‘To everything there is a season, and a time for every purpose under the heaven: a time to be born, and a time to die ...’ Ecclesiastes 3.

When I last edited an edition of CME on palliative care it was not a recognised specialisation. That has changed and not before time. Palliative care is not simply about making death an easier experience. It is about the total care of a patient at the end of life.

The end of life ... This brings me back to a subject that some of you may well be seriously fed up with by now – my hobby horse of the medicalisation of old age. Last year my father-in-law died, at the age of 88. He did not have an easy death. At the age of 80 he had a triple CABG – for, I suspect, spurious indications because none of the symptoms for which the bypass was carried out were alleviated. He was not a man who took infirmity well and the bypass simply started a very long progression into increasing frailty. Two years before he died he was admitted as an emergency with suspected unstable angina – there was nothing acute going on – just a harassed GP on a Friday afternoon with a particularly difficult patient. Unfortunately he landed in the care of a very conscientious cardiologist who did not consult the family and who ordered a series of very expensive investigations (that the medical aid would not pay for), one of which was a CT that confirmed a clinical suspicion of an aortic root aneurysm. Further cause for major anxiety and a further decline into infirmity.

The final two years of his life were hard – on him and on everyone around him. He had always had an expectation of medical intervention for everything and that did not change as he got older and more infirm. And no-one – other than my husband – was prepared to confront the old man’s inevitable death. This meant that his GP continued to intervene and medicate – the investigations stopped – the money had run out. My father-in-law was eventually so immobile that he died with large pressure sores on his buttocks – my mother-in-law could not cope and family circumstances were such that there was no question of transferring him to a frail care unit – which is where he would have had appropriate care.

He finally had a series of falls, the final one of which resulted in a broken hip. At this stage I intervened (for family reasons it was not possible to me to intervene much earlier) and, with the full agreement of his GP, started palliative treatment – pain control and 24-hour nursing. He was in no state for any kind of surgical intervention and the family refused hospitalisation. Fortunately, death intervened within days and the pain control and excellent nursing ensured that, at the end, it was peaceful.

My point is that palliative care is not just about terminal cancer. Palliative care is excellent care at the end of life. When do you define the end of life? Should a triple bypass have been carried out when my father-in-law was 80? He very nearly died and was in hospital for weeks. The investigations that confirmed an aortic root aneurysm were certainly not justified – I fully agreed with the medical aid’s refusal to pay – even though it hurt my bank balance. Why can we not talk about death with an elderly person in the same way that we can with a much younger person who has a recognised terminal illness? There has been a recent large study that shows that cardiac medications after the age of 80 make no difference at all to the eventual outcome – of course they don’t. We are all going to die. What is important is making sure that our death is as peaceful as possible and this does not involve introducing medications with side-effects and intrusive and uncomfortable investigations. I am not saying that there are never circumstances where we should intervene aggressively in an older person – my father would have died an unpleasant death without his amputation last year, for example. But let’s not make old age into an illness. Let’s transfer the principles of palliative care to the care of the elderly and allow them a dignified end to their lives.