I’ve written previously on end of life care and hospice on this blog. It’s a topic of conversation that while often uncomfortable and depressing is unfortunately lacking in clinical settings as well as medical school training. Physicians, nurses and medical personnel have a very different view when it comes to death and dying.
In February 2012, Dr Craig Bowron wrote an opinion piece for The Washington Post about our nation’s unrealistic views of death and dying. Dr Bowron touched on some interesting points regarding our collective inability to accept death, but the portion of the piece surrounding medicine and public health is what caught my eye in particular.
Our unrealistic expectations of what medicine can do begin with the notion that medical care has been the driving force behind the increase in life expectancy over the past century. There’s no denying that life expectancy has increased; according to Bowron, the average life expectancy in 1900 was 47 years and 78 years as of 2007. That’s a rather impressive change, and you might assume that there weren’t a lot of old people around back in the “good old days”.
But modern medicine didn’t invent old age, because average life expectancy is heavily skewed by deaths in childhood, and infant mortality rates in 1900 were astronomically high – to the tune of about 10% of live births resulting in infant death. That rate now? Less than 7 deaths per 1,000 live births in the year 2000. We have simple public health measures to thank for that change – things like improved sanitation, nutrition, education of expectant mothers and safer deliveries. These same interventions led to a steep decline in maternal mortality. According to Bowron, by 1950, average life expectancy had increased to 68 years of age.
According to this logic, if a woman born in 1900 “managed to survive childhood and childbearing, she had a good chance of growing old. A person who made it to 65 in 1900 could expect to live an average of 12 more years; if she made it to 85, she could expect to go another four years.” Modern times haven’t changed thos numbers much. In 2007, a 65-year-old will live on average another 19 years; an 85 year old could expect to go another six years.
So why are we so loathe to let go? Medical professionals know that “at a certain stage of life, aggressive medical treatment can become sanctioned torture.” We often end up doing more harm than good. But for many Americans, medicine has turned death into an option rather than an obligation. We’ve come to view death as a failure of medicine rather than an inevitability. Faced with the prospect of failure, we automatically turn to the notion that something else must be done. And for many, “doing something often feels better than doing nothing.” Sitting by and idly watching death make its curtain call often feeds into a feeling of guilt on the part of family members who wonder why they cant do more.
What I gather from Dr Bowron’s opinion piece is that if we are to do anything, it’s one of two things, and possibly both. We must be honest, open, and upfront as physicians that death, like taxes, is inevitable. While we can prolong life, we cannot defeat death. We must also encourage the idea that sometimes doing nothing is the right course of action; we must stand by the principle of non-maleficence and help families understand that interventions often do more harm than good. And finally, most importantly but also most difficult, sometimes we must be willing to stand up and say “no”.