Intended for healthcare professionals

Views And Reviews Taking Stock

Rammya Mathew: Let’s help people live successfully to the end of their lives

BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l807 (Published 26 February 2019) Cite this as: BMJ 2019;364:l807
  1. Rammya Mathew, GP
  1. London
  1. rammya.mathew{at}nhs.net
    Follow Rammya on Twitter: @RammyaMathew

On reading the headline “GPs should consider offering statins to all patients over 75,”1 I was left wondering whether modern medicine has become a quest to defeat death. The headline referred to a recent meta-analysis,2 which found that statins reduced the risk of major vascular events in all age groups. Given that older people have more strokes and heart attacks, the authors proposed that offering statins to all over 75s might be a worthwhile endeavour.

This same logic sees older people having proportionally more antihypertensives, more oral anticoagulants, and more antidiabetic drugs prescribed than their younger counterparts. And it’s why more than half of over 85s are taking five or more medicines.3

Risk factors accumulate with age, and this is ultimately not preventable. Trying to mitigate these risks with more and more medicines doesn’t feel to me like the right approach, especially when the risk-benefit calculations in older, multimorbid populations are mostly uncertain.4 And let’s not forget that polypharmacy itself is associated with increased mortality.5

Colin Baigent, representing the Cholesterol Treatment Trialists’ Collaboration, said that statins for all over 75s could prevent as many as 8000 deaths a year. What he really meant is that statins for all over 75s could delay these deaths. On the face of it, prolonging life seems like a worthwhile objective—but is extension of life what people over 75 really want? Or is it more years spent in good health, free from the burden of chronic illness and frailty and free from fighting the myriad side effects of an ever increasing list of medicines? Is it outlandish to suggest that, at some stage, we must stop prioritising prevention and accept the inevitability of death?

The risk-benefit calculations in older, multimorbid populations are mostly uncertain

The flip side of this argument, of course, is that strokes and coronary events, when not life terminating, can be severely disabling. We know that the odds of surviving a vascular event reduce significantly with increasing age,6 but this doesn’t stop me worrying that I might forgo the opportunity to prevent someone living in a state of severe disability that’s unacceptable to them, by not prescribing the statin.

But let’s say I decide to prescribe the statin and it prevents the stroke my patient would have otherwise had—and she lives an extra five years. Whether this should be celebrated depends on what those five years offer her: five years of good health versus five years she’d rather not have had to live through.

I’m not saying that no one over 75 should be taking a statin. But we do need to challenge the prevailing dogma of “prevention at all costs”—and create a broader vision of how to help people live successfully to the very end of their lives.

Footnotes

  • Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I have no competing interests.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

References

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