of nature. We think we are masters of nature. One of the things we do in the report is imagine different scenarios of what might happen in the future. But one thing we imagine, which has actually happened since we originally imagined it, is that health systems are overwhelmed. And plenty of health systems around the world were overwhelmed by the pandemic. And we began to realise that if we had a system like we would like to see, that was much more community-based, much more around families and relationships that would be a much better way to respond to the high levels of death that may come from another pandemic, or will come from heat waves, or from the problems that we are facing as climate change cleverly ratchets up. 

Libby Sallnow: And I think COVID really exemplified the paradox that we have at the heart of our commission report to say that how people are dying around the world, there's not one story. COVID exemplified people being hugely over treated, treatments that are not going to necessarily increase their life expectancy, or their quality of life. And, in many examples, just extend the dying period and actually increase suffering. Whereas while we have other people often down the road in the same country or across countries where they have no access to basic opioids, or preventative services for curative cancers. And this kind of huge paradox that we saw anyway, as we began looking at some of the evidence when we compiled this for the commission, COVID then came in and just, as it did with many things, shone a huge light on that and really demonstrated this huge polarizing experiences really. And the Palliative Care and Pain Relief Commission by The Lancet that was published a few years before demonstrates a stark in inequity where the majority of the world's population cannot access simple morphine for pain as they're dying. And yet, you've got other people needing to put advanced care plans to prevent themselves having treatments that they don't wish to have. So there's something really wrong there. And we would really argue that it's not that death is being devalued, it's being fought at all costs. 

Jennifer Dixon: So you've got these powerful forces, which pull people into a medicalised environment. And in the last year of life in particular. So how do we counteract that force then, both in the healthcare side but also, more importantly, wider in the communities and families in particular? 

Libby Sallnow: Well, I think the first step, which has been taken in a number of different settings around the world is to realise that death, dying and grieving are not medical challenges. They're social processes, they're universal. So when you're looking at population health, or public health response to things, there needs to be a kind of understanding first, these are social events and they are normal, and they will happen to everyone. And the next part then, is to understand the kind of response that's needed. I'm a palliative care doctor and an academic, so I spend a lot of time caring for people in their own homes. And I talk about the idea that actually healthcare creates a kind of platform on which death, dying and grieving can take place. It's very hard to do that if you are in great pain, or if you don't have kind of support, your family are frightened to know how to deal with certain symptoms. So you need healthcare in there to manage, and social care to manage, to create those kind of supports and manage those symptoms. That doesn't create a good death. What you then, need to look at is those much broader issues. Death and dying are relational, the kind of person you've been, the connections that you wish to have with your family, the things you wish to say. And actually, at the moment, healthcare is obscuring those contributions. It's kind of pushing back so that it becomes centre to stage and there's no space for other contributions. And around the world we see where death and dying have been reclaimed really. And seen as part of life and as everyone's responsibility. So in Kerala, we've seen over the past two decades a really radical reframing of what death, dying and grieving mean in society and how there should be responded to. Kerala has a strong history of civic activism and some doctors in the '90s realized that the care they were delivering to people as they were dying was hugely inadequate. Much like the hospice response movement in the UK in the 1960s. And they went out to the communities and said, ‘What should we be doing? How are people dying?’ And the community said, ‘Well actually this is something we need to be involved in.’ And so, they started a volunteer movement, a huge kind of social movement it turned into. They had the first palliative care policy that explicit incorporated community participation anywhere in the world back in 2008. And that spread throughout Southeast Asia and increasingly into the UK to, say, actually if we turn these I this idea that living with a life limiting illness are medical issues, but there's social components. If we flip it say there's social issues with medical components, then that's really what we say death and dying today in so many settings is unbalanced. And we need to get that balance back. And it's not to say we don't need palliative care, of course we do, and inequity of access is shocking and we need to address that. But it can't be the entirety of the response. And I think I see that as a palliative care doctor, often death and dying is conveniently kind of swept up into palliative care. But of course, it's much broader than that. So you have death from suicide, from miscarriage, from trauma. And actually, we're not having a kind of joined up response to understand this and how loss is experienced by us in society. 

Jennifer Dixon: How would that work in a place like the UK, where there may not be such close knit communities in some parts? 

Libby Sallnow: So when we had spent a lot of time, lots of different palliative care thinkers had understood what was happening in Kerala. And the question was whether it would work in the UK? And a lot of people said it sounds a bit utopian, sounds quite risky. What will these models of volunteer care at the end of life, what will this be? I was working in a hospice at the time. And we partnered with a community development charity to help us begin understanding how you would work beyond an institution. And we started something called Compassionate Neighbours that's now running across the whole of the southeast of England through a number of hospices. And the idea is you go out to the community to say what is it like to be caring for people? What's it like to die here? What are the kind of things that you feel are working? And what are the things that are not? And a hospice really kind of acts as a catalyst. And people were worried that no one would want to come forward. Death is private. We're kind of a society often, that doesn't have the kind of explicit kind of social capital that you might see in other close-knit communities. But actually, we were overwhelmed. I mean, the waiting list to take part in this was enormous. People were really, really keen to come and take part. They said these are universal issues, these affect all of us. And actually, many people were coming because they'd had bad experiences. Or they had experiences that they wanted to share. So people come forward, they're put into kind of groups that are around a particular street, or an area. And they talk and understand what it's like and how people can be supported in that local area. And then, many people are matched with someone who's dying, or caring. And they then, begin a kind of supportive relationship. It's different to befriending services. Hospices have had a long history of befriending services. But these are kind of service-based responses to loneliness. And I read a great reporter a while ago, which likened befriending services to food banks. You get to the point where you are so desperate for connection and you've got none of your own networks that can give you that you need to go to a service to kind of almost give you a bag of food for that week, give you some companionship or some connection. And actually, what we need to be looking at is how we create these networks to exist around all of us. And we know that relationships and networks are good for our health. Huge meta-analyses demonstrating that they not only are good for a range of health outcomes, people live longer. And that's very clear. And just as important at the end of life as it is at any other point throughout our lives and across the life course approach. So about building networks, building relationships such that when the time comes for serious illness, loss, death, grieving, there are people to support. Rather than this kind of isolated response, which often just means a palliative care nurse, or a general practitioner coming in, giving you some medication, leaving. It takes more than that to die well. 

Jennifer Dixon: And do we know who comes forward to volunteer in this way? To work in this way? Are they people from all ages? Are they generally older people? Who are they? 

Libby Sallnow: Interestingly, very different to the classic hospice volunteering model demographic that's often older and female. But we saw lots of young people who were working locally, had moved to London, felt very disconnected just staying in a flat and really wanted to be part of the local community. We saw many older people who wanted to share the experiences that they'd had of caring for people and supporting people. We had lots of young mothers who felt they had time in the day. And I mean it was hugely different. And what we saw in East London, which is obviously an area with of great diversity, is that we had participants from across all different ages, ethnicities, geographies. And at the beginning the hospice was quite surprised and wondered whether people would actually come together. But when you begin asking people how have you experienced loss in your life? And actually, that cuts across difference because everyone can reflect on a bereavement, a loss, a caregiving experience. And we saw some of the most amazing experiences being discussed. And people were talking about things for the first time. And it's hugely levelling. These are universal human experiences that all of us will experience. And a bit like we were talking at the beginning around what is the value of death? And we struggled with this quite abstract concept of how to really get that across, the idea of death as a gift. But death is unwelcome, and sad and difficult. And we're not trying to kind of romanticise that. But there is something that we can access, our shared vulnerability, our commonality, and it's a way of connecting and understanding what life is really about. And that unites people. And so, when you begin having conversations on that level, then you suddenly have a very different response to say, ‘Okay, well actually what would a response to people on the street, or in this local area to help them die well?’ And once you start at that, then you can build up some very powerful responses. 

Jennifer Dixon: I've also been reading, and I think you put in the report something called the ‘End of Life Doula Network’. Could you explain that to people? 

Libby Sallnow: Many people might be familiar with the idea of a birth doula, who supports mothers, families around the process of birth. And the movement of death doulas started, there's lots of different people around the world, different initiatives set up throughout the world for death to develop the idea of death doulas. And the idea is that they're bridge between the family, the dying person, the carer who are kind of very much intimately involved in caring for that person and the broader healthcare systems, or funeral systems, the kind of broader death systems as we name them, really that operate. And often, people don't know how to navigate them. They can be quite overwhelming. The same with most healthcare system. We know that there's social gradients, the same with access to all different types of health services. Those social gradients are just as prevalent at the end of life. And so, death Doulas are trained people, some people pay, some people don't. It's not a kind of regulated field. But they will come and accompany someone on the journey. And this may be hands on care, supporting the carer. It might be advocacy, helping them decide on their wishes and where they'd like to be. And sometimes it's around funeral planning and supporting carers to understand what the dying process is. The key thing that they're trying to get to really is this concept of death literacy. And the idea that, same with health literacy, we have lost some of the kind of skills, the knowledge, the confidence to deal with these issues that we will all face. And they are there to try and fill in some of that knowledge, that skills, that gap. And there's a lot of examples around the world of how we might build death literacy, the same as you need to improve health literacy. That's one of our key recommendations actually, that there must be efforts globally to increase our death literacy. We often, as Richard said, don't see someone dying until much later in life. And it feeds a fear. And I see that so much in my practice that when I go to support people at home, people say, ‘What happens to people? How do they change? How would I respond?’ because these are so unfamiliar. And actually, that then feeds this fear. And it feeds this further dependence on medical responses. 

Jennifer Dixon: So talking about death literacy in your report, there are some interesting examples. You call, you talk about, death cafes and death festivals. Can you just say a little bit about what are some of the big ways to try to improve death literacy? 

Richard Smith: I think the kind of core finding in our report is that this is a systems problem. And we recognise that so many things are a systems problem. Obesity is a systems problem. Climate change is a systems problem. Antimicrobial resistance. And that therefore, we need a systems response. And I think if we're honest, we have to say that we as a whole group of thinkers about health, we're pretty ignorant about how best to respond to systems problems. But one thing I think we do know, if you want to change a system then fundamental to it is changing how people think about death and dying. Now, that's not an easy thing to do. There are death awareness programs here that are being run. There are, as you say, death cafes. And I went to the death festival on the South Bank. It's funny you laugh because that's how everybody responds to the idea of a death festival. But it went on for three days. There was music, there were plays, there were discussions. And it was a tremendous risk that they took because they weren't really sure whether anybody would turn up. But they had to turn people away. And I think it shows that there is a big appetite for this kind of thing and that we need to find better ways of doing it. And I think some sort of bottom up, locally based form of talking about death and dying is probably a better way to go than kind of mass campaigns. Although, maybe we need those as well. I mean, simple things. I think if we were to stop hiding death, I wonder, for example, if the queen's funeral, if it had been an open coffin, as of course happens in lots of communities, would that begin to make us think differently about death and dying? Sharing stories about death and dying. We put a lot of emphasis on the report, on narrative. And actually I think, in some ways, the discussions around assisted dying, because when you start talking about death and dying in a political context, the first thing that comes up is assisted dying. And maybe conversations around that. Not so much assisted dying as a solution because it isn't a solution. Again, it's a sort of limited, almost technical response. And then I think, very importantly, much more conversations between health professionals and people, not just when they're at the end of life, close to death, but much earlier. I mean, we talk in the report about the difficult conversation, which is a phrase that people don't really like because this conversation about the end of life shouldn't be difficult. We know it's going to happen; it's going to happen to everybody. And so, people prefer the essential conversation. And much better if that happens further back in the process. Not when people are days or weeks away from death. And then, I think there is a role for things like power of attorney. I mean, I hope everybody here's got a power of attorney about the people they love, advanced care plans, advanced directives. These are not solutions. But all of these sorts of conversations can help change the way we think about death and dying. And view it in the end as something positive, something that has value, something that's fundamental to life, not something that's to be pushed on one side, and ignored and hoped it never happens. Because of course it will happen. 

Libby Sallnow: And I think there needs to be so much more space given to discussing well, first of all, acknowledging and recognising that death and dying will happen and is universal. Because we looked at a lot of policy report strategies, guidelines from the UK and globally. And actually so many healthy aging reports, responses to COVID, to serious liver disease, dementia. No one mentions death and dying. And actually in a lot of strategic reports in the UK, for example, death and dying is seen as a subset of palliative care, as a subset of personalised care. These are universal events. These are not owned by palliative care. And palliative care only sees a tiny fraction of people dying because you die from a multitude of different causes. So until I think we give more space both within communities and within healthcare settings and social care settings, but also in those much broader policy space. We must understand not only are death and dying part of life but understanding the implications for poor bereavement. These have huge health and social care implications and huge economic implications, but some how they're kind of hidden away. And that might be all of our own personal difficulty with dealing with these issues. We just need to make them more front and centre. And, particularly, with an aging population and the prolonged dying phase that many people have, these are going to be more and more prominent issues over coming decades. 

Jennifer Dixon: So Richard, you've got this huge report, it's really thought provoking and so I recommend everyone who's listening to this to take a read at least of the summary. What would you like to see now happen to begin to address some of these things? Not just the medical side and the palliative care side, but actually some of these wider social determinants, which is probably the most interesting angle I think, isn't it? 

Richard Smith: We make a whole heap of recommendations. And we set out these ideas of a realistic utopia, one that can be achieved. And we are arguing that this is a systems problem and that we have limited understanding of how best to change systems, which I think is why many of the interventions that we've tried before have not been that successful. So I picked out three things, which of course is slightly crazy in the context of a systems problem. So I think encouraging death awareness programs, having many more discussions about death and dying is going to be fundamental. Then I think working with communities and get them to analyse the death system in their community and think about how they would like it to change, which would include changes in the health system because I think there've got to be changes there. And I think if they were led by the community rather than by professionals, they might be more acceptable and work more effectively. And then, I think we do have to work within health and care and recognise that death and dying shouldn't just belong to palliative care. I mean, one of the palliative care physicians on our commission joked that the NHS is not really cradle to grave, it's cradle to system failure. And then, you get handed over to a hospice. And we need to work with health and recognise that everybody in the health and care systems needs to be comfortable with people at the end of life. Recognising that sometimes they will need specialist palliative care to help, but much of the time they won't. And there needs to be education at every level from medical students, nursing students right through. So those are the changes I would pick out. Last word I would say is you urged people to read our report. I think, we've struggled to capture the essence of it in simply the executive summary. So if people can possibly find the time, please read all of it. 

Libby Sallnow: I think I would echo much of Richard's points and really leave with a challenge to us all, both personally in our lives and professionally, that we must recognise our role in systems that support or inhibit good dying and grieving. And this will be our role as people, as professionals, we must look beyond palliative care and we must look beyond healthcare. We must look beyond social care. All of these have crucial roles. But actually, we have to understand the role of media, the role of museums, of how we can create healthier attitudes, better conditions, and a way to support people to die better. So I would challenge us all to understand that we have a role in this. We then, need to start having conversations with other people in the system. These systems are often invisible and we need to make them explicit. And link up these different areas that are not having conversations at the moment. The challenge is to understand our role within it and begin making links and relationships across these systems. 

Jennifer Dixon: So sadly, we must leave it there. A lot of food for thought. I hope you agree. Thank you so much to Richard Smith and Libby Sallnow for their reflections and for their great work on The Lancet's Commission on Death and Dying. Please take a look. We'll put the link in our show notes, as we always do so take a look. We are also setting up an email address for those of you who would like to comment on the podcast or give us suggestions. And the address there is podcast@health.org.uk. That's podcast@health.org.uk. And we'd love to hear from you. So next month we'll be turning back to the NHS and how to sustain it in the future through faster improvement. Until then, goodbye for now. This podcast was chaired by me, Jennifer Dixon, with supporting help from Kate Addison and Grace Everest from The Health Foundation and produced by Malt Productions. 

• The Lancet Commission on the Value of Death (2022) The Lancet
• Overdiagnosis and overtreatment during the covid-19 pandemic (2021) BMJ
• Neighborhood Network in Palliative Care (2022) Centre for Health Market Innovations
• What is an End of Life Doula? (2022) End of Life Doula UK
• The Lancet Commission on Palliative Care and Pain Relief (2018) The Lancet