Further ideas on the problem the Lancet Commission on the Value of Death is responding to

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)

  1. 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.  

  1. 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.  

 

2 thoughts on “Further ideas on the problem the Lancet Commission on the Value of Death is responding to

  1. A previous post cited the RAND Health Insurance Experiment in the US from the late 1970’s which found that when consumers were required to finance their own health care, they reduced spending by about 30%, suggesting that at least 30% of healthcare would fit into the definition of overtreatment.

    Working in Germany, in a high-resource setting, I find this position very challenging. As a palliative care physician I frequently meet patients who want to stop life-prolonging therapies, or even ask for assisted dying, and one of the most often named reasons for this is that they do not want to be a burden on their caregivers. Not wanting to spend money on healthcare might not indicate overtreatment, but rather a wish to reduce the burden on the caregivers.

    Overtreatment is indeed a problem in developed as well as in developing countries. In both settings it is mostly due to lack of education, both for patients and caregivers and for health care professionals.

    Families in Eastern African countries will use all financial resources they have to pay for a patient with advanced cancer to fly to India for radiotherapy, if there is no access to a radiotherapy machine in their country. And quite often cancer will be too far advanced, radiotherapy will be rejected, but there will be no money left for the patient to return home, and he will die alone in a foreign country.

    In developed countries there is often a conspiracy of denial between health care professionals, family caregivers and the patient himself. This is complicated by the difficulties in prognosing length of survivial in patients with other diseases than cancer. In cancer, emerging new targeted therapies have changed prognosis so rapidely for many types of cancer that physicians are feeling very unsecure and are afraid to give up too early on the individual patient.

    A major barrier to an optimal allocation of resources is the partition between health care and social care budgets in developed countries, but also in many developing countries, Money saved in the health care sector, for example with less admissions to hospital in the last year of life, cannot be re-allocated to social care in the community or to improved literacy on death and dying. Finding innovative models to overcome this barrier would be needed to improve the quality of dying.

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