We need to talk to patients about quality, not quantity, of life

Following Professor Chris Whitty’s report on health in an ageing society, Dr Burnt Out says GPs need to have difficult conversations with older patients about prioritising their quality of life over prolonging it

Dear reader,

‘No pleasure is worth giving up for the sake of two more years in a geriatric home in Weston-Super-Mare.’*

– Sir Kingsley Amis CBE (1922-1995)

Now, the late author Sir Kingsley may have taken it a bit too far, but it seems that even England’s chief medical officer Professor Chris Whitty agrees with him.

In his 2023 annual report, published this month, Professor Whitty says we need to talk to patients about quality, rather than quantity, of life. He also says this should be a major aim of policy and medical practice.

Unfortunately, we live in an age of digital, industrialised general practice where our patients are often sheep-dipped in medications such as statins – the prescribing of which is then measured in terms of targets and metrics, not to mention the financial incentives GPs have to meet, such as QOF.

It’s safe to say the McNamara fallacy reigns in our primary care system. How often do we have the time to ask our especially elderly patients difficult questions about their health? For example:

‘Do you want to spend the last years of your life going to and from hospitals for treatment that is likely not going to work with many horrible side-effects?’

‘Do you mind taking 14 medications a day?’

‘Can you tell me about the side-effects of all the medications and treatments that you have had?’

There are many wonderful GPs who practise fantastic holistic medicine, and they do ask the difficult questions. But I would suggest that there are many of us – myself included – who tend to shy away from the difficult questions and take the path of least resistance in a sort of unspoken, colluding denial that we all know can happen in the GP-patient relationship. This is perhaps necessary on many occasions, but perhaps we do sometimes need to ask those difficult questions. Patients may be grateful to us for doing so.

Speaking before the publication of his report, Professor Whitty said: ‘Modern medicine is amazing at keeping people alive and extending life… and this, for some people, is exactly the right thing to do. But I think the question should be: what do people want themselves, and, particularly if treatments have significant side-effects, you’re always going to have a trade-off.’

The chief medical officer went on to say that families should have conversations with older relatives about their health choices, wishes and health interventions in the event of a medical emergency and other serious illness. He also said that we need to have more realistic conversations about the side-effects of some treatments, and prioritise people’s quality of life. Furthermore, he emphasised that most older people do want to have these conversations, but possibly also shy away from them. Of course, it can be difficult to have these conversations within families, and denial is a very powerful factor. According to the report, it seems sometimes ‘less is more’ when the pros and cons of medical treatments are weighed up and balanced.

The report also highlighted the ageing demographics in many areas of the UK, especially by the coast; those living in these areas are projected to age far more rapidly than those in urban areas. Coastal communities are already known to often have bigger health inequalities than those in most other areas, and the state of general practice in many UK coastal towns is in a perilous situation.

Professor Whitty continued: ‘The biggest concern I have is that Government and professional bodies have not recognised the degree to which the population living in older age is concentrating geographically. Being an older person in many parts of the country is extremely difficult… we will soon be in a situation where a fifth of the population is over 65, and if you look to the middle of the century, a quarter.’

So, as GPs, this is something we are going to see more and more with the ageing demographic time-bomb that Professor Whitty talks about. Perhaps we do need to start asking more of those difficult questions and broach tricky topics such as the side-effects of a treatment on an individual’s quality of life, and whether someone wants to carry on with a particular treatment.

It is not easy, though, and there are no simple answers. It is also likely that as GPs, we will do as we have always done: try our best to give good medical advice, and try to do the right thing by all the patients that come and see us. Every consultation is different and unique, and we all must navigate each one the best we can, however difficult this may be.

Sir Kingsley was very interested in the processes of getting old, the indignities that can accompany the process of ageing, and how humans can cope with this. He wrote two comic masterpieces on this very topic: Ending Up and The Old Devils, which outline in excruciating comic detail the trials and tribulations of senescence. I recommend reading them – you will laugh, but you will also wince.

He himself never did end up in the old people’s home in Weston-Super-Mare.

I hope you are all keeping safe and well in these troubled times.

Yours faithfully,

Dr Burnt Out

*Apologies, and no offence intended to those people from, or those GPs who work in Weston-Super-Mare. I have been there and it is a very pleasant place, if at times a bit blustery.

Dr Burnt Out is a GP in London