Is Death Optional?

An old joke spoofs the way we in the U.S. think about death:

In India, death is seen as a potential step away from reincarnation and towards blissful Nirvana. In Europe, death is seen as an existential tragedy we must face. In the U.S., death is seen as optional!

Last summer, Daniel Callahan, author of "Taming the Beloved Beast: How Medical Technology Costs are Destroying our Health Care System," and Sherwin Nuland, author of "How We Die: Reflections on Life's Final Chapter," (both have written many other books as well) took on the American myth of eternal youth in the New Republic. They argued that "the war against death as the highest priority should give way to a new goal: aiming to bring everyone’s life expectancy up to an average age of 80 years (already being approached), reducing early death, and shifting the emphasis in the direction of improving the quality of life of those in every age group. The highest priority should be given to children, the next highest to those in their adult years (the age group responsible for managing society), and the lowest to those over 80."


This is the kind of discussion we need to have in the U.S. in place of the vacuous tit-for-tat between Republicans and Democrats over who loves Medicare the best and who is out to destroy it. Medicare is an amazing achievement for a society in which many, perhaps a majority, agree with President Reagan that "government is not the solution to our problems; government is the problem." Medicare is cherished by its beneficiaries and by the generation concerned about care for their parents. Medicare's popularity is so deep that it's been known as the "third rail" of American politics since the Clinton presidency. Touch it and you're dead!

Callahan and Nuland could argue for giving priority to children and younger adults because they're both over 80. The ordinarily lethal accusation of being "granny bashers" is hard to pin on grandparents themselves. I'd guess that in a forced choice, a majority of Medicare recipients would agree with Callahan and Nuland's perspective.

Medicare costs must be brought into line with general inflation. But we won't make progress until our political leaders develop more backbone, and that won't happen until they hear from us Medicare constituents ourselves. I think the right starting point for that advocacy process is for those of us in the Medicare age group to demand that Medicare focus more on interventions that promote quality of life and less on costly hi-tech interventions that may forestall death by prolonging deterioration and suffering.

As Callahan and Nuland noted in their article, this will require a heightened political and medical awareness among Medicare recipients, and will engender economic losses for those who currently profit from the way health care is provided. Overtreatment is always bad medicine, but it can be economically rewarding for those who provide it inflict it.

In a followup to the New Republic article cited above, the July 3 New York Times featured a letter on the topic from Dan Callahan along with several responses. Among the responders, Doris Fenig wrote "We are a very strong lobby. We have a very loud voice. Let’s use it...for 'common civic sense.'"

Doris got it right! Her letter was one of the prods for me to start this blog.

[This post is a tweaked version of a post I wrote on my healthcareorganizationalethics blog shortly after the Callahan/Nuland article appeared.]

When Will We Die?

The most recent issue of the Journal of the American Medical  Association has an important article, with an accompanying editorial, on the effort to predict life expectancy for patients over 60.

My armchair research (conversation with friends) suggests that our Medicare cohort has two antithetical fears about longevity and medical treatment. Some fear we'll be flogged with aggressive interventions way beyond the point of usefulness. Others fear we'll be consigned to the grave too quickly, and even if not actually buried alive, won't be offered interventions that could reasonably be expected to provide significant quality of life.

I'm on a week's holiday in Puerto Rico. This morning another guest was playing good tennis on the adjacent court. When we chatted later he told me he'd had a total knee replacement two years ago. He enjoys skiing and tennis. He's experienced impressive improvement in the quality of his life.

In contrast, 13 years ago my beloved father-in-law, 90 at the time, experienced angina that limited his walking. His physicians recommended a surgical revascularization procedure. He was an activist, and without telling anyone in the family until the night before he went into the hospital, scheduled the surgery. The results were catastrophic - an extended period of delirium and progressive heart failure. He declined rapidly and died after a few miserable months. Poignantly, his oldest grandson's best friend is a distinguished cardiovascular epidemiologist. Had he been consulted, he would have given a strongly evidence-based recommendation against the procedure.

My father-in-law was a thoughtful, forgiving man. He said  "my doctors were young men [i.e., in their 50s]. They were thinking about young hearts, not about 90 year old hearts."

The article identified 16 systems of prediction that show reasonable accuracy, but none were good enough to be recommended for routine use in practice. The editorial urges physicians to (a) consult readily available life tables (predicted longevity by age, race and gender) and then (b) consider individual factors. Here's the relevant passage:

These calculations could be facilitated through use of an electronic comorbidity and functional status. Lung disease requiring regular use of corticosteroids or supplemental oxygen, New York Heart Association class III or IV congestive heart failure, renal disease requiring dialysis, advanced dementia, inability to walk more than a block, and need for personal assistance with bathing are examples of factors that would reduce life expectancy substantially below the average. The absence of significant comorbid conditions or functional limitations would identify older persons who are likely to live longer than average.

As a starting point, age-, sex-, and race-specific life expectancies (median and interquartile range) can be calculated using data from standard life tables.

The authors have created a remarkable website - ePrognosis - that allows health professionals (identified by self report) to apply relevant tables to their patients. They've also created GeriPal (GERIatrics and PALiative care), a blog for health professionals and others interested in care of the elderly and palliative care. I'm proud that one of the sponsors - Dr. Alex Smith - did his primary care residency in the program I teach in. ( He was a star!)

Conversations based on life tables, individual status, and the patient's guiding values, won't achieve mathematical certainty. But they're crucial elements of wise, compassionate health care decision-making. It was monstrous when politicians branded support for this form of humane medical practice "death panels." We Medicare folks need to fight that form of demagoguery!