Editorial
Prolonging life at all costs: quantity versus quality
Medical advances have meant that people are living
longer but, as the 2015 Global Burden of Disease data
showed, the corresponding increase in healthy life
expectancy was significantly less, meaning that people
are also living with illness for longer. This situation
creates an increased burden on health-care resources
and more challenging discussions around appropriate
medical interventions and intensive treatment near the
end of life.
Two recent reports in The New York Times highlight
this emotive and contentious issue. In the first, called “Is
it better to die in America or in England?”, Ezekiel Emanuel
and Justin Bekelman discuss their recent research
comparing end-of-life care for patients with cancer in
seven developed countries. Encouragingly, the USA had
just 22% of patients dying in hospital, which is lower than
in Canada, England, Norway, the Netherlands, Belgium,
and Germany. However, where the USA didn’t fare so well
was in use of the intensive care unit (ICU), where it was
noted that 40·3% of Americans had an ICU admission in
the last 6 months of life compared with less than 18% in
the other six countries. Furthermore, although patient
outcomes in the USA and UK are similar, the USA spends a
quarter of its Medicare budget on the last year of life and
has 25 ICU beds per 100 000 people, by contrast with the
UK, which has only five beds per 100 000 people.
A 2011 poll in California showed that peoples’ main
concerns about dying were not to burden their family
financially by the care they received, and to be comfortable
and without pain. This seems to be at odds with the reality
of how people are actually dying today in the USA. The
second New York Times article “Not just a death, a system
failure” is a heartfelt viewpoint about this disconnect
between a patient’s wishes and the reality of care. Barbara
Moran tells the story of her mother’s death in the ICU,
which she describes as filled with unnecessary procedures,
pain, and distress, and how this has encouraged her to
want to change how people die in America. However, the
reasons for increased use of intensive care at the end of
life are incredibly complex and the nearly 300 comments
posted after the article from readers highlight the difficult
ethical and logistical task ahead.
To this end, Derek Angus and Robert Truog reported in
the Journal of the American Medical Association potential
ways to improve ICU use at the end of life. They suggest
www.thelancet.com/respiratory Vol 4 March 2016
a need to reduce inappropriate admissions through more
considered gatekeeping by ICU physicians, more detailed
discussions with patients and families before admission
DNA Illustrations/Science Photo Library
about goals for care and potential outcomes, and, lastly,
reducing the number of ICU beds to create an impetus to
use the resources for those who will truly benefit. They
also believe that ICU physicians and staff need more
training in palliative care to aid in shared decision making
with families and colleagues and to help the re-evaluation
of treatment goals during an ICU admission. Published Online
February 15, 2016
These suggestions are all excellent but health-care http://dx.doi.org/10.1016/
systems also need to adapt to enable such changes. The S2213-2600(16)00059-X
USA currently has a pay-for-service set up that rewards For The Lancet GBD 2015 study
see Lancet 2015; 386: 2145–91
more treatment and investigation, and it is difficult to For the New York Times article
quantify or code for a good death. However, positive by Emanuel and Bekelman
see http://www.nytimes.
steps have been made: Medicare announced in October, com/2016/01/20/opinion/is-it-
2015, that it would now reimburse doctors for end-of-life better-to-die-in-america-or-in-
england.html?_r=0
discussions. This step should help to open up this taboo
For the article comparing the
subject, with both doctors and patients being better seven countries see JAMA 2016;
informed about personal wishes and goals. 315: 272–83
For the Californian poll see
Public perception of death and dying also needs to
http://www.chcf.org/media/
be addressed so that unrealistic expectations from press-releases/2012/end-of-life-
care#ixzz2eLhnscM1
medical treatments can be managed and death is not
For the New York Times
seen as a failure. A recent multisociety statement on the article by Barbara Moran
fine line between futile and potentially inappropriate see http://opinionator.blogs.
nytimes.com/2016/02/06/
treatments was the subject of an impassioned debate at system-failure/?smid=fb-
the CHEST 2015 conference. Even the smallest chance nytimes&smtyp=cur&_r=1
of success can be seen as worth taking when your life, or For the article on better ICU use
see JAMA 2016; 315: 255–56
the life of a loved one, is at stake, even if a patient will For the multisociety
experience increased pain and suffering as a result. This statement on futility see
Am J Respir Crit Care Med 2015;
situation makes withdrawing or refusing treatment 191: 1318–30
extremely difficult, and doctors in the USA are not well For the Stanford study see
supported by guidelines or criteria to help their decisions. PLoS One 2014; 9: e98246
Interestingly, a study done at Stanford University showed
that 88·3% of doctors would not want invasive or
intensive medical intervention at the end of their life and
would opt for a do not resuscitate order for themselves.
The goal to reduce inappropriate ICU admissions at
the end of life is gaining traction in both the media and
in medical societies. Maintaining hope at the end of
life is very important, but managing expectations and
changing outlooks so that this hope is focused towards
quality of life, not just quantity of life, might mean
that more people get the good death that they deserve.
■ The Lancet Respiratory Medicine
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