Living With Dying Introduction

Tuesday, 9 December 2014  |  pinterandmartin

Introduction by Margaret McCartney

Each day, almost 1,400 deaths occur in the UK. Death is also happening, on average, later: we are living longer. A child born in 1900 had an average of about 50 years ahead of them; a child born today should expect around 80 years of life. As a species, the increased lifespan humans have achieved in a relatively short period of existence is phenomenal. We are succeeding in becoming older. This is worth celebrating: a new generation of people who have the wisdom of a longer living memory can continue to inform and contribute to our society.

But this change has also created complex and unforeseen dilemmas with new difficulties around death. We humans are having to learn how to live longer and how to die of different things. War, famine and infectious disease still take an unforgivable toll, especially in the poorest countries. In the west, we are living longer but with more diseases. Over 40% of us have one long-term condition, and a quarter of us have two or more problems – like chronic bronchitis, diabetes, or high blood pressure. So as we live longer lives, we accumulate more diagnoses, take more pills, and attend more doctors and nurses as we go. And in the end, we still must die.

So have the medical advances which have prolonged life also improved our deaths? In the last hundred years, science has discovered and created incredible things: the atom has been split; DNA has been unfurled and held open for examination. MRI scans have meant that searing anatomical detail can be exposed without a scalpel; vaccinations have enabled cohorts of children to grow up outwith the shadow of smallpox or measles. Keyhole and minimally invasive surgery has meant that many large operations are virtually day cases. Joint replacements have enabled millions to stay mobile and independent for longer. Endoscopies have meant that the bowel can be explored relatively easily and quickly. HIV can be a long-term illness rather than a death sentence; babies can be operated on within the womb. Medicine has reaped numerous harvests from science. But medicine also harms. In my first book, The Patient Paradox, I explored how too much medicine can also damage us. Screening causes many people to be treated for disorders that would never have affected them, causing resources to be diverted from people who are sick and unwell to people who are healthy. At the end of life, medicine yields a similar power. It could give us a peaceful, painless death – but can also spoil and corrupt our humanity.

For when it comes to our still inevitable deaths, we have reached an awkward impasse. What kind of death do we want to have? We frequently use medicine awkwardly and badly. We perform cardiopulmonary resuscitation in patients in whom it virtually never works; meaning that the end of life becomes a violent struggle against death. People sue doctors who do not provide treatments at the end of life – even when these ‘treatments’ are extremely unlikely to help and come with draining side effects. We are living longer, we are dying later, and we struggle still against the end. Medicine has a new battleground in death, but death, in the end, can be the only winner.

But is death always the enemy?

The way we approach the end of life is troublesome. General practitioners are pushed and financially rewarded to diagnose and treat risk factors which would, in very many cases, never lead to death from the disease we were trying to prevent. We fund pharmacological treatments that make little difference to quality or quantity of life, while neglecting to fund proper, hands-on, humane care for people in their own home where they would often prefer to die. When it comes to the final illness, the desire to use more medicine to push death back can easily take precedence over the wellbeing and contentment of the dying person.

I want to explain how medicine can get in the way of good care, and suggest what we – citizens, families, carers, doctors, nurses, politicians and health service managers – should ask about what we want at the end of life and how we should work together to provide it.

More information on Living with Dying is here.