Death, dying and deciding: surrogate decision making in end-of-life care
Most of us, if we were to imagine or wish our manner of dying, would take our cues from the way it has been portrayed in films. Death either occurs suddenly as part of a climax or as a more prolonged scene with a supporting cast of family and “significant others”. In reality most deaths occur after variable periods of ill health in the later stages of life and this proportion will rise in India too, as poverty declines. A recent article in The Economist estimates that by 2050, 80% of all deaths worldwide will occur after the age of 60 and the three main causes will be malignancy, chronic organ failure and overall frailty with or without dementia, each of which has a separate trajectory. In general, patients with malignancy retain control till the terminal decline sets in, and this usually has a predictable course. For people with organ (heart, kidney, lung, liver) failure, once identified, some degree of foreseeable decline is part of the remaining life span. Most can be expected to succumb during a severe episode of their basic illness. For those who survive the mid-70s without cancer and with functioning organs, the good night is neither short nor gentle nor predictable. The quality of life is usually poor but, above all, both dementia and strokes impair judgment and the ability to communicate so that the subject can neither make decisions nor express them. Thus it is quite possible for a senior adult previously capable of informed consent to gradually lapse into a state where all the decisions about his or her medical care have to be made by others.
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