How do we get those statistics on causes of death in the US? How do we know that heart disease is the number one killer in the US? Here is a real story from the front lines of where the statistics come from. (Names changed to protect identities).
Ben died yesterday. An 85 year-old Holocaust survivor, frail and racked with severe Alzheimer's, Ben was known for his ebullience, his buoyant "Shalom!", which by the end was the one of the few words he could enunciate. His background in sales was evident in his genuine effusiveness and he became one of my favorite patients.
Last Friday, Ben developed high fevers after a bout of diarrhea and vomiting. Per his stated wishes, we treated him at home. We placed him on antibiotics for a possible lung infection from possible aspiration (taking fluid into his lungs). He died late on Sunday night, unresponsive to antibiotics, holding the hand of his devoted daughter, whose name was another of the words he continued to speak.
On Monday morning, James arrived from the funeral home, a large, convivial man who strode briskly into my office, waving a copy of Ben's death certificate for my signature. This form needs to be completed and filed with the New York City Department of Health for a burial permit. Without this permit, a funeral cannot take place. Speed was of the essence as Ben's body was being sent to Israel for his burial and per Jewish law, he needed to be buried speedily.
As was usual in these circumstances, I allowed myself to be guided by the able emissaries from the funeral home, who, in this case, came directly to the point.
"What are you gonna put down as the cause of death, doc?" James asked, 25 years of funeral director experience infusing him with an authority I did not dare quibble with.
"Pneumonia?" I said feebly, already knowing this was not going to be acceptable.
"No good, not going to fly," said James, dismissively. "What about coronary artery disease?"
"Well he did have some of that, but that was not the actual cause of death. I think he may have had an infection of some sort," I replied.
"Well, but do you know that for sure? The only thing we know for sure is that his heart gave out, didn't it? Wasn't that how he died? Who doesn't have some level of atherosclerosis by his age?" James used technical jargon with all the fluency and gravity of a physician emeritus at a major university teaching hospital.
"Yes," I admitted. James was correct, of course. Ultimately, a person dies when their heart ceases to function. But this was not truly reflective of the cause of death in Ben's case. "How about sepsis? What about aspiration?"
"No go, doc! C'mon, you know better than that!" James chided. "We'd be stuck talking with the ME (Medical Examiner)'s office until kingdom come! What about cardiopulmonary arrest? Would you feel comfortable with that?"
"I guess that will have to do," I sighed. Once again I would use this catch-all diagnosis on a death certificate.
"Hold it!" James interjected. "What are you going to say the arrest is a consequence of?"
Uh-oh. "Infection? Aspiration?" James emphatically shook his head no.
"Don't even go there! Aspiration? Anything to do with choking is a problem. And no to infection as well! Forget it, we could have adult protective services down our throats."
James realized I needed some help and whipped out his mental laundry list. "What about atherosclerotic heart disease or coronary artery disease? What about cancer? No, he didn't have cancer? Hypertension is always good? No? Alright, what about the Alzheimer's disease?" He saw me nod. "Great, let's put that down."
"Alzheimer's causing cardiopulmonary arrest?" I said.
"Sure," said James, confidently. "Alzheimer's or if you want to put in dementia, that's fine too. What's the matter, you don't think Alzheimer's caused his death ultimately?"
"Well, yes." I reluctantly agreed and started to write it in. In essence, James was right. Ultimately, Alzheimer's had caused Ben's death as it had left him progressively infirm and prone to infections.
"Make sure you write advanced Alzheimer's," instructed James, "otherwise it's no good. Crazy I know, but that's bureaucracy for you!" He shrugged. "I get all worked up when everyone goes around saying that heart disease is the leading cause of death in the US. We both know where the get their numbers from!" He jabbed the form with his finger. "From here. And they say the numbers don't lie!"
Here indeed was the incandescently American reincarnation of Alfred Doolittle, the contrarian philosopher of Bernard Shaw's Pygmalion.
"You think of the three big causes of death in America," James continued. "It is atherosclerotic heart disease, cancer and stroke. You think of the diagnoses on these certificates that the DOH gives us the least heartache about. It's these same three!" He snorted. "It's the old story of the tail wagging the dog, doc. The tail wagging the dog. The worst is getting these forms filled by the young residents in the hospitals. Their minds are full of medicine and they want to put down things they just learnt in their textbooks and they get upset with us when we won't have any of their nonsense. We have no use for it. Just trying to do my job, is all."
The three leading causes of death in the United States in 2008 according to the Center for Disease Control were coronary artery disease, trumping the others by a whopping 100,000 more cases, followed by cancer, then stroke. Alzheimer's was on at that list too, a distant sixth, followed by pneumonia and influenza.
James was a revelatory repository of other fascinating facts such as that it was acceptable to die from cardiopulmonary arrest due to old age if one is over 95. However, according to James, the Department of Health looks askance at any person whose heart had the temerity to stop beating from the wear and tear of "old age" at say, 93 years of age.
"You just cannot die of old age, unless you happen to be really, really old," James said. "Don't look at me that way, I don't make the rules, the Man did. I'm just doing my job, helping folks get buried on time."
Old age was not in the CDC's top 10 list of causes of death, despite the life expectancy rising to 78 years on average, and 80 years for women.
As James rose to leave, he finished off this refreshing facet to my medical education. "Here's something else that might interest you. You know all this talk about the rise in obesity? Well, remember plain obesity won't do on a death certificate, it has to be morbid obesity."
And with this final volley, James sailed out of my office, clutching a form that ultimately will be used in tallying health care statistics in the United States. Perhaps not entirely accurate, but thanks to James, Ben's body was already soaring through the skies to Israel by the time the sun set over New York that Monday.