Abstract
Dear Editor:
Whereas we fundamentally agree with the notions and sentiments Dr. Ravakhah expressed in “Nobody Dies of Old Age Any More?,” published in the April 2011 issue of the Journal of Palliative Medicine, 1 we offer alternative perspectives based on our experience as learners and teachers of palliative medicine and from many years of providing primary care to a multitude of patients. We acknowledge that, given the medical condition and overall prognosis of Dr. Ravakhah's patient, palliative care was the most appropriate option. Yet, we argue that the author's method and rationale for completing the death certificate were flawed. Use of “old age” as the cause of death seems to be an oversimplification; furthermore, he diminished the focus of palliative care and the role of the physician to basically no more than that of a by-stander. Dr. Ravakhah specifically and appropriately discontinued life-prolonging therapies (which may also be considered death prolonging); he did not withdraw care. Indeed, he fulfilled the role of a palliative physician with counseling, prescribing medication, and providing comfort care.
If there is a preeminent attribute of palliative care, it is communicating with the patient and family; it is what we do best. How we counsel our patients and their families while the patient lives (before we sign the death certificate) is extremely important, and the language we use matters. 2
The importance of our communication and our responsibility as practitioners does not end when the patient ceases to have a pulse or take another breath. It continues into bereavement care, including completion of the death certificate. In fact, at this point our responsibility as physicians takes on a broader legal dimension. The death certificate is a legal document used by attorneys and insurance companies to determine whether an insurance claim will be accepted or declined. For instance, if a patient has a cancer policy and dies of complications related to colon cancer, but cause of death is listed as old age, that policy might be denied. The cause of death noted on the death certificate can also affect Social Security benefits, veteran's benefits, and retirement benefits. 3
From a public health perspective, data collected from death certificates help epidemiologists determine death rates related to disease processes. Funding for research and education for these diseases is based on statistics derived from death certificate data. If everyone over the age of 75 years with cancer, chronic obstructive pulmonary disease, coronary artery disease, or diabetes was classified as dying of old age, monies for research for many diseases would be cut, with the quality of life of our nation as a whole would suffer. Therefore, taking the necessary time to properly complete the death certificate can have a lasting impact for our patients, their families, our specialty, and our society.
In the academic environment, the death pronouncement and signing of the death certificate offer fertile opportunity to touch the patient, to care for the family during bereavement counseling, and to debrief the staff and learners. 4 If special cultural rituals are desired by the family, support in this regard is also offered at this time.
The patient's cause of death associated with myriad medical maladies is often realistically reflected in the words of our patients and families who tell us “it is what it is,” it is “God's will” or a “Divine Call,” or, to paraphrase Shakespeare, it is “a necessary end” that will come when it will come. Anticipating death, offering to listen and counsel offers hope; however, changing the focus of hope defines palliation: “We wish we could cure; we cannot. Yet, we promise we will comfort at every opportunity.” This is nature; it is life. We take solace in this insightful and serene practical wisdom of our patients and families. Therefore, we may use “natural causes” instead of “old age” as the immediate cause of death because it acknowledges precisely Dr. Ravakhah's point; ultimately, a combination of age (if we are blessed, old age) and any number of medical conditions contribute to death. Yet, we need to do our utmost to describe the medical conditions using our best medical terminology for all the reasons noted.
Let us continue to ponder what happens prior to signing the death certificate as well as the words that we choose when signing it. At the most philosophical level, we agree that it is ultimately beyond our ability to label, measure, describe, and quantify the cause of death. For all that we do as healers, teachers, and learners, it is important to learn from anyone, everyone, and under all circumstances, even those who have died.