33 meditations on death
The author is a geriatric physician spending his entire career with people moving toward the end of life. His first hand account and deep understanding of human conditions lead to many insights that are very informative for people outside of his field.
“Life itself is a sexually transmitted condition with 100 percent mortality”
Existence and Quality of life
There is a big difference between enjoying a meal with your loved ones and lying in a tilted chair in a nursing home on your own being fed a tasteless liquid feed.
Flaws in fee-for-service system
Geriatric medicine had a hard time establishing itself in North America, or any country with a fee-for-service-funded health system. This is partly because doctors get paid for doing things: operations, investigations and procedures. And so things are done to generate income. Taking a full history, performing a full examination and thinking about what to do doesn’t cut it.
Medicine: expectation vs reality
Much unhappiness stems from a ‘bogus contract’ between doctors and their patients, which leads to dissatisfaction on both sides. In other words, from the gap between what we expect and what we get.
Patients believe that modern medicine can do wonderful things and will cure all their ills. They think a doctor can look inside their body and know what is wrong. That doctors know everything about medicine and cannot really make mistakes. That doctors can help even with social and personal problems. And that because they can do all this, they deserve status and money.
The doctor’s side of the contract is very different. Doctors know that medicine is limited in what it can achieve and can at times be downright dangerous. That medicine, like life, is complex and unpredictable. That there is a fine balance between doing good and doing harm. That they can barely scrape the surface of patients’ social and personal difficulties. As a profession we have not been upfront and wholly honest about this. Confessing what we don’t know would undermine the status in which we are held.
Setting things straight
We need a new, unwritten understanding between patients and the medical profession.
Here are a few basic principles it should enshrine.
Death, sickness and pain are part of life. There are limits to what medicine can do. It cannot solve society’s ills or a person’s social or relationship troubles. We, as doctors, must be open and honest about the failings of medicine. Individual doctors have different skills and don’t know everything. They also sometimes get things wrong. Too often they become the passive recipients of a technology they can barely comprehend, for little or no health benefit and potentially much harm. I’m not convinced that hospitals are for everyone.
The doctor and patient must work things out together. Patients cannot just leave their problems at the doctor’s feet.
Power of suggestion
We are here to make people feel better through our skills in medicine and surgery, but this is only part of the story. All that expertise falls flat without the healing power of personality. A tablet prescribed with a blank face may work but a medicine prescribed with the reassurance that ‘I’ve found this works well and you should be feeling better in a few days’ will work better. A patient does not want advice delivered in a monotone but with a bit of enthusiasm and panache.
Medicine and legal system
The legal system is adversarial by nature. Court cases are structured like a battle – albeit a civilized battle. One side stands up and tries to humiliate and discredit the other side. One side wins but both lose. Medicine is all about grey areas and consensus. There is seldom absolute clarity in important decisions. If things were that simple these decisions could be made with some clinical algorithm. Life is not like that. I rarely feel resentment towards relatives who insist on futile treatments that serve only to prolong their loved one’s suffering. Everybody wants what is best for the patient and people’s views, even if I find them bizarre and ill judged, are none the less heartfelt beliefs held in good faith. I cannot know in what furnace their ideas have been forged. Perhaps the furnace of guilt, religious conviction, poor education, an abusive past? Who knows and who are we to judge.
With every public condemnation of healthcare staff who have shouldered the responsibility of serving society, their willingness to take risks and think fast is eroded. Ambulance and paramedical staff will not just dust down and check over an old person who has fallen and leave them in peace at home but will, for safety’s sake, bring them into hospital. The emergency department staff will likewise be reluctant to discharge the patient and will admit them. The ward staff will be risk-averse in discharging and the length of stay will increase. The crisis of bed occupancy in our hospitals is as much a consequence of fear of litigation and complaints as it is due to a genuine shortage.
Cost of care
A Dutch study showed that the amount spent on health in the last year of life is thirteen times more than the expenditure in other years
Problems with attitude
Interventions that can be borne by a forty-year-old may be little short of torture for an eighty-year-old. A shift in attitude towards a more traditional view of death would free the health service from its current role of overseeing the time-consuming and costly overtreatment of those with little if anything to gain from it. Medicine, and especially medicine dealing with the very old, should be about what matters most in people’s lives. This should be our new priority.
“Emotion neither proves nor disproves facts.”
What can be easily measured might not be what should be measured nor focused on.
Trials measure outcomes. These outcomes have to be simple things, easily measured, like death, admission to hospital or strokes. But with the very elderly what matters is health – a general feeling of wellbeing that is very hard to measure. I am a strong advocate of evidence-based medicine but we should not worship at its altar with a totally unquestioning faith. In the very old and frail, perhaps we should remember the fifth ‘M’ of the new definition of geriatric medicine and concentrate on what ‘matters most’. And if that, for an individual patient, is sitting under a tree, smoking a pipe and drinking wine, then so be it. When EBM finds a way of measuring what matters most in people’s health then I might change my mind.
Clinical decisions vs Inquiries
Real-life decisions are made in real time – forward time – which is limited. Real-life decisions are made with incomplete information and with all the background noise and distractions of having to care for a multitude of other patients simultaneously. Inquiries are conducted in retrospect with all the time needed to contemplate all the options.
“Broadly speaking, most care is good enough. Perfection in clinical care is like perfection in parenting. It’s impossible.”
Living life
We can only do so much to prevent death. We must not smoke, period. Make the effort to exercise, drink alcohol by all means, but not to excess, and try to eat a reasonably healthy diet. Outside of this we are just like a huge herd of buffalo roaming through the prairies. To the side of this herd, and slightly out of view, are God, Allah, Krishna and all the other gods we have created. Among them are Jeremy Bentham and Voltaire, representing the atheists. These gods and philosophers, armed with bows and arrows, are shooting at random into this herd of rather self-important, smug buffalo. So do not ask, ‘Why me?’ Ask, ‘Why not me?’ If you haven’t been hit yet, give thanks to whatever god or philosopher you follow and get on with having the best life you can.
Living will
We can look into the future and, when lucid, set limits on the interventions we will accept as appropriate and desirable. We can document these views and share them with our loved ones and those health professionals we trust. Yet individuals alone can take these plans only so far. Society needs to have the big discussion about letting go and rejecting suffering-prolonging intervention.
We all need to decide, and document with our families, what type of old age, and what trajectory of decline, we want and what we do not want. At some stage we should decide when it would be appropriate for us to stop our preventative medicines, flu jabs and all the other paraphernalia. If we request not to be given antibiotics should we get pneumonia, it follows that we should agree not to be admitted to hospital and not to be put on a life-support machine. There is no point allowing oneself to get a life-threatening condition and then going through all the treatments for it.
When should these decisions be made? Probably sooner than we would all expect. Seventy? Seventy-five? Eighty? There is no optimum age, but certainly they should be made long before cognitive decline impairs judgement. And who should be made aware of these decisions? Everyone who you trust and is dear to you, and certainly your GP.
“The sun rose and set as the universe ground on with its benign indifference to all our individual suffering.”
Why are we performing procedures with virtually no chance of success on people with very little time left in this world?
Dad was adamant that he wanted his cataract surgery but he had little insight into the minimal chance of any meaningful benefit. The reality is that it is sometimes easier to do an operation or procedure than go through the exhausting task of trying to communicate risks and benefits to a cognitively impaired person.
A huge input for little discernible gain.
For most of us, those extra months and years spent immobile, in pain, deaf, blind and disorientated are not going to be the most treasured of one’s life.
We cannot science ourselves out of every problem. We all need to realize that when there is so little left that even our memories have deserted us we have to throw up our arms and proclaim ‘Obesa cantavit!’ The fat lady has sung.