I am unsure as to what constitutes a normal lifespan in current day UK. I no longer know when a person is considered to be old enough to have died of ‘old age’ or ‘natural causes’ or indeed what is acceptable as a ‘natural death’ in 21st century Britain.
The issue needs debate and clarification because of its importance in general practice, especially with regard to the change in emphasis in practice brought about by the shift from a ‘therapeutic’ to ‘preventive’ paradigm. With a therapeutic approach, the treatment of disease requires the presentation of a patient with symptoms that a doctor can treat; preventive care is defined as a set of measures taken in advance of symptoms to prevent illness or injury. The dilemma facing doctors is at what point does prevention become therapeutic and, if it does, then have we in some way failed in our duty to prevent that potential for illness becoming a reality? Yet it is inevitable that we all die and thus we need to define at what stage and manner death is acceptable.
For example, cardiovascular disease (CVD) remains the biggest killer in the UK1 despite the large resources mobilised to prevent it. Yet when faced with an 80-year old woman with treated hypertension we remain uncertain as to our treatment goals, particularly in the application of primary CVD prevention requiring, for example, the use of statins. Her age suggests that she may well die in the next decade or so regardless of what we do. However, statins have been shown to be universally beneficial (it is disingenuous for us to hide behind the lack of clinical data/evidence on their use in older females) and intuitively a doctor would be inclined to prescribe them. But how strongly should we press the point if she is disinclined to take them? In such a far from hypothetical case where a statin was not prescribed, would the blame, if indeed any, be subsequently placed were she to sustain a disabling cerebrovascular accident the following year?
So where should the profession stand in this debate? We are, for example, as scientists, only too familiar with the concept that, as the body ages and weakens, it does not take much of an insult to trigger a domino effect of organ failure. Yet we make that case poorly when dealing with, in particular, the relatives of our aging patients so that any physical failure in health leading to death is deemed by some to be an equal failure in medical management. The paradox is that, anecdotally in closed debate, non-medical individuals will often state that they would not personally want to be kept alive if they had a terminal illness or indeed a severely incapacitating one such as a severe stroke. Yet the same individual will shy away from withholding treatment to another in that position.
GPs and hospital doctors are faced daily with management dilemmas requiring laudable efforts to reverse or stem the abuse of longevity on the human body. At what stage should we describe such efforts as being successful? At what age should life itself be considered a bonus rather than a right?
The average age of death in the UK for a man is 77 years and a woman 82 years.2 Should these numbers act as a threshold above which heroic interventions should no longer be considered? In a target-driven culture should preventive medicine be hailed as a success if it drives these population ages ever higher? Alternatively would we, as doctors, feel that we have failed in our duties if an individual in our care dies below these figures? Our problem as a profession lies in our conscientious adherence to pursuing the wellbeing of our patients at almost all cost. It is because of this that the loss of any patient is taken as a reflection on our performance. If the move towards preventive medicine is to not lead to a massive demotivation of the sensitive and caring doctors within the profession then we need a target age for longevity, the attainment of which would be deemed as a success.
It has to be stressed that this subject is NOT about euthanasia or assisted suicide nor is it a charter for the psychopathic culling of older people. It is, hopefully, a reasoned debate, which may be summarised, as an example, in the following proposal:
Based on the indisputable evidence that the average life expectancy of a woman in the UK is currently 82 years, should we cease to pursue a policy of primary prevention of CVD, such as the prescribing of statins, after that age?
- © British Journal of General Practice, 2010.