What do we want to die from?BMJ 2010; 341 doi: https://doi.org/10.1136/bmj.c3883 (Published 21 July 2010) Cite this as: BMJ 2010;341:c3883
- Iona Heath, general practitioner, London
Successive governments have been committed to reducing mortality, and the recent white paper shows that the current coalition government is no exception (BMJ 2010;341:c3796, doi:10.1136/bmj.c3796). The problem with such a commitment begins with the word: mortality means both the number of deaths in any given context but also the condition of being mortal and subject to death. We must all die, and so we must all die from something. The mortality rate for the population as a whole will always be 100%; so to what profile of causes of death should we aspire? If we continue to fight all causes of mortality, particularly in extreme old age, we have no hope of success, and we will consume an ever increasing proportion of healthcare resources for ever diminishing returns.
The World Health Organization’s 2008-2013 action plan for the prevention and control of non-communicable diseases states that these diseases, mainly cardiovascular diseases, cancers, chronic respiratory diseases, and diabetes, “represent a leading threat to human health and development. These four diseases are the world’s biggest killers, causing an estimated 35 million deaths each year—60% of all deaths globally” (http://whqlibdoc.who.int/publications/2009/9789241597418_eng.pdf). Yet surely this is, in many ways, a cause for celebration: millions of people are no longer dying from acute infections and malnutrition in childhood and are living long enough to develop the whole array of chronic non-communicable diseases. But WHO also informs us that of the 35 million people who died from chronic disease in 2005 half were aged under 70, and these are the deaths that should demand our attention—globally and nationally.
If healthcare services are ever to do anything serious about health inequalities they will need to find the courage to concentrate their efforts on premature mortality and to resist the inevitable but inappropriate accusations of ageism. Those who die early suffer the most tragic loss of life years. Mortality among under 5s in the United Kingdom is the highest in western Europe, and rates of child mortality in poor countries are a continuing testament to the failure of global economic and social justice.
Death in extreme old age is often timely. When the ageing body begins to fail, diseases are like Shakespeare’s sorrows: “they come not single spies, but in battalions.” All clinicians caring for older people have the experience of treating one disease process, only for another to take its place; and the more diseases that coexist, the greater the hazards of overtreatment and polypharmacy, and the more the challenges of daily life become a struggle. We continue to prescribe statins to those aged over 70 despite evidence that although this reduces deaths from cardiovascular disease it does not reduce overall mortality and increases rates of diagnosis of cancer and dementia (BMJ 2007;335:285-287, doi:10.1136/bmj.39241.630741.BE1). When one cause of death is curtailed, others must inevitably come forward to fill the gap. Everyone is obliged to die from something. If we close off all the alternative exit strategies, more and more older people will face the prospect of dementia.
Indeed the contemporary management of dementia in high income countries perhaps demonstrates the nub of the problem. The natural history of dementia offers the failing body and mind a way out: eventually the swallowing mechanism begins to fail, causing aspiration pneumonia and the possibility of dying. Yet now when swallowing becomes problematic health services provide percutaneous endoscopic gastrostomy (PEG) tubes and expensive enteral nutrition. And if pneumonia does supervene, healthcare professionals all too often banish “the old man’s friend” with antibiotics. A study of the care of patients with either advanced cancer or advanced dementia dying in an acute hospital in the United States showed that for 24% of both groups cardiopulmonary resuscitation was attempted and that 55% of those with dementia died with feeding tubes in place (Archives of Internal Medicine 1996;156:2094-100, doi:10.1001/archinte.156.18.2094). Is this what we want for ourselves or for those we love—or indeed for anyone?
WHO publishes profiles of causes of death for countries with different levels of economic resources (www.who.int/chp/chronic_disease_report/part1/en/index2.html.) Predictably, high income countries have the highest proportion of deaths from non-communicable diseases; low income countries have a higher absolute number of such deaths, but an even higher number and a greater proportion of deaths are still caused by infections, maternal and perinatal conditions, and malnutrition. Which profile is the one to which societies should aspire? Healthcare professionals, politicians, and journalists have a responsibility to begin to think about these issues. All too often in global statistics it is difficult to unravel total mortality from premature mortality, and we urgently need to see profiles for the causes of premature death. And again, what sort of profile should we be aiming for?
A long life almost inevitably culminates in some form of non-communicable disease. Total life expectancy now exceeds healthy life expectancy by about two decades, and this gap seems to be widening with the ever earlier diagnosis of chronic disease. The public health dream of a long and healthy life followed by a rapid and easy death grows ever more elusive. Non-communicable diseases are here to stay. Memento mori.
Cite this as: BMJ 2010;341:c3883