The ‘Lancet Commission on the Value of Death’ has much to commend it, says James Le Fanu.
Like many before me, I find myself at that stage of life when those known – or known of – now feature regularly in the obituary columns. This inevitably prompts reflections on their closing years and the manner of their dying. For Pope Benedict it would seem to have been as good as it could be. The details of his final illness have not been disclosed, but there remains the impression that it encompassed the several desirable attributes set out in the recently published “Lancet Commission on the Value of Death”: free from physical pain and psychological stress, not prolonged unnecessarily and sustained by the emotional support of family and friends and the rituals of faith.
The main purpose of the commission’s report is to address the question as to why for many – “over-treated in hospital with their families relegated to the margins” – these conditions for “a good death” are not being fulfilled. To be sure, it acknowledges that the situation has vastly improved in recent years – particularly in Britain, which was rated in the Economist’s 2015 Quality of Death Index as the best place in the world to die. This is due in large part to the reinvention by the redoubtable Dame Cicely Saunders of an ancient institution – the hospice – where the latest advances in palliative treatment are combined with compassionate nursing in an atmosphere that permits the dying to meet their end as serenely as possible.
This seismic shift for the better is only part of the story. It has taken place against the background of a remorseless rise over the same period in the “medicalisation” of our final years. Much of this is certainly to the good in alleviating the discomforts of the “chronic degenerative diseases of ageing”: mobility restored with new hips and knees, narrow coronary arteries replumbed and stiffened heart valves and vision-clouding cataracts replaced with implants. But this rise in medicalisation has also exposed people to the hazards of inappropriate or futile medical interventions – the “overtreatment” alluded to in the report – their lives immiserated by too much medicine. This comes in two main forms. The first, a recurring theme in my medical column in the Daily Telegraph, is the phenomenon of polypharmacy (literally, many drugs) with a threefold increase in just 20 years in the number of prescriptions.
Thus it is now not unusual for those in their seventies and beyond to be taking half a dozen (or substantially more) different medicines with all their potential for debilitating side-effects: nausea, fatigue, low mood, muscular aches and pains and general decrepitude. So while the justification for this polypharmacy might seem reasonable – that it may, possibly, marginally reduce the risk of a heart attack or stroke at some point in the future – it can result in a marked diminution in the quality of people’s everyday lives.
The further instance of the immiserating effect of overtreatment, emphasised by the commission, is the inappropriate prescribing of cytotoxic chemotherapy to those with advanced cancer. The cure with chemotherapy of several forms of cancer – leukaemias, lymphomas – ranks among the supreme medical achievements of the 20th century. The same drugs, however, proved to be ineffective against the much commoner “solid” tumours of later life (so-called because they arise from the solid organs like the lung, liver, gut or brain). The development of new forms of chemo drugs in the 1990s raised the prospect that these too would become amenable to treatment – but despite some successes the results have been disappointing. Thus a review of the 48 anti-cancer drugs approved by the European Medicines Agency revealed that on average their benefit in improving survival is in the region of just two to three months.
Nonetheless, the trend for prescribing chemotherapy continues to spiral upwards. For those with advanced cancer, their final months are therefore vitiated by a continuous round of trips to hospital, numerous tests and scans while coping with well-known and often grievous side-effects. The fault here, one might suppose, lies with the oncologists for not appraising their patients of the gravity of their prognosis. And indeed, as the commission observes, it can be easier to circumvent that difficult conversation by advising a course of chemotherapy. But they also have to contend with unrealistic expectations of what medicine can achieve where in one study two-thirds of patients with lung cancer – despite being advised to the contrary – anticipated that their chemotherapy would be curative. These forms of overtreatment, with their seriously adverse consequences, remain deeply entrenched with no immediate prospect of their being reversed. But perhaps Dame Cicely’s insight that it only required a change in perspective to transform the care of the dying can act as a precedent to “rolling back the harms of too much medicine”.
James Le Fanu is a doctor, historian and columnist for the Daily Telegraph and Sunday Telegraph.
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