Two deaths last week highlight a problem for modern medicine: as treatments improve, dying can be prolonged. Atul Gawande, the surgeon and author who will deliver this year’s BBC Reith Lectures, says it’s time to rethink our approach

How do you want to die? Not the most cheerful question to ponder over your cornflakes, but increasingly urgent in a population that is older and better treated – medically speaking – than ever. Last week it was thrown into sharp focus by the stories of two women.

The actress Lynda Bellingham told an interviewer last month why she had decided to end chemotherapy. The cancer in her bowel had spread through her body, far beyond the point of operation. “I look at myself now on a bad day, haggard and drawn,” she told the Daily Telegraph, “with my white hair flat against my head and a stoop of tiredness and pain. I do not want Michael [her husband] and the family to say goodbye to me looking like that.”

With her will drawn up and preparations for her death made, Bellingham wanted to enjoy the time she had left. She hoped for a final Christmas with her family, but it was not to be. She died in hospital in London last Sunday, aged 66, in the arms of her husband.

The following morning came news of Jean Davies, 86, who had died on 1 October after starving herself for five weeks. She was a life-long euthanasia campaigner and author of a 1997 book, Choice in Dying. Her health had deteriorated to the point where she could no longer bear to live. She feared that an overdose of medicine might not work, and did not want to travel to the Dignitas clinic in Switzerland. She believed that starvation was the only legal way to exercise her right to die. After a last slice of cake, she stopped eating. In a final interview with the Sunday Times, a month into her fast, she described her situation as hell: “I can’t tell you how hard it is.”

Hard for patients, of course, but hard for doctors as well. It is an irony of medical science that every advance in treatment for other conditions makes death, the acutest condition of all, more prolonged and complicated. Heart disease, strokes and other potentially fatal conditions are increasingly treatable. The population is ageing rapidly, and on average 70% of our lifetime medical costs come in the last six months.

A new book by American surgeon and New Yorker writer Atul Gawande, Being Mortal, addresses the conundrum of how to balance longevity with quality of life. Gawande has spent much of his career trying to extend the lives of his patients but found himself questioning whether procedures that caused the patient suffering, for a small chance of an extended life span, were worth it. He contrasts the experience of his grandparents in India, where it was expected that the family would look after the elders, with the often horrendously lonely final chapters, played out in grim and uncaring nursing homes, of patients in the west.

Gawande is not alone in wrangling with these issues. Henry Marsh, one of Britain’s pre-eminent neurosurgeons and an author himself, says it is only natural for doctors to shy away from discussions about whether, in some cases, more treatment is a good idea.

“It’s very painful to tell someone to go away and die,” he says. “As patients we want optimism, but we also want hope and the two are often in conflict. That’s very unpleasant. All of us go on hoping right to the end. Towards the end many people develop a split consciousness where part of you wants to go on living, and the other half knows you’re dying. For doctors, the temptation is to run away and say, ‘oh, we’ll treat you’ – shoot first, and ask questions later.”

Marsh believes there are two main areas of concern. One is whether to go on treating people with advanced cancers in the hope of prolonging life: “Most of us would accept a great deal of suffering in hope of a cure. The issue is whether doctors should subject patients to unpleasant non-curative treatments. To my mind there is no question that we are over-treating at the moment.”

The other is how we cope with mental decline, as he saw in his own father. “He was a brilliant man, one of the founders of Amnesty, and died slowly of Alzheimer’s. He was only a shadow of the man he had been, but if you’d asked him he would have said he was happy. He wouldn’t have believed in euthanasia. My own view is that the euthanasia available in Europe is very civilised, where you can get doctor-assisted suicide on grounds of intractable suffering and hopelessness. Lord Falconer’s proposed bill is a milder version – where you have to have a terminal diagnosis of six months.”

Euthanasia doesn’t get round the issue of incapacity, where someone’s life is unbearable but they lack the ability to make decisions about themselves. Advanced Directives, where a patient explains the circumstances in which they would like to be treated, work only in the event of loss of consciousness.

“I don’t know how you’d establish whether someone was incapacitated when they were still conscious,” says Marsh. “Some kind of IQ test? You’d be pretty reluctant to say that doctors should kill people off.”

A turning point for Gawande was watching his father succumb to a spinal tumour. After a career on the other side, he saw these decisions through the eyes of the patient. He had a tough conversation with his father, recounted movingly in the book, in which they discussed how much the older man would be prepared to go through. “What are your fears? What are your goals? What are the trade-offs you are willing to make?” In the end, the older man, like Bellingham, decided enough was enough.

Gawande’s proposed solution is for doctors to take a more circumspect approach to the care of end-of-life patients. When patients ask him if they are going to die, he has learnt sometimes to reply “I’m worried”, rather than offer blanket reassurances. In particular, he advocates improved hospices, of a sort which have begun to crop up in America. Rather than the grim, bland nursing homes of lore, these concentrate on quality of life, with pets, music and other activities for residents. (Although in a review of Being Mortal for the Financial Times, the novelist Diana Athill noted that her own nursing home, of which she thinks Gawande would approve, is run on principles drawn up in 1877.)

Last-ditch chemotherapy and other treatments can often be extremely expensive. In a health service with limited resources, perhaps more money should be spent on making death more pleasant rather than drawing life out indefinitely. But no form of care is free. Marsh concedes that his father’s relatively happy slide into dementia was aided by round-the-clock care, paid for out of savings.

None of these approaches is perfect. Gawande accepts that the miraculous cure, when a patient recovers against the odds, is one argument against managing decline. While many of these ideas are sound in principle, it’s hard to say how we would behave when death is staring us down. How can we legislate for our reaction in the face of the unknowable?

“There are no easy answers, but we need a more open discussion, and more realism about the fact that we are all going to die,” says Marsh. “We need to make decisions about it. In the pre-modern era there weren’t decisions, you just sort of died.”

Easy answers or no, the questions will not go away. From the lessons of last week, it’s hard not to think that we would all prefer to die like Lynda Bellingham rather than Jean Davies. Sometimes, maybe, it would be better to go gently.

Facts of death



In 1964, the average age of death in Britain was 65. In 2011, figures from the Office for National Statistics showed that men could expect to live to an average age of 78.2 years and women 82.3 years.

Across the UK, life expectancy is highest in England, particularly in the south, and lowest in Scotland. Glasgow has the lowest life expectancy (71.6 years for men and 78 for women)

One in five people who travel to Switzerland to end their lives are from the UK. Out of 611 people who went for an assisted suicide between 2008 and 2012, 126 were from the UK; there were more Germans than any other nationality. One in three people who seek assisted death have more than one condition, and neurological conditions such as motor neurone disease, Parkinson’s and multiple sclerosis accounted for almost half of the total cases, followed by cancer. The average age is 69, but ranges from 23 to 97, and 58.5% are women.

In 2012, the leading cause of death for men in Britain was heart disease (15.6%) and the leading cause for women was dementia and Alzheimer’s disease (11.5%), according to the ONS.