Repeating hospitalizations, multiple doctors and specialists, increasing numbers of medications, tests and procedures; this is what I see when people are on the healthcare conveyor belt. The modern medical system offers us many advantages, including highly skilled physicians and increasingly sophisticated treatments and medications. People imagine that the increase in life expectancy that we have seen since 1900 is attributable to these advances in medicine and technology, when in reality, it is not.
If we examine the numbers from the Centers for Disease Control and Prevention (CDC) from 1900-2018 the average life expectancy in the US went from just 47 years in 1900 to 79 years in 2018. It is natural to thank advances in healthcare as the chief cause for the rise. But when broken down into 30 year periods, a much different picture emerges. From 1900-1930, a period before the widespread use of vaccines to prevent childhood deaths as well as being prior to the discovery of antibiotics, the life expectancy in the US increased by 13 years; from 47 years to 60 years.That is the largest increase and it was not because of medical technology. It is attributed to the improvements in public health initiatives such as improved sanitation and access to clean water and safe food. By contrast, in the past 60 years, wherein we have seen phenomenal advances in medicine, the life expectancy has gone from 69 in 1958 to 79 years in 2018, just a ten year increase.
In fact, in recent years, the life expectancy in the US has been declining. This is largely due to deaths from drug and alcohol abuse as well as suicide rates increasing. Medical advances do not seem to have impacted these devastating realities. There is no doubt that improved access to highly advanced medicine has extended many lives and has led to the reduction of cancer deaths especially among children. But those benefits have not translated into large increases in life expectancy over-all.
What I do see and that has been verified by research is that medical technology has succeeded in prolonging suffering at the end of life. We have become accustomed to the aggressive pursuit of life at all costs as a general rule. Yet, when we see our loved ones suffer through multiple hospitalizations and watch them die in a sterile ICU, we say we do not want that fate for ourselves. But, without assertive planning and communication, that is the likely end that will greet most of us.
What is the Goal?
This is the filter through which we should view all medical decisions. What is the goal? The goals may be different for a 20 year old with a fractured pelvis than for a 89 year old with a fractured hip.
And not all people who are 89 years old will have the same goals. One who lives independently and travels frequently will have different goals than an 89 year old with dementia, kidney disease and congestive heart failure and who lives in a nursing home. These goals cannot be generalized, they must be individual. And they should be the guiding force for physicians as well as for family members who are advocating for the person.
My goal in writing this is to help avoid suffering for both the patient and for his family when unrealistic goals are driving the course of treatment. Or perhaps even worse, when there are no goals that are specific to the patient, when the healthcare system seems to put the patient on a conveyor belt and runs her through the system, blind to individual needs.
Medicine has made so many amazing advances, it can be easy to think that there is a way to avoid the unavoidable. Our lives on this earth are finite, each of us will come to the end of life at some point. While it is natural and even healthy to want to postpone the end of life for as long as is possible, there comes a point where the postponing is futile and even harmful. Indeed, studies have shown that often the more money and advanced medical methods we use for people approaching the end of their lives does not improve care but does increase suffering.
Eighty percent of us wish to die at home, and yet, only 20-30% of us actually do. Why is there this disconnect? It is easy to see the reason when you look at the patterns most people follow as they age or as a chronic illness progresses. There is the slippery slope.
We can see this slippery slope all around us. As we age, there may be new health problems that creep up on us. We start to manage high blood pressure, perhaps diabetes and then a heart attack or stroke, kidney disease and congestive heart failure may be diagnosed. These are common scenarios. And definitely these issues need competent medical management. Although some of the most effective ways to control these conditions involve life-style changes, it is clear that all too few of us are willing to do the actual work of changing our diets and increasing our activities. So we become frequent customers for our physicians.
Given that reality it is easy to see how the snowball starts to roll. More medications are added, surgeries may be required and so on. At what point do we step in and say "no" to more interventions? That is a highly personal choice. But it needs to be a conscious choice that comes from thinking about how we want the final years of our lives to be and from having discussions with our loved ones as well as our doctors. This is an important consideration no matter our age, but as more years pass in our life, this becomes an essential issue.
If you are helping an older loved one with medical decisions, take the opportunity to help her to articulate her goals and values for healthcare. And use those goals as the way to decide what treatments, medications and procedures are appropriate. Future postings will help you to know the questions to ask and the pitfalls to avoid as you navigate the healthcare maze. But it starts with setting goals and having open communication with your loved ones.
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http://fortune.com/2018/02/09/us-life-expectancy-dropped-again/ https://www.cancer.gov/about-cancer/understanding/statistics http://www.dartmouthatlas.org/data/topic/topic.aspx?cat=18