Longer Life, at Any Cost?

John L. Marshall, MD


October 30, 2014

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This is John Marshall for Medscape. I have been thinking about what our patients want. I have started to ask, perhaps somewhat boldly, of our patients during our first encounter, "How long do you want to live?" I get one of two answers. Most people say, "I want to live forever." Or they want to live to age 90, or they have an age in their heads regardless of how old they are. I say, "Really?" And they say, "Well, as long as I am okay. As long as I am doing all right and my world is good."

I have another group of patients who answer right away, "I only want to live as long as life is good." They consider quality of life. So, there is a group who say they want to live to a specific number of years, and another who say that it is more about quality and less about the number.

I don't know many 90-year-olds who are well, driving their own cars, and are in control of their bodily functions. How many 90-year-olds are enjoying life, out there on the golf course, playing tennis, hanging out with grandkids, that sort of thing? I know many 90-year-olds who are struggling day in and day out, and their major social event is a doctor's appointment or their next dose of whatever they are taking.

I wonder whether our patients really do want to get to that point. For oncologists, it affects what we do for a living. We are trying to extend survival. We are trying to improve survival time—and our measures of success are much shorter, typically, at least in my world of gastrointestinal cancers. We are extending time only a relatively small amount. What is the quality of that time? Is it spent going to doctor's appointments and experiencing side effects of treatment?

Are we actually meeting any of our patients' targets? We are not going to meet those targets regarding time for many of our patients, and with respect to quality of life, we are not meeting that for our patients either. It is interesting. Our patients are becoming more in tune to all of this. There is clearly a shift, at least in my American population, of more acceptance of quality being important, and not necessarily scrapping for huge chunks of time.

I heard a fairly prominent physician on a broadcast program, who claimed that when he got to age 75, he was going to stop all his medicines, quit going to doctors, and let nature take its course.[1,2] We will see when he gets to age 75 whether he is willing to do that, but I like that strategy. It felt good to me as a 53-year-old. I have a little time before I have to make that choice.

If we all were to do this, if we shared the belief that this was the right thing to do, I wonder what would happen to Medicare bills. They would be significantly lower. I wonder whether our quality of life and our goals and many end-of-life issues, particularly for the elderly, would improve.

It is a challenging subject. There are no right answers, and when the gun is pointed at me, I am not sure whether I will want to live to age 90 or just make sure that I have a few good, quality days.

We all ought to think about that. We ought to talk with our patients about that. I am doing it at all first visits now with patients who have gastrointestinal cancers. Let's make sure it is part of our daily discussions.


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