My career has been as a geriatrician, a physician who deals largely with older patients. This inevitably provided an uncommon familiarity with the process of dying and death. It was so much a part of my routine that I wrote a paper, "The Trajectory of Dying," that was published in the Journal of the American Geriatrics Society in 1992. Its content was straightforward. I reviewed the records of the deaths of all the patients in my practice for the preceding year, 97. I surveyed where they died, whether they had pain, mental competence, and mobility six months, one month, and one week before they died.
I need to assure you that the reason behind my high total of dead patients was not the result of my inattention, but merely represented the fact that a large number of my colleagues at the Palo Alto Medical Clinic where I practiced were unfamiliar and uncomfortable taking care of the last swoon of their patient's lives, and thus referred many of them to their friendly geriatrician colleague for that chor. Many of these referrals, perhaps 50 percent, were in a nursing home.
I wanted to see whether the death had occurred acutely or gradually, a square-edged finale or a slow downward decline. A happy finding was that those who died acutely often died in the hospital where high tech care was available, whereas those who died incrementally on a slippery slope died in a nursing home or at home. I generally regard the nursing home as a choice of last option. Having such a familiarity with death meant that I was often called upon to sign the death certificate. For many occasions this was straightforward, having gathered enough data and experience to know why deaths had occurred. But for many others death occurred not on cue or with substantial antecedent. Often my first contact with the decedent was a call often in the middle of the night that so-and-so had died, the reporting nurse often spoke poor English and had slim understanding of the clinical circumstances. Ignorance of cause of death did not excuse me from having to fill out the death certificate because I was officially designated as the responsible M.D. at that particular moment. Generally I wrote "cardiac arrest, secondary to generalized arteriosclerosis." Such designation gratified the coroner and other associated bureaucrats, despite the fact that my entree was clearly bogus, it fit their SOP.
My good colleague, Leonard Hayflick, esteemed gerontologist, has repeatedly written that the death certificate is usually wrong. The major condition of "frailty" which is certainly an active agent in many old deaths is not acceptable as a death certificate diagnosis, nor is" failure to thrive." "Aging" doesn't fly no matter how old the person is or was. The end result of this imprecision therefore is that the death is recorded as due to heart disease when in fact there is no direct support for that conclusion.
Such sloppy practice I'm sure was not unique to me. It serves to distort public health records and other conclusions based on death certificate diagnoses.
As we and the population age this problem will grow worse, because almost old people die not of a component problem such as heart disease, but of a system failure, i.e. frailty. The standard operating procedure requires a component notation. Wrong.
Oliver Wendell Holmes in "The One Hoss Shay" likened this to, "All at once, nothing first, just like bubbles go when they burst." Death certificate diagnoses are often phony.
Let's get real.