The normal process of dying has been hijacked by medicine.  It is not a cruel deception and it is not what the elderly want; not what treating doctors want and not what society can afford.

So how did it happen?  It was not a conspiracy.  It occurred incrementally.  Over the last 50 years we have learnt to keep people alive with impressive technology.  Initially the interventions were developed to keep young people alive after serious infection or complex operations.  Because we could do these things, they were increasingly used for older patients who had no treatable diseases; they were just old and wearing out.  Nothing could renew the ravages of ageing but we could keep them alive for the last few days, weeks or even months of life.  A cruel degrading end for a person and for those close to them.

It wasn’t a conspiracy, it just happened.  Here are some reasons why it occurred.  Society has unreal expectations of modern medicine, reinforced every day in the media by reports of the latest miracle.  Physicians are trained to cure and maintain life, not to accept dying and death.  Medical specialisation means that we concentrate on optimising individual organ function and hence, have lost the ability to stand back and look at the big picture.  Uncertainty is part of medicine.  If there is even the slightest degree of doubt we will continue treatment even if it is not in the patient’s interest.

Many countries reimburse doctors for each intervention they perform.  This results in many unnecessary operations and continued treatment in the face of futility.  It is often seen as more `ethical’ to continue treatment rather than to be honest with patients and their caregivers. This can achieve the opposite of ethical practice by subjecting patients to unnecessary pain and suffering. Ironically, in these types of medical systems, it is financially more lucrative for the treating physician to perform complex procedures than to discuss the patient’s prognosis and more appropriate ways of treating.

Perceived or real legal pressures to continue `treatment’, even if it is futile, can influence clinical decision making.

A conveyor belt can operate, taking an elderly frail person from the community when they deteriorate; carrying them to the hospital and placing them on life support machines.  It is currently difficult to pluck patients off this conveyor belt.  Finally, it is often easier to admit an elderly frail patient to a hospital because of a lack of community support to care for them in a more appropriate environment.

These are some of the complex factors and depending in which society you live, each will assume a different degree of importance.  Whatever reasons are more dominant, the odds are stacked against the elderly frail being able to choose their own way of spending the last few days or weeks of life.

Ken Hillman
Professor of Intensive Care University of New South Wales

Publication

The ten barriers to appropriate management of patients at the end of their life.
Hillman KM, Cardona-Morrell M.
Intensive Care Med. 2015 Sep

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