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Quality of years, not quantity

Quality of years, not quantity

Dr David Turner says that we need to start a national conversation about ageing and quality of life

My paternal grandfather died in his sleep at the age of 91.

He was living in a retirement home at the time, which offered no nursing or personal care. For all intents and purposes, it was a long-stay hotel. He had been there for 18 months and, prior to that, had lived independently at home. He only stopped driving at the age of 89.

In his younger days, he was a farmer and in his later years, he was a greengrocer. He retired in his seventies, but even into his early eighties, he would occasionally help out in my parents’ hotel.

He never had central heating and spent the first few decades of his life with no indoor toilet. If the temperature dropped, he added another pullover to the numerous layers he always wore. He was never fat and grew a lot of his own food.

He walked with his dog for an hour twice a day. In his younger days, it appears he was very fit. I have a wonderful black-and-white photograph of him riding a horse bareback.

My grandfather was never a wealthy man but could always pay his way, was never in debt and owned his own house. The only time he really bothered the NHS was for a carpal tunnel release procedure in his middle years and a TURP in his old age. He did not take any regular medication and died quietly in his sleep from old age.

I have outlined his life because I think he was a good example of what we would all want: a good quality of life almost right until the end, minimal contact with the health service and a peaceful death.

Sadly, most nonagenarians will experience nothing remotely like this. More people than ever ‘collect’ diagnoses as they age and so many nonagenarians suffer from a list of conditions that runs right down the computer screen and take more medications than you can shake a stick at.

In an article in The Times, the renowned oncologist and health adviser Dr Ezekiel Emanuel said that he will refuse all medical treatment – even for cancer – after the age of 75. He fears that for many, the two decades that follow this milestone could be blighted by poor health.

As much as we wish it were otherwise, the NHS is going to need a big shake-up very soon and some difficult choices around rationing services are going to have to be made.

One consideration is the quantity versus quality of life. Would we prefer to fund a health service that gives longer lives with poor quality for the last couple of decades, or spend that money investing in health interventions that give the younger members of society the best chance possible to thrive early in their lives? This choice may sound brutal, but it will soon become a reality.

We must start a grown-up, national conversation about ageing and quality of life – and I believe that this should be led by those of us in the medical profession, not politicians.

Dr David Turner is a GP in Hertfordshire. Read more of his blogs here



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Decorum Est 2 March, 2023 3:14 pm

• 66% of people say they would like to die at home. In Birmingham and Solihull just 24% do so.
• People from deprived areas are more likely to die in hospital than people from affluent areas.
The reverse is true for deaths in care homes.
• 40% of people in Birmingham and Solihull who die do so after being admitted to hospital as an emergency. Their length of stay in hospital is often short. The most common experience is a terminal episode of two days.
• If patterns of care follow those observed nationally, then as many as a third of palliative patients (around 2,300 people) in Birmingham and Solihull may have died with their pain not properly controlled.
• Over 90% attend A&E at least once in the two years prior to their death. 85% have at least one emergency admission. Around 50% call 111.
• 16% of those dying are in contact with mental health services. This is lower than for the Midlands region (25%).
• Patterns of service use differ radically by cause of death. People dying from cancer access all types of service (bar critical care) more than those dying of other causes; this is especially true for planned care.
• People’s use of urgent care starts low and increases slowly for much of the last two years of life. There is a rapid increase a few months prior to death. The same is true for use of hospital beds.
• Use of planned care rises steadily over the last two years of life. There is then a sharp peak in the months or weeks prior to death, at which point use declines. There is a consistently higher rate of planned care use in Birmingham and Solihull compared to the Midlands. People dying from cancer account for much of this use.
• Not all treatment adds value. Palliative chemotherapy, for example, can be associated with worsening quality of life, often without commensurate gains in survival. In Birmingham and Solihull, people receiving chemotherapy in the last four weeks of life started their treatment later than those that did not. Their use of chemotherapy increased sharply six months prior to death. People with sarcoma or haematological cancers feature significantly in this group.
• Use of emergency admissions and A&E attendances does not differ greatly by age at death. What drives use of these services is not age, but proximity to death.
• Use of hospital beds is dominated by stays following an emergency admission. This increases as age at death increases. In the final year of life, the oldest decedents spend approximately an additional seven days in hospital compared to the youngest decedents.
• In the last two years of life around £135 million is spent on hospital services for decedents in Birmingham and Solihull. Urgent service events account for around two-thirds of this.
• Spend per decedent on hospital services was around £17,386; the highest in the Midlands.
• Having declined for decades, the number of deaths has begun to rise and is set to continue. The greatest number of deaths is among those aged 85 and above. This is also the group with the largest expected increase.
• If patterns of care do not change, the current growth in de…etc
Lots of evidence (pre-pandemic) that the present approach is unsatisfactory!

Dylan Summers 5 March, 2023 8:57 am

According to Stephen Pinker’s book Enlightenment Now, the increase in life expectancy over recent decades has improved healthy life expectancy MORE than it has increased the number of years in poor health. I haven’t followed back to his original sources.

Which implies to me that medical intervention may indeed give you more years of disability but it may well give an even bigger boost to your number of disability-free years. Is this good? Is this bad? Each individual might have their own view.

So the headline dichotomy “quality vs quantity” is not really a dichotomy but something much murkier.