As we get older it is good to see that ageism in healthcare is much less prevalent than it was in the past.
When I was a house officer, our cardiac unit’s policy was not to admit anyone over the age of 70, and medical wards also had an upper-age limit beyond which admissions were routed to geriatric medicine, subsequently renamed ‘care of the elderly’, and latterly ‘medicine of older age’ so as to avoid stigmatising its users.
Nowadays cardiac and stroke thrombolysis and coronary stenting have provided opportunities for recovery for the older population who are now welcomed with open arms by cardiologists reinvented as interventionists.
Recently one of our neighbours, aged 93, who last year passed a breast screening mammogram test, has undergone coronary artery bypass grafting successfully. I don’t know how much her cardiac surgery has cost the NHS, but assume it runs into £25,000 to £30,000 including cardiac recovery and ICU costs; nor can I second guess the decision on the cost/risk/ benefit calculation upon which the surgery was based.
Presumably any increase in her life expectancy cannot be huge, coming as it does at the end of her natural lifespan, so this may not justify the significant risk and cost involved. However, it may be that her surgical benefit could lie in an improved quality of life or reduced dependency on others with potential reduction in social care costs.
Unfortunately, in the two months since her discharge, she has been admitted twice through my emergency department, something which hadn’t happened in the previous 12 months.
The admissions can be linked directly to her surgery, so her quality of life hasn’t improved much so far, nor any medical savings accrued, although hopefully there is still time to prove it was all worthwhile.
There is no doubt that the range of possible care available to our population has expanded significantly but there are some who might suggest that this expansion is the root of NHS congestion and overload, where capacity has not kept pace with increased demand, expectation and medical possibility.
Some of this pressure could be abated if we were to recognise that just because something is possible does not necessarily mean it should be offered to everyone, a concept which hasn’t proven particularly popular when suggested by healthcare commissioners.
Emergency medicine is not immune from questionably appropriate care: resuscitation
is often done without knowledge of or regard for premorbid state and may well result in a protracted inpatient death rather than a return to the hoped-for good health.
When one stops to think about it, a life saved could instead be defined as a death deferred: if someone has reached their mid-90s, it is unlikely to be deferred for very long. Despite medical advances, humans are still subject to a maximum natural lifespan.
I do, however, accept that the classical three score years and 10 does now seem a little dated.
Charles Lamb is a consultant in emergency medicine. He writes under a pseudonym
I suppose all medicine is a variation on deferred death be it vaccination of babies or treating chest infections in the elderly. Is death deferred a bad thing? Is it the extension of life or the quality of that life which is the important thing to consider? And who am I to judge for someone else?
All I can do is discuss likely outcomes, risks and benefits and help people come to their own decisions.
What I dislike, however, is doing something to a person who can't consent, even if as benign as a 'flu jab.
Bearing in mind that bypass surgery is for symptoms not for longevity
I do not think age should be a measure of whether patients receive treatment. We all know that there are people much younger than 90+ who have a poorer outlook and prognosis. We should not deprive a fit and healthy 90 year old just because of their age.
In this cash strapped era it surely cannot be justified doing a bypass on a 93 year old. I am constantly having to make difficult decisions about much younger patients who I know would be very likely to benefit from a particular (expensive) treatment
Flu jabs are not so benign. Do a bmj search, nhs england's own data showed that receiving 2016 flu jab was actually associated with developing the flu.
They are as keen as ever for the elderly to have it this year.
Next year, we will have handy "life stones" installed on our palms....
Getting older, more frail , with increasing co-morbidities is a natural part of ageing. My mother of 89yrs is a T2DM with an HBA1c of 49, yet she has to go through the whole rigmarole of diabetic checks and reviews. Sometimes we just have to apply common sense. It is not ageist to say that we have the option of using less medical intervention in the elderly than the younger; it's just being realistic.
My dad, aged 87, recently had a redo of an emergency dynamic hip screw which was needed as complications of the original surgery had resulted in virtual immobility. The surgery was a success and his mobility is far, far better. His quality of life is (and hopefully will continue to be) much improved and no doubt he will be less of a burden on others, be it family or social services. However, while in hospital, he had a cardiac event, so the cardiology team arranged a myocardial perfusion scan. He had a PSA which was elevated (20), so he is being invited for a repeat and urology opinion. In my opinion the latter two interventions are inappropriate and wasteful. At his age, some event is bound to occur in the reasonably near future which will limit his life. It is natural and unavoidable. Why increase anxiety and increase healthcare costs, almost certainly to no benefit to him?
As someone in their 90s I agree 'one should not strive to keep alive'. Death is preferable to al ife of continued medical interference or the threat of dementia. How many of those with dementia would have opted for such a life when fit and compos mentis?
I had a 95y demented man come into my ED three days on the trot at 0630, having fallen out of bed and banged his head each time. Because our local cardiologists decided he needed a pacemaker six months earlier he was on Rivaroxaban. It seems that we have become frightened of the concept that patients die and are making irrational judgements to prevent it. We are not here to fix everything and should have the courage to say "No" to people.
My 87 year old father was diagnosed with locally advanced colorectal cancer with liver mets. Previously in good health, his performance status had plummeted over the 8 weeks prior to diagnosis. His only symptoms being anorexia, weight loss and marked fatigue. The diagnostic CT scan was followed by colonoscopy with biopsy, MRI to stage the liver, ECHO cardiogram to monitor side effects of chemo, insertion of a central catheter and doppler when he developed a Left DVT the week before starting chemo. He told me it was the offer of "treatment " which would possibly extend his life by 3 years, that influenced his decision to accept palliative chemo. He was my disabled mother's main career and believed he should do all he could to continue caring for her. The alternative of best supportive care was not explored by any professional. I gently discussed this option, but he had great faith in the medical profession ( and on this occasion I was his daughter, not the Palliative Care consultant) , and he was convinced he would not be offered treatment that was unlikely to benefit him. His words " It will be cowardly not to accept it" troubled me.
I accompanied him to all his hospital appointments including anti coagulant clinic for the 4 weeks before his death, observing the increasing struggle with all activities of daily living. At the pre-chemo check I politely enquired that as the chemo was with palliative intent, what symptoms were likely to be palliated being as my father's main complaints were fatigue and cachexia. I pointed out his falling albumin and worsening leg oedema. The aggressive regime was modified.
He died from pneumonia on Day 18 of the first cycle, before major symptoms from the tumour arose, and for that I'm grateful. He also died believing it would have been cowardly not to accept the treatment offered.
What struck me was the seductive language that was used when obtaining consent . " We can offer you treatment with which you may live years". And I considered the cost to the patient and the NHS as he endured investigation and procedure after procedure during the work up. At 87 years, the offer of extending his life was not the right conversation. Quality of life and death could and should have been discussed. He was not frightened of dying. He was a pragmatist and trusted the medical profession to tell him the facts.
As doctors, are we the cowards who cannot face discussing death? Are we squandering precious resources for fear of being accused of ageism?
my mother was 86 and choked whilst eating a dry biscuit. Her carer called an ambulance. The enthusiastic on call ENT doctor decided he swallowing problems required a tracheostomy. She was then admitted to the ITU for 10 days, partly because she suffered an MI during or after the surgery.
On discharge from the Intensive care ward there seemed confusion about her long term care. She wanted the tracheostomy removed so she could go home. The surgeon decided that she should be subject to a Deprivation of liberty order for persistently demanding the tracheostomy should be removed. The care of the elderly ward did their best to keep the airway clear, but had less nursing resource than the ITU. She died from pneumonia 10 days after being moved to the general ward.
It is sad that no one in A/E thought about avoiding food that might cause choking as an alternative to tracheostomy.
If we don't have an honest discussion about what we should and should not do any government will have no option to let the NHS go bankrupt or be privatised by the back door. We will then see people with less money on our streets with advanced cancer of the mouth as I did recently in New York.
Doctors have to lead this discussion. It is irresponsible to hide behind 'doing my best for the patient in front of me'. In any case may often be kindest Not to do what is possible. I wish my father had not had a CABG at 86.
Lamb writes here about reduced ageism in healthcare.
But age feels very different if you live in a deprived area. Martin Wilson is clear that it’s a “different planet” there. In the least deprived areas of Scotland, a quarter of people aged 75 will have long term health problems or disability. In the most deprived areas, healthy life expectancy is only 53, with 17 years in bad health before death.(1)
And it’s not just about healthcare. The elderly have been hit particularly hard by cuts in social services budgets that will soon leave some Local Authorities struggling to meet even their basic statutory responsibilities (2, 3). We all know the knock-on effect this is having on the NHS.
Even if we were treating old people (whatever that means) equitably (whatever that means!), then if you’re disabled, the PIP ‘system’ means, for example, that 50,000 people have had their Motability vehicles taken away — before they have any time to appeal (4, 5).
Should we buy CABGs for ten 93 year olds
or help 50,000 disabled people to be independent, maybe even work?
Of course, it shouldn't have to be either / or.
But with austerity an idea that just wont die, however much evidence there is against it (6, 7, 8) and richer pensioners able to overturn policy initiatives they don't like (the 'dementia tax'), even at the expense of their poorer contemporaries (9), then maybe we doctors should just stick to the doctoring end of things?
Lamb specifically mentions CABGs and resuscitation.
For CABGs — and other similarly major interventions — I think scenario planning might work a lot better than more simplistic ideas about ‘success’ rates. Schwarze has described how patients can be presented with best, worst, and most usual scenarios to allow more truly informed decisions.(10) Dr Lamb’s 93 year old might have been relatively well and active, but the significant risks of hospitalisation increase with age (11), so even the best-case scenario is not without hazards, as he has witnessed — and she has experienced.
For resuscitation — and surely Dr Lamb means attempted resuscitation — ReSPECT has already tried to move away from simple DNACPR orders. But DNACPR is just as much of a zombie problem as austerity. Wouldn’t discussions be helped if more families and individuals understood the difference between heart-stops-first cardiac arrest (for which CPR may help), and heart-stops-last natural dying (for which having the family at the bedside is surely much more dignified and humane)?(12, 13)
More generally, I think we doctors need to be braver about the limits of doctoring. Drazen and Yialamas have recently written about how very hard it is, when caring for a patient, to leave “diagnostic stones unturned and therapeutic paths untrodden”.(14)
The fact that so many of the responses here are anonymous underline how difficult it is to even write about this.
1. Martin Wilson. Realistic palliative care for an aging population. www.youtube.com/watch 2016
2. Kings Fund & Nuffield Trust, Social care for older people: home truths September 2016
3. The Richmond Group of Charities. Real lives. September 2016.
4. Jon Vale 50,000 disabled people 'have adapted vehicles removed after benefits assessment’ The Independent 11 April 2017
5. Frances Ryan. Paralympics hopeful Carly Tait: ‘My lifeline is being taken away’. The Guardian. 6 April 2016
6. Phil McDuff. Even the IMF says austerity doesn’t work. It’s the zombie idea that will not die The Guardian. 7 July 2017
7. Owen Jones. No alternative to austerity? That lie has now been nailed. The Guardian. 24 August 2017
8. Brad Plumer. Austerity is much worse for the economy than we thought. Washington Post. 12 October 2012
9. Rob Merrick. Theresa May’s dementia tax U-turn will deepen the crisis facing poorer people ‘without assets’, warn health experts The Independent 28 May 2017
10. Margaret L. Schwarze, and Lauren J. Taylor. Managing Uncertainty — Harnessing the Power of Scenario Planning N Engl J Med 2017; 377:206-208
11. Kenneth Covinsky; Edgar Pierluissi; Bree Johnston. Hospitalization-Associated Disability JAMA. 2011;306(16):1782-1793.
12. Dan Beckett. From Cradle to Grave. www.bbc.co.uk/.../p05d3lbh 23 August 2017
13. Related details from the work of Gordon Caldwell are included in
drcaromawer.com/.../ Aug 31 2017
14. Jeffrey M. Drazen and Maria A. Yialamas Certain about Dying with Uncertainty N Engl J Med 2017; 377:208-209