Death is often said to be the last taboo, despite being the one event that we all have coming to us at some point. Talking about dying can be very difficult for many people, not just the individual and their loved ones but also medical professionals who may be equally uncomfortable approaching such a sensitive topic or regard death as the ultimate failure of their skills.
The NHS has over its lifetime played perhaps a leading role in this country in bringing up life expectancy to the point where of the nearly half a million people who die annually, around four fifths are over 65 and two thirds are 75 plus. The major workload of the NHS has changed from treating working age adults with single acute problems to treating patients in later life – about of every ten patients in hospital around 6 will be over the age of 65. In later life, patients are more likely to be frail or living with more than one serious condition and so require a different approach to their care.
The recent national confidential inquiry into perioperative deaths (NCEPOD) showed that the NHS has yet to grasp universally that its success in making sure that most of us don’t die before we get old requires a rethink of its medical model and how it approaches care.
According to the report less than a third of acutely ill patients admitted to hospital got good care when they had a cardiac arrest. Whilst the report did not solely focus on older patients, the vast majority were over 65 and the mean age of people in the study was 77. And most people had at least one co-morbidity.
In nearly half of the admissions, patient assessment was deficient and in over a third of cases did not pick up warning signs that the patient was deteriorating and might arrest. Better training and understanding of geriatric care would, we believe, help medical staff to see beyond the immediate presenting problem and understand that an older person is likely to have other serious underlying medical issues, helping to better anticipate deterioration. All health professionals need to have the skills required to deliver healthcare in the 21st century.
Geriatric medicine remains, despite the fact that the majority of its patients are over 65, the Cinderella of the NHS. Bright young medical students can see it as a less attractive specialism and Age UK would like to see more focus on raising the profile and prestige of this area of medicine.
Care of patients in later life must not only be about saving life, but also how to allow a good death.
How we die is important both for the individual and their family. Ending a long life with a dignified death, free from pain is something that we all would wish for and we need our medical practitioners to help us achieve that.
Medical professionals often share the difficulties of our society in general in discussing death and the Dignity in Care Commission, of which Age UK is a leading member recently highlighted the importance of staff being well trained and supported to engage older people and their families sensitively in these potentially difficult conversations.
Sadly the report showed that in nearly 80% of cases patients were not asked about whether they wished to be resuscitated in the event of a cardiac arrest or did not have their wishes recorded, even in cases where clinicians knew that the patient was acutely ill. This is a failure of care as people have an absolute right to be consulted about every aspect of their care, including what should happen if they arrest.
Also very worrying was that 52 patients in the study who received CPR already had a documented Do Not Resuscitate decision and those wishes were not honoured when the time came.
We as a society must look death in the eye and whilst embracing life for as long as we can, when the time comes engage in making those decisions that help in obtaining a good death. Those who care for us have a moral and ethical duty to help us in that question.