John Dewey, the philosopher, said that a problem well defined is a problem half solved. To that end the Lancet Commission on the Value of Death is working had on defining the problem, and here are some useful thoughts from Penny Dash, a friend and McKinsey partner as well as medical doctor.
I wonder whether you could try and structure the list below. I think there are two broad points you are making so I’ve put those together – and restructured to have the problem statement (and the impact of that) and then the drivers of that problem. I’ve put the atul gawande quote in the heading.
You could also add some prioritisation in terms of what the potential impact is of addressing each one (in terms of $, quality of life, intergenerational equity, spend on other areas …….. and wider environmental impact) and the feasibility of addressing. That way you could have a 2×2 showing impact versus feasibility which could then inform further work? Red is my comments and black is the original text/list of ite
Society and medicine have an unhealthy relationship with death. “In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.” (Atul Gawande)
- Overtreatment is common in high income countries at the end of life. And Overtreatment is spreading to people in low and middle income countries, often pushing families into poverty.
Combined this results in a vast amount of money spent with little benefit (health or wellbeing or economic). Death increasingly occurs in old age and from prolonged frailty, giving people a long time to experience “biographical pain” and generating large costs. The “compression of morbidity” is pursued but seems to be a myth. Overtreatment at the end of life is a major driver of heath costs and of expenditure being concentrated in hospitals, where most deaths take place; this high expenditure crowds out other programmes around education, housing, city design, environment, and the like, which do more for health than does health care. Resources are shifted to the old rather than the young, creating intergenerational unfairness and possibly conflict.
The reasons for this are multifactoral:
a)Doctors find it hard to talk to patients about death and dying and opt instead for continuing treatment.
b) Medicine has come to see death as “failure” rather than “normal”
c) Resources in medicine and medical research are concentrated on countering mortality rather than morbidity
d) Medical research implicitly (curing cancer, heart disease, dementia, neurological disorders, etc) is implicitly if not explicitly pursuing immortality
e) Societal expectation is to save lives at all cost …….
f) Families often find it difficult to talk about dying – any sense of denying treatment/curtailing treatment is seen as “killing mum/dad” or “not doing all I could to save my child”
Addressing this would have high impact but is of medium feasibility.
- Many people die badly (we know what people die of and at what age, but we know little about the quality of dying; place of death is a poor measure of quality of death). Palliative care is beneficial, but is not available to most people in the world–and its existence as a medical specialty can mean that doctors in other specialties shy away from death. There is gross global inequality in how people die: many people in the world die without any access to care or morphine. Spiritual needs are neglected; indeed, perhaps medicine is incapable of responding to those needs.
The reasons for this are also multifactorial but include:
a) The curative medical model is pre-eminent as a driver of health service priorities; supportive and palliative care services remain marginal, often relegated to charitable NGOs
b) Plans for developing health systems often give little or no attention to end of life care
c) resources remain tied up in hospitals (which societies, doctors, politicians value) resulting in little resources for palliative out of hospital care
d) One of the main jobs of culture/religion is to provide meaning to life and death and rituals to govern death and dying, but medicine replacing religion as the “owner” of death and dying has led to loss of meaning and rituals around death and dying. People are left with an existential crisis that medicine can’t help (Ivan Illich)
e) very little medical/nursing training goes on palliative care
Addressing this would also have an impact (though probably smaller) but would be easier to do/have greater feasibility.