HCR -- The Four Ways We Die

By John Ballard

One factor of America's extraordinarily high medical costs is our belief that dying is optional. Your death is inevitable, of course, but mine is not. I and those I love simply don't have to die. I'm being sarcastic, of course, but there is not a reader who doesn't get what I mean.

The dramatic change in the causes of death by Dr. Stephen Schempff describes how the advances of science and the art of healing during the last century have changed how we view death.

Most of us will not have the opportunity to just die of "old age" or to simply fall to sleep one night never to wake again. Most often, we develop an illness which causes our death. These have changed markedly over the years. For the pioneers, accidents, infections, childbirth were times and causes of great likelihood of death. A century ago, infections were the leading causes of death. Today, we will probably survive much longer than our ancestors but it is more likely we will die of heart disease, cancer or stroke. This is a dramatic change in the causes of death that has occurred over the years and with it is an equally dramatic change in the factors that predispose to those deaths.

The New England Journal of Medicine, arguably the most influential medical journal of our times, is celebrating its 200th year of publication with some special articles. A recent one called "The Burden of Disease and The Changing Task of Medicine" by Jones, Podolsky and Greene looked at the changes in causes of death from 1812 to today. The changes are not really surprising but worth contemplating. [Excellent graphs at the link.]

In 1812 the city of Boston recorded 992 deaths of which the greatest number by far were due to "consumption." Various other fevers combined were the next most common. Cancer killed five and sudden death (heart attacks?) took 25.

[snip]

As our population rapidly ages there will be increasing numbers of the chronic diseases that come with aging such as visual and hearing dysfunction, mobility problems, arthritis and Alzheimer's. And as society persists in eating a non-nutritious diet and too much of it, avoiding exercise, having chronic stress and (20%) smoking there will be literal epidemics of obesity, hypertension, coronary artery disease, stroke, chronic lung and kidney disease and cancer. Just as sanitation and vaccines made a huge impact on the diseases of a century ago, so too could aggressive preventive measures to assure health and wellness make a difference in this century.

What is evident is that the causes of death have switched from acute illnesses to chronic illnesses. And we know from insurance companies that chronic illnesses consume about 70-85% of claims paid. What is less well appreciated is that our medical care delivery system was established over the years to deal with acute illness and for one provider to care for one patient. In this regard, think of the internist who treats a pneumonia with an antibiotic or the surgeon who cures a patient by removing the appendix. But patients with complex chronic illnesses need not one doctor but a multi-specialist team to give the best possible care. And the team needs to be well coordinated, probably by the primary care physician or in the case of some situations by a specialist. In both circumstances the coordinator directs - orchestrates - the entire team to offer the patient the highest quality at the least expense. This is a change in how care is delivered that needs to fully occur as illnesses have increasingly become chronic, complex, life long, difficult to manage and expensive to treat.

This TEDx talk by Peter Saul summarizes the four ways we die out in plain, if uncomfortable detail.
I got the graph above showing the four main categories of causes of death from one of the power point slides in his talk.  They are

1. Sudden Death


2. Terminal Illnesses


3. Organ Failure


4. Frailty

 I may change my mind, but given a choice I would choose #1 or #2. Option #3 can be manageable in many cases but #4 definitely is the worst. Living longer doesn't mean a longer youth. Longevity means a longer old age.