this is bbc news. i'm kasia madera, and these are the headlines... prime minister rishi sunak says he's willing to discuss the issue of pay with the nurses�* union to settle strikes but didn't make a firm commitment to increase salaries. china has fully opened its borders for the first time since the start of the covid pandemic with international travellers no longer having to quarantine on arrival. the ukrainian military has rejected a russian claim that hundreds of ukrainian soldiers were killed in a russian attack on the city of kramatorsk. in his latest television interview, prince harry reveals that he felt guilty for being unable to show any emotion in public after the death of his mother, princess diana, saying he only cried once.

thatisit that is it from me for the time being. now, hardtalk. stephen sackur speaks to palliative care doctor and writer, rachel clarke. she asks us to consider a tough question — can dying be life—affirming? welcome to hardtalk. i'm stephen sackur. we humans know that one day we will die. but as long as our end has no specific timetable attached, many of us choose to shelve the thought, avoid it. covid, which took such a grim toll in so many countries, challenged us to confront the reality of our mortality. but still, health care professionals say what they call "death literacy" is lacking. my guest is rachel clarke, a doctor who made a choice to work with the dying, and who's written about it too, from a personal and professional viewpoint.

can death be life affirming? dr rachel clarke, welcome to hardtalk. thank you. now, you have had pretty much two decades of doctoring. how has that time changed the way you do the job? well, i think i was pretty naive when i started, in the sense that i went through medical school that taught me essentially how to fix broken body parts. so that's the way you learn medicine. a sort of mechanical

approach to medicine? yes. so, liver — how does a liver work? how does it break down? how do you fix it? then you'll move on to heart, lungs, brain. so you end up acquiring this kind of piecemeal, jigsaw approach to fixing broken bodies. and, strangely, given that most people want to become doctors because they care about people and they want to help them, patients as human beings are very often just sort of shoved to the periphery somewhat, and you're never taught overtly how to heal, how to imagine yourself in an empathetic relationship with patients, wherebyjust the act of talking with them itself can be therapeutic. so i think i came out of that very much of the mind—set that that was my job and if i couldn't fix the broken body parts, then i was failing as a doctor. and that meant i was

almost set up to fail. so, in a sense — i mean, this is blunt — but were you trained to park your feelings, maybe your empathy, at the door as you enter the surgery, the clinic, the hospital, whatever? yes, very much so. so, my first year, i dissected one single human body, sort of in increments, twice a week throughout a year. and that's a perfect example of what you're taught. so i was older than most medical students. they were all 18, fresh out of school. i was a decade older. but still, you're confronted with one of the ultimate taboos that human beings have — a dead body — and you violate it. you pick up a scalpel — and i was the first person in my group who violated this dead human being. but nobody talked about it, everybody acted cool. they pretended it didn't matter. and that continues all the way

through with senior doctors who appear to be completely cold and detached from the various violations that being a doctor involves. and just to continue the thought, then, if you were trained that medicine was a form of sort of high—grade biological mechanics, i guess the corollary of that is, if the body is failing beyond repair, if it's terminally ill, dying, and death is approaching, that is failure. exactly. the machine is broken and there's nothing more to be done. yes, exactly. and in exactly the same way as a mechanic will kind of wring the oily rag out in the garage and says, you know, "sorry, guv, nothing more to do here, send it to the scrapheap." so it is with a human being, if that's your approach. there's one extraordinary quote, and you use it in your very passionate and powerful memoir of your

involvement with dying and with death, but it's a story you tell about a doctor, a specialist who, having seen that a patient he was treating for cancer was beyond help, he said — quote — "there is nothing more for us to do here. send her to the palliative dustbin." mm. is that a prevalent feeling in the medical profession? er... it is not as bad as it used to be. so that was 20 years ago. i vividly remember it. i was disgusted, but too timid to stand up and say, "how can you possibly speak about a patient like that?" to my shame. it's less prevalent, and there is more awareness now that doctors have to be human beings. we are not doing a good job if we're not empathising with our patients. so things are getting better, but it's slow and it's...

there are still attitudes like that. doctors who dismiss patients once they have a terminal diagnosis. and i want to talk much more about how palliative care can and should work. but actually, at this point, i want to rewind a little bit, because everything you've told me so far suggests that you were a person who wanted to be a doctor because you cared enormously about helping people in their lives, particularly at their most vulnerable time when they have real health problems. i know "care" is a word that doctors are very careful about — showing emotion, engagement and all of that — but i'm just surprised in a way that you, after training, you wanted to be a doctor still because you'd left your previous profession, journalism, precisely because it didn't have enough meaning for you. and then you're being told by doctors, be very careful about investing too much in this health care profession. well, i thought that was complete nonsense. and it is what you're taught. so, perhaps unintentionally, a lot of senior doctors will encourage young doctors

in training to make themselves sort of hard as nails through their example of apparent insouciance as they move through this world of sort of broken, sometimes dying human beings. but i felt, perhaps with the benefit of a decade ofjournalism behind me, that i wasn't going to accept that, i was sceptical of that and i challenged that. and i can remember, even as a medical student, sometimes if a senior consultant plans to behave in a way that actually was going to distress a patient, i would stand up to them and say, "no." and i think i believed, i could see that although all patients were vulnerable, some were particularly vulnerable, and patients who were dying almost literally sometimes didn't have a voice. they were too frail

physically to be able to speak, to ask for help. and i naturally gravitated towards those very vulnerable patients. and far from feeling as though there wasn't anything i could do in this environment, ifelt the opposite. i felt i want to advocate, i want to use my skills for these particular patients, because it's not right that certain patients are kind of cast onto the scrapheap. you took a choice that most doctors do not make. you took a choice not to turn away from death, but to actually turn toward death and to focus yourself, give yourself to palliative care, the people in the last days of their life. yes. why did you do that? well, certainly not for the glamour or prestige! so in medicine, there's a great hierarchy, and you have your brain surgeons and your heart surgeons at the top. and palliative care doctors are definitely one of those specialities that are low status. we're not rock stars.

we're the support act that no—one wants to be and no—one wants our autograph. butl... i believed that... ..what i observed as a young doctor was that dying, in a way, is a more extreme version of what we all go through in our lives. we go through losses of one kind or another — of our health, of the people we love, of our resilience, our youth — and ultimately, that ends up with the final loss. we are mortal creatures, we will die. and we can and do, of course, live our lives in denial of that. we might drive ourselves mad if we thought about it every day, but nevertheless it's coming to us all. and what i noticed as a doctor was those patients who were very close to the end of life, not only were they being badly served very often by the medical profession, but they were also human beings who were showing such

astonishing courage, resilience, strength, determination to carry on living however little time remained of their life. and so i actually found it the opposite of depressing. i found it incredibly uplifting, because there is something about death's proximity, that sort of shadow leaning over your shoulder, that concentrates the mind. it forces you to think, "what do i really care about? my time is limited, it's coming to an end." and that's when i think people rise so often to their best selves, and i get to see that. and would it be true to say that the focus of your care, then, is perhaps less on the mechanics of medicine? because, by definition, people in hospices where you work, they are — they know, and their doctors know, that they are going to die fairly imminently, so the focus is less on the sort of mechanics

of fixing, and it's more on, in a sense, what's happening in their minds. and are you, in a sense, as much sort of psychiatrist as medical doctor? to some extent. the medicine of palliative care, the kind of hard medicine, is really interesting, precisely because palliative care patients often have a lot of things going wrong with their bodies simultaneously. so if your liver, your heart and your kidneys are all failing, working out which drugs you can safely give, which ones will make improvements rather than make things worse, is really challenging. so it's a very intricate... i mean, on that level, it's fine calculations about pain relief as much as anything. yes. but the really important question, and the one that i always ask every patient when i meet them for the first time — and it's a question that's sadly missing

from a great many medical encounters — it's this, it's, "tell me what really matters to you as a patient, because myjob as your doctor is to help you live however long remains of your life as richly and as fully as you possibly can. but on your terms — not mine, not anyone else�*s — your terms." and that question, i think, should be at the heart of every single medical encounter, but it often isn't — it's often kind of pushed to the edges by the medical machine. do you encourage people to take whatever medical options there are to prolong their lives? i mean, i'mjust thinking of cancer care, where there are experimental drugs offered — they can be very punishing to the body, but they might extend your life by three weeks or three months, or possibly a year. is it automatic to you as a doctor that you would encourage the patient to go down that track? no, and it never should be

automatic for any doctor. ourjob is to ensure to the best of our abilities that we inform a patient. so we give them the information about all of the risks and benefits of a treatment — for example, a cancer drug, more chemotherapy. and that's the most important thing to do that in a sensitive and clear way, and then discuss with the patient how that information marries with what matters to them. so, for example, i recently cared for a young patient, a young woman with young children. she has to get to christmas. she has to be there so that her little children — and they're pre—school children — will have one more christmas with mummy, and she knows it's going to be her last. so it's incredibly important for her to live for another five or six weeks because she's so desperate to get to christmas.

and that changes everything because we have to try and help that. whereas, if you have had sort of three years on and off of chemotherapy, every few months of it have made you feel rotten, you've been in hospital for a lot of it, you may well reach the point where you think, "i've got a choice. i may get a few more months of life if i have more of this. or i could just say, �*you know what? let's just ditch all of the hospitals, the tests, the scans, the rotten drugs that make me feel sick. i'm just going to live my life now and i'm going to go on holiday to ibiza." which, again, is something that recently someone decided. but you have to empower your patients to make those decisions for themselves. and too often doctors will fail in both directions. they may push somebody towards treatment without really exploring whether or not it's right for them, or they may write them off. and sometimes a patient may come to hospital and their doctor may think "they're 75, they've got terminal cancer, there's not much more we can do here." and, again, you just can't do that. you've got to talk

to the patient. your memoir of all of this is woven with extraordinarily moving stories, and it's clear that there is one heck of a burden on a doctor doing the work that you do. does it grind you down? are there times when, actually, you can't take the pain you see amongst both patients and theirfamilies, the horrible decisions that they have to take and that you have to take with them? does it get too much? it's a strange thing because i always at work want to be working in the most difficult situations, where somebody has incredible amounts of distress or pain, or young children, or something that makes it really traumatic. and that's not out of masochism. it's because that's when you metaphorically really roll your sleeves up and you're operating at the absolute edge of your abilities —

both in terms of prescribing and the medicine of it, and also the conversations you're having to have. so that's when it's most fulfilling, in a strange way. but, of course, it does take a toll. and when it really hit me hard was during the pandemic. i was on covid wards where, every day, i would be seeing patients dying in the same way of the same disease over and over again. and in the first wave in particular, we had no treatments. all we had was oxygen, nothing else. and to see patients dying with that speed and with that repetitiveness was soul—destroying. and i think i use that in a very precise sense. i felt as though my soul was being corroded away at points in the pandemic. but i got to do something —

i got to try and help. and i know i have lots of friends who desperately wanted to do something and couldn't bear the fact that they were sitting at home on furlough, not able to do anything. one of the hardest things it seems that you ever had to do is treat your father. i mean, you weren't his direct oncologist, but you dealt with your father's cancer. so you were a very loving daughter, but you were also a doctor who was analysing your own father as a patient. and, as it happens, he was a veteran gp himself. you write about it in a way that suggests to me that you were surprised that it actually hit you in the way that it did. despite all of the years you'd had in palliative care, this was something very different for you. yes. dad was diagnosed with terminal cancer from the outset. it had already spread. and he was my classical sort of hero father figure, on a pedestal.

i had worshipped him for as long as i can remember, since being a tiny little girl. and he was my rock. and if i ever had a problem in my life, he was the person, not only that i would call, but he would fix it. he would know what to say to fix it. and ifound it unbelievably difficult to see this man, who was such a colossus for me, steadily, relentlessly being stripped away by this horrible disease, both physically and mentally. he, towards the end, became frightened, became angry, went through periods of almost bitterness as he gradually adjusted to his diagnosis. i mean, that's interesting because what i think is important to say from what you write about death is that no amount of morphine is going to get rid of the pain. there is pain in death... yes. ..and it's notjust

physical pain. it's the grief, it's the sense of loss. and that is beyond drugs, and people have to confront it. exactly. yes. and i think we often hear these days of the concept of a good death, as though somehow, if you do death right, it's not going to hurt at all. do you ever use that phrase with your patients? "a good death." no, no. no, never. no. because of precisely what you've just alluded to. i think there is an inescapable, momentous horror to dying, in a way, for all of us. every single thing that we love in the world, every one that we love in the world is going to slip through our fingers one way or another when either we die or they die. and that's. .. you can't palliate or sugar—coat that. that's the price of being a human being. that's necessary suffering that goes with being human. but the other stuff — the symptoms around dying — we've got great drugs,

great meds. so how is it, then, that for you, as a doctor, so committed to this day—on—day addressing of the most difficult situations for patients and their families in hospices — how is it that you, in recent years, have also managed to convey so much political activism — and i'll be honest with you — so much rage about what you see happening to the national health service in england and wales? i mean, is there room for that in your professional life? well, in a sense, no. i'm always far too busy and kind of working too hard and juggling too many things. however, for me, being an activist and fighting and campaigning for the british national health service is absolutely just part and parcel of what i do as a doctor.

but by which i mean... ..patients are some of society's most vulnerable members. if you have a diagnosis of terminal cancer, you have got a tough time ahead. and we are meant to have a cradle—to—grave health service in this country funded by taxpayers, so that everybody in need receives high—quality health care. that's a defining principle of the country. interestingly, palliative care isn't entirely funded by the nhs. indeed, probably only a third of it is funded by government. absolutely. the rest of it is funded by charity, which i guess tells you something about the priorities put on palliative care. exactly. but more generally, i believe that every government — i don't care what political party they are — every government should honour those founding principles of the nhs and should be honest about what the nhs is achieving orfailing to achieve, and what is needed in terms of funding and resources.

can you go too far? just a couple... a quote from you on twitter, i think we took it from. "everything is falling apart in the nhs in the most catastrophic way. how, in a rich, civilised country can patients be dying on a trolley in a corridor or in a lift?" i mean, in a sense, is it helpful to the patients you are seeing on a daily basis to signal to them that you think the system of which they are now a part is totally failing? mm. that is happening right now in every hospital up and down the country. there are patients dying in corridors, in ambulances. they can't even get inside the hospital because the hospital is full. my hospital is on black alert today and so the patients are being diverted away to other hospitals because we're completely full. you say you're not political, but this is political. it's political in the sense that wanting a functioning

health service is political. i think it's important to draw a distinction between party political activism and campaigning for a principle you believe in. and i believe deeply in the principle of good—quality, universal health care. and so i believe i have a duty to be candid about that, because if we pretend it's not happening, it doesn't make it go away, itjust increases the chances of it never being fixed. final question — a significant number of doctors are leaving the medical profession early, many of them saying they no longer believe that the system is fit for purpose and they can't be a part of it. they feel — as you used the phrase earlier on — burnt out by it. could there become a point where medicine no longer feels right for you ? never, ever, ever. i will fight for my patients and for this beautiful nhs. the principles of the nhs are just about the most

wonderful thing we have in this country. i will fight for them for as long as i'm possibly able to. and i... i can't imagine living now not being a doctor. i love it to bits. dr rachel clarke, it's been a pleasure having you on hardtalk. thank you very much. thank you. it certainly has been a sundae of sunny spells and scattered showers, don't take my word for it, look at this picture. beautiful rainbow in the sky and cornwell, but wet weather on the roads as the show is

eased through. there is going to be further shows to come over the next couple of days, and overnight we still keep the low pressure to the north. most of the shows at the west, look for a time we will see some clearer skies. favourite spots that will be through eastern scotland and eastern england, and under the clearer skies, temperatures are likely to follow way. it will be a chilly start on monday morning, in comparison to of late. we start off on monday with low pressure to the far north—west, wind direction swing around to a north—westerly, a fresh resource, that will drive 20 shows into northern scotland, northern ireland, west of england and wales. some shows are push further east where we will see some drier and brighter weather. we willjust scrape double figures somewhere in the south—west. as we go through monday evening, for a time we will have clear skies, but out to the west is the next set of fronts that is going to bring out

cloud and rain. we will start to see temperatures a bit milder to begin with on tuesday morning. for tuesday, it will be a wet and windy day for many. these frontal systems will start to push their way steadily northwards and eastwards, and we will start to see this wedge of milder air arriving as we go through the day. tuesday will be e—mailed today, with the wind direction swinging round to a south—westerly. quite a lot of cloud around, quite wet at times. there will be... it will be a windy afternoon. gusts of winds from any of 30 mph. we could see highs of 14 degrees in the south—west. tuesday will be mild, wet and windy, those frontal systems will ease away, when swing round tomorrow more of a westerly, so it won't be quite as one, and because it is in a westerly

direction it will still feed in showers from the west. throughout the week, it was a pretty windy at times, and stay quite unsettled.

this is bbc news — welcome if you're watching here in the uk or around the globe. i'm kasia madera and these are the latest headlines: uk prime minister rishi sunak says he's willing to discuss pay with the nurses�* union to settle strikes but there's no commitment to increase salaries. when it comes to pay we've always said we want to talk about things that are reasonable, that are affordable and responsible for the country. international travellers are streaming into china after it fully opened its borders for the first time since the start of the covid pandemic. translation: downgrading covid doesn't mean letting it rip. - rather, we are more scientific, targeted and efficient in our response. the ukrainian military has rejected a russian claim that hundreds of ukrainian soldiers were killed in an attack on the city of kramatorsk.