Medical science deserves hearty congratulations for extending the lifespan of Americans to 80 years and beyond. This is truly an impressive feat, considering that most babies born in 1900 did not live past the age of 50.
But there's a problem: When Americans do reach the end of our lives, that same medical establishment finds it very difficult to let us go in peace.
Instead, machines and tubes and a variety of high-tech and high-priced medical interventions try to keep us alive.
According to a 2013 Atlantic Monthly article called "How Not to Die," these aggressive interventions often persist even if "there is no hope of a cure, and when the patient, if fully informed, might prefer quality time and relative normalcy to all-out intervention."
Thirty years ago, Richard Lamm expressed doubts about our national obsession with curative medicine. In 1984, when he was Governor of Colorado, Lamm made headlines by suggesting that Americans should be very careful "that we don't impose life on people who ... are suffering beyond the ability for us to help.''
Lamm took a lot of heat for his remarks. Media reports suggested--erroneously, it turned out--that Lamm believed older people "had a duty to die."
Thirty years later, our societal aversion to aging and death continues to prevent us from having the public discussion about end-of-life care that Lamm tried to spark. Given our current health care crisis, however, it may be time to reopen that discussion.
More Years of Poor Health
Anyone who has watched an older friend or relative suffer with Alzheimer's disease understands that longevity has a downside. Our longer lifespan brings with it a greater chance that we will suffer with and die of terrible diseases that occur only in old age.
Alzheimer's deaths tripled from 1990 to 2010, according to the Global Burden of Disease (GBD) Study. Deaths from Parkinson's disease doubled during that period.
The GBD study found that for every year we've added to our life expectancy since 1990, we spend only about 9 months in good health. The rest of each extra year is marred by "pain, immobility, mental incapacity or medical support such as dialysis," according to a report about the study in The Washington Post. People who survive to age 50 get only 7 healthy months for every year added to the lifespan.
It seems clear from these statistics that our first job as a nation should be to improve the aging experience by placing much greater emphasis on population health throughout the lifespan.
We need to promote good nutrition and regular physical activity from an early age. We need to take deliberate steps to control environmental factors that impact health. And we need to support a robust preventative health care system that forestalls chronic disease and disability as we age.
Bringing Death into the Health Care System
We also need to get better at recognizing when high-tech interventions to extend life are not in the best interest of the patient or the health care system.
I'm not talking about forcing patients to accept government-imposed restrictions on end-of-life care.
What I am talking about is creating person-centered care delivery models that offer a high-quality care experience as well as a high-quality dying experience, when that is appropriate.
The best geriatric care models I've seen make palliative care specialists full-fledged members of every older adult's health care team. These professionals are trained to educate older patients about their end-of-life care options, to empower those patients to make care-related decisions that align with their personal beliefs and preferences, and to support those patients in fulfilling those preferences.
Palliative care models don't depend on the latest technology or high-cost services. Instead, well-trained and caring health professionals are what make this care model work. These caregivers know and respect the older person. They also have the skills and the tools to support that person along every step of his or her final journey.
Palliative care models also depend on good, 2-way communication between physicians and patients. The Atlantic Monthly article about dying suggests that physicians should sit down with patients to outline their conditions, treatments and prognoses. Patients should share their goals for the time they have left. And then the medical establishment should actually listen and respond with a person-centered approach that meets those goals.
We're a long way from making these honest and direct conversations about end-of-life care the norm in our care settings. But I believe it's an ideal worth striving for.
No Simple Answers
There will never be simple answers to questions about how long treatment should be extended, and at what cost. But that doesn't mean we shouldn't encourage patients and their health providers to ask those questions.
This difficult discernment process will be a burden for some patients and families. But the process could also represent a wonderful gift to those seeking help and support as they try to make peace with the inevitability of death and to die on their own terms.
If that isn't person-centered care, I don't know what is.
This blog is based on a June 2, 2014 interview with Dr. Tom Elwood, host of The Health Crossroad podcast.