I personally have made an advanced directive. (You can find it on this site) My family know what I would like, and it is clear. It is also clear who and how has to make the decisions in the absence of my wife. A friend and colleague was in his late 80s and an “event” happened leaving him incapacitated and in pain. He had multiple health problems, but his mind was sound. Full mental capacity entitled him to determine his own future, and he chose to stay at home, with pain relief, and without a diagnosis. He died 2 days later, and the death certificate reads “pneumonia” because that’s what happens when you lie still. The “old man’s friend” as it used to be called. Lord Darzi is right, and Lord Howard of Lympne commends him. I respect my friend’s decision, and laud his bravery. He died at home, surrounded by family, without prolonged distress, over investigation or overtreatment, and it was his choice. Even the “Non-terminally ill seek right to die” (Sarah-Kate Templeton and Becky Barrow in The Times 9th October 2016)
Apart from old age and multiple morbidity, one of the greatest areas for saving is at the interface between oncology and palliative care. Oncologists may hold onto patients too long, and it could help to have a GP attached to both teams and encourage appropriate transfers.
Sir, Lord Darzi’s article is timely. We octogenarians and nonagenarians should be given a choice, when we have such multiple chronic conditions and functional disabilities. Some may tolerate a form of highly restricted independent life, but many of us would rather be allowed to die with dignity, before our lives become an intolerable burden.
Lord Darzi in “We need to keep high-cost patients out of hospital” on the 30th September opines in the Times:
The NHS finds itself increasingly trapped between soaring demand and squeezed budgets. Health leaders warn of “draconian rationing”, chronic understaffing and hospitals on the brink of collapse. Savings must be made. But are we looking in the right place for them?
This week it was reported that some patients are facing waits of up to 15 months for cataract operations. Yet cataract surgery is cheap and highly effective.
A survey of 1,000 doctors last week found seven out of ten said they had witnessed restrictions on NHS treatments. They cited breast reduction, varicose vein removal, IVF, and the excision of benign lumps and bumps, but these account for a tiny proportion of spending.
When looking for savings, instead of restricting minor activities that yield little, it makes sense to focus on the costliest patients and the costliest treatments. Figures from the US show that 5 per cent of hospital patients account for 50 per cent of health spending. In the UK, a study in one NHS trust found that 3 per cent of patients accounted for 45 per cent of expenditure. David Blumenthal, president of the Commonwealth Fund, said in a lecture to the Institute of Global Health Innovation this week that these figures were likely to be true across the world.
These high-need, high-cost patients are typically older, with multiple chronic conditions and at least one functional disability, such as an inability to dress or feed themselves or manage their affairs. Patients with three chronic conditions and one functional disability cost 400 per cent more than the average. Their numbers are increasing as the population ages.
This is where we should be putting our efforts — designing high-quality, low-cost interventions to keep these patients out of hospital and living independently. One example is the “Call and Check” scheme in Jersey which uses postmen to deliver prescriptions and link elderly people with other services.
There are good humanitarian reasons for doing so, too. Given their frequent contact with the NHS and multiple treatments, these patients are much more vulnerable to things going wrong. Improving the performance of the NHS will require improving care for those who need it most, not those who need it least.
Lord Darzi is a surgeon and director of the Institute of Global Health Innovation at Imperial College London
Do not resuscitate’ is doctors’ own choice for end-of-life care – but perish the thought to educate patients!