Sick To Death > Chapter 1 > Which Illness Will It Be?
Our national priorities in health care are said to be "to promote health and quality of life by preventing and controlling disease, injury, and disability" (Centers for Disease Control and Prevention 2002a). The headlines trumpeting a success often say something like "New Drug Promises to Save 10,000 Lives per Year," or "Treatment Offers Hope to Millions." "Saving lives" and "offering hope" are metaphors brought forward from the triumphs of public health in the past century, when millions of children actually did live full lives rather than dying from polio or diphtheria.
What is missing is the recognition that opportunities for prevention and treatment eventually run up against mortality. Immunizing a town's children to save them from polio has obvious benefits in terms of extended life duration and life opportunities. Saving a young adult from death from meningitis with a few doses of antibiotics generates the same enthusiasm. Yet saving a frail nursing-home resident from any particular complication extends life a bit, changes the manner of dying, and may or may not, on balance, be a good thing (Rich and Sox 2000; Lynn and Cretin 2000). When we use the language of prevention and cure, we often carry along the enthusiasm and approval from historical triumphs of public health and medical treatment, but these sentiments may not fit the current situation.
When public health aims at "preventing and controlling disease, injury and disability," it tries to reduce the incidence (the rate of new cases) and prevalence (the rate in the population at any one time) of disease and disability. Among very sick or very old people, these measures are inadequate and possibly misleading. Most people living their last few years now have multiple medical problems - co-morbidities, to use technical language - from diseases or just from old age. Preventing one condition from causing illness and death necessarily means increasing the likelihood that another one will cause illness and death, just a little later (Welch et al. 1996). If a person has some heart disease and some memory problems, as well as the reduced reserves of all of the organs that come with being eighty-eight years old, then treatments that slow the heart problem will increase the chances that the person will live long enough to be greatly burdened by memory problems. Again, that may or may not be desirable.
People would expect a headline that shouts "New Drug Prevents Heart Disease in Elderly" to herald a story about something thoroughly laudable. The headline could be equally correct and say instead "New Drug Promises Major Increases in Dementia." Saving the lives of children who otherwise faced polio was reasonably understood to be a very good thing. Saving the lives of elderly persons by eliminating one among a group of competing causes of death is more complicated. Eliminating one illness might well change the nature of the death and delay its timing, but the language of saving lives is misleading.
Half of the elderly who survive one trip to an intensive-care unit die within a year (Rockwood et al. 1993). By age eighty-five, most people have more than two established diagnoses of conditions that can be expected to worsen and cause death (Wolff, Starfield, and Anderson 2002). A quarter century ago, Tauber (1976) computed the effects of eliminating cancer as a cause of death and found less than a year of prolonged survival on average (and a substantial increase in the likelihood of dying from heart disease). Winning the war against a particular cancer would yield major gains for a few people who now die young, but it would mostly have small effects on older people, since old age is when most people die of cancer. Another illness is, all too often, waiting in the wings.
Welch and colleagues (1996) pointed out that the expected mortality risk for a patient was composed of the risks associated with aging and the risks associated with particular conditions. Thus, a young person's risk of dying with a medical condition almost entirely arises from the risks associated with that condition alone, since the risks associated with aging are slight. However, an older person faces substantial risks from an array of aging-associated illnesses. Indeed, those risks can greatly attenuate the merits of treating any one specific disease. For example, mild prostate cancer can have a 5 percent mortality at five years. A sixty-five-year-old man will lose an average of two years to that disease, changing his predicted survival from fifteen years to thirteen years. The same cancer in an eighty-five-year-old will cost him only a few months on average, shaved off his expected survival for five years.
The age-related component of a patient's mortality risk becomes much more substantial with increasing age, so the contribution of successful treatment or prevention of any particular illness becomes correspondingly smaller. In addition, older persons usually have more burdens and more limited success from interventions, considerations that further limit the merits of intervening. Of course, estimates of future survival and function should consider the patient's actual condition, not just the patient's age; and age-related risks apply to predicting disability as well as mortality. The upshot is that, for persons approaching the end of life, it is common to find that treatment is not worth its burdens. If a person is living with one fatal illness and evidences another, very often the suffering imposed by treatment more than outweighs the possible advantage of success in that treatment.
None of these outcomes argue against prevention or cure. Our success in meeting those aims gives us the opportunity to live long before becoming mortally ill. Even in advanced illness and old age, some conditions merit prevention or cure: pain or skin ulcers, for example. But there is no way to avoid aging, really, except to die young (figure 2). Exercise, good diet, mammograms, and colonoscopies help delay the onset of serious illness, but each person's future includes a fatal condition.
Now that Americans mostly live into old age before becoming seriously burdened with chronic illness, we need more appropriate language and metaphors. We hope to live as well as possible, even with serious illness. It matters to ease symptoms, enhance autonomy, avoid bankruptcy, alleviate depression, and otherwise relieve what suffering can be relieved, even in the "valley of the shadow of death." But we can't tackle these urgent issues unless we learn to reach beyond the folly of focusing only on prevention and cure.