Richard Smith: Two deaths

Richard Smith A woman I hardly know and I are sat in a café in a country far from Britain, and the conversation turns to death. She tells me of two deaths in her family in the NHS. The first is remarkable.

An elderly woman, my companion’s mother, is waiting in a hospital for news of her elderly husband. A doctor comes out and tells her that he has died. Unfortunately, she doesn’t understand the very thick accent of the doctor, but she gathers that she can see her husband. Without understanding that her husband is dead she goes and sits beside him. The body is still warm. After about half an hour a nurse arrives, and the woman tells the nurse that she thinks that her husband would like a drink. The nurse realises that things have gone horribly wrong.

This remarkable climax follows a sadly more familiar story. A few months earlier, her stepfather, who was in his 90s, was repeatedly clawed back from death during three and half months in hospital with a series of complications after a hip fracture. It was a long drawn out and miserable time, but it seemed to be what her mother and stepfather wanted. I wondered with no evidence whether within the triumvirate of the man, his wife, and the doctors it was hard for anybody to say “enough.” My companion in the café thought that she should keep her mouth zipped shut, and she acted doing so as she said it. When her stepfather returned home, he was greatly diminished in mind and body after months immobilised in hospital. The first story tells of his death less than 24 hours after hospital readmission.

The second death was of her 42 year old husband many years ago. He was a free spirit, something of a hippie, the last person you thought would expect to insist on having every last medical intervention. But that’s what he did want. The cancer spread, but he and his doctors went on with treatment to the very end. I thought of Atul Gawande writing about if there is a one in a million chance that a treatment might work then both the patient and the doctor may hear the one and not the million.

After our brief conversation I was left with two thoughts. Firstly, we none of us know how we will feel as we come close to death, although I do think that we can try to prepare ourselves—and should do so. Secondly, modern healthcare has hugely increased our potential to die badly.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.