BMJ  2007;334 (10 March), doi:10.1136/bmj.39147.418310.43

Editor's Choice

Editor's choice

Memento mori

Next week in London a taster for the Wellcome Collection goes on display for a few brief hours. It includes a male figure—part human body, part skeleton—belonging to the long tradition of memento mori ("remember that you must die") (doi: 10.1136/bmj.39146.630775.DB). These images were a favourite of medieval religious art, and there are good arguments for introducing them into today's general practices and hospitals. Doctors as well as patients would benefit from reminders of our mortality.

Caricatured until the 20th century as agents who hastened your death (and took your money), doctors are now most likely caricatured as those who unnaturally prolong your life (and squander millions in their ultimately futile battle against death). Unfortunately, confirmation of this modern caricature is distressingly easy to find—see this week's personal view (doi: 10.1136/bmj.39127.437998.59). "As each weekend approached the risk loomed of an out of hours admission from which his own GP's wisdom would be absent," writes Paula Newton of her frail 77 year old father. "If it was a bank holiday weekend then his anxiety levels rose even higher." You can guess where this one is heading.

We all know a bad death when we see one, but what is a good death? A BMJ theme issue posed the question in 2003 (26 July www.bmj.com/content/vol327/issue7408/index.dtl). Spurred on by the contributors' inability to answer the question because of the dearth of research, Marilyn Kendall and colleagues embarked on a qualitative study of researchers, patients, and carers (doi: 10.1136/bmj.39097.582639.55). They asked why researching end of life issues was so challenging and how the obstacles could be overcome.

The good news is that many people nearing the end of life want the chance to participate in research. And encouragingly, many researchers resist the idea that end of life research is a special case, more difficult to conduct than other social research. Yet the modern taboos surrounding death and dying stifle inquiry, and funding bodies and ethics committees need to loosen up.

One of the researchers quoted in Kendall's study had started off researching stroke patients but couldn't have continued because "some of the things that those people were going through, living with disability, wasn't going to get any better, it was going to get worse...whereas dying is something that is going to happen to all of us and so in that sense it's not a problem for me."

Except that en route to that shared experience of death will be disability, not getting any better, but getting worse. Not that healthcare systems have recognised this. They're "designed as if disability and ill health were aberrations, rather than a phase that lasts months or years near the end of our lives," say Sydney Dy and Joanne Lynn. They describe three different trajectories of patients with eventually fatal chronic illness and the different services they require (doi: 10.1136/bmj.39127.653704.80). The research programmes they describe hold out the prospect of better ends of life and deaths.

Hallmark cards have no problems with staring life in the face. Their new range of greetings cards, called Journeys, is "designed for people whose most optimistic prognosis is gradual but inexorable deterioration," writes Trisha Greenhalgh (doi: 10.1136/bmj.39146.492870.59). "The over 40s are likely to have at least one disease that won't go away; those over 65 have an average of three." For Hallmark, decline and fall is "the new normal." Memento mori remind us that they were "the old normal" too.

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Looking at life and death

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