Vedamurthy Adhiyaman is a Geriatrician in North Wales. Tweets @adhiyamanv
Our beloved Queen Elizabeth II recently died of ‘old age’, surrounded by her family. She was very fortunate not to endure spending her last few weeks in hospital or institutional care, which is often the case for a lot of older people. Their journey frequently starts in an ambulance waiting outside a hospital, followed by lingering for hours on a trolley in the emergency department before being admitted to a ward.
Older people who are admitted due to a sudden or gradual decline in their health are invariably subjected to various blood tests, treated with antibiotics for suspected infections, given endless volumes of intravenous fluids, injected with heparin to prevent clots which causes multiple bruises etc. If they are unable to eat or drink because of their generalized weakness, the clinical team may even consider non-oral feeding. When they eventually pass away, there is often a scrutiny of their care, which can pick up shortcomings in their care, including issues around nutrition. Despite these checks and balances in the healthcare system, it is rarely questioned whether there was a need for an admission to hospital in the first place.
When we talk to older people with frailty and multiple co-morbidities, they often indicate that they want comfort and peace – if given a choice, many would like to die at home. Clearly not everyone is as fortunate as the Queen in terms of social and medical support. Primary care and social care services throughout the United Kingdom are stretched beyond their limits and in many places are only functioning adequately due to the goodwill and selfless work of health and social care professionals. In addition, there is the need to manage the great expectations of both patients and their families on the prognosis of a patient’s condition. Though skilled in breaking bad news, it is very challenging for clinicians to convey in an empathetic way that further interventions, including admission to hospital, would be futile. Many older adults are admitted due to a lack of community or family support at home.
Inability to provide adequate medical care and social support at home is not due to lack of intention, but a result of pressure on the scarce resources available in the healthcare system. And although the majority of hospitals have a service to cater for frail people, their capacity is also constrained and advanced frailty is not always considered a terminal condition.
When the death certificate for the Queen was released, it only listed ‘old age’ as the cause of death, with no underlying conditions. Interestingly, the same cause of death was reported for Prince Philip in 2021. The guidance for doctors completing medical certificates on cause of death advises doctors to avoid using ‘old age’ as a sole cause of death. It recommends that ‘old age’ should only be used when there was general decline in a person’s health with no other identifiable cause of death1. Perhaps this might have been the case with the Queen, but I suspect the other reason would be to protect her confidentiality.
One study analysed patients who were certified as dying solely from ‘old age’ and revealed that the majority had one or more comorbid conditions, with only 8% having no underlying medical condition2. In another study, many geriatricians wanted just ‘old age’ on their death certificates3. There are arguments for and against using the term ‘old age’ alone on the death certificate, especially after the Shipman enquiry4. It could be argued that if a person has suffered some consequences of old age, such as a fall due to frailty and sarcopenia, and subsequently dies, ‘old age’ may be reported as an acceptable cause of death.
The Queen has not only led by example in her life, but also in her death. We should make more provisions to care for people who want to die at home, without over-medicalising their last moments of life and should not hesitate to certify ‘old age’ as the cause of death. What is good enough for the Queen should be good enough for her subjects.
References
Guidance for doctors completing medical certificates of cause of death in England and Wales (accessible version) - GOV.UK (www.gov.uk). Accessed 10th October 2022.
Hawley CL. Is it ever enough to die of old age? Age Ageing 2003; 32:484–6.
Adhiyaman, Vedamurthy, and Indrajit Chattopadhyay. "Is it appropriate to link ‘old age’ to certain causes of death on the medical certificate of cause of death?." Future Healthcare Journal 8.3 (2021): e686.
Kafetz K. “Old age” should not be acceptable on death certificates. BMJ. 2001 Apr 21;322(7292):993.
