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The number of older people -- mostly from the middle and upper social class, with difficult, multiple, and long-standing medical conditions -- dying at hospitals has been on the rise over the last few decades in Bangladesh. Instead of staying at their home, they are meeting the end of their life in an unfamiliar hospital environment often remaining in Intensive care units (ICU). Death in a confined, limited space compartment, in a room full of medical gadgets, and in presence of no or very few family members, well-wishers and friends is becoming more common. Some are dying in foreign lands after spending a handsome amount and sometimes exhausted a large portion of their or their children's wealth or saving. Sad, helpless, isolated, with a lot of wires hooked up inside their body, people are dying lonely death in artificial and strange environment.
Factors leading to this growing trend of death on a hospital bed -inside ICU or not- include 1) an increase in the elderly population demographic segment in Bangladesh many of whom have long-standing and multiple health conditions; 2) a large number of them suffer from these chronic diseases for several years before their death; 3) access to desired healthcare facilities has become faster and easier; 4) raise in income level and wealth of a larger social class-some can afford to pay for the very high fees at the private elite hospitals inside and outside Bangladesh. Compounding the situation is the sad reality that family members attempt to do their best to prolong the lives of their loved ones for a few more days or months. This is particularly true for the middle and upper-class people who try their best to prolong the life span of their dying family members by putting their all-out effort, time, and resources. The lower socio-economic class may give in earlier. Is anyone gaining from this trend-- dying an expensive death?
In many cases, during the life-ending distressing period, frail patients are rushed to ICU, CCU, or another hospital unit that requires high-skill professional care intervention consuming a vast amount of resources, and consequently the family members must pay very lofty medical bills while some hospital authorities may see these as high-profit cases. Hospitals and their doctors have been demonised on occasions that they intentionally, and deliberately make profits out of these cases.
Is this necessary to die in an artificial, highly technical, unfamiliar environment and far away from one's own and familiar home, village, district, or country? Would people really prefer to die at a hospital if they were given the choice to make a decision? Did anyone bother to ask for their opinion about their preference, where would they like to be treated at the tail end of their life? Is there any way to develop a system in Bangladesh like some other countries now have to know from them before they are too frail or become unable to say anything? Even if they had an opinion, would that be respected by their own children or caregivers?
This very painful and uncomfortable question has come to the forefront as it is becoming more apparent that many of these high resource intensive admissions, stays, and professional care is not really necessary or do not bring any meaningful change to the health conditions, nor it is able to prolong the life by more than a few hours or days or in a few cases by months. As stated before, hospitals are accused of making outrageous profits from these terminal cases. What should the hospitals and the on-duty doctors do or say? Would they tell the attendants to take the patient home? Would that be acceptable? What should be done in these situations? How is the United States (USA) doing in these situations and what is the trend there-the country of medical wonders? In a New England Journal of Medicine report, the authors assessed changes in place of death in the US from 2003 through 2017 by analyzing national-level data on natural deaths. In 2003, a total of 905,874 deaths occurred in hospitals (39.7 per cent), which decreased to 764,424 (29.8 per cent) in 2017; the number of deaths at nursing facilities decreased from 538,817 (23.6 per cent) to 534,714 (20.8 per cent) whereas the number of deaths at home increased from 543,874 (23.8 per cent) to 788,757 (30.7 per cent) during the same period. The number of deaths at hospice facilities also increased from 5,395 (0.2 per cent) to 212,652 (8.3 per cent). After about 50 years, more people were dying at home than in hospitals in the USA and the researchers commented that dying at home will continue to be more common.
Now, the trend has been probably the opposite in Bangladesh for its middle and upper socioeconomic class. The change in the USA may be attributed in part to the growth in home hospice care a kind of care that is uncommon and unfamiliar in Bangladesh. Hospice provides pain management, along with emotional support and care to terminally ill patients.
The circumstances and causes of dying and death have changed in Bangladesh over the last few years. These days, people die more often from chronic progressive diseases in their old age and not from infectious diseases with the exception of accidents, violence and other traumatic deaths are still common in Bangladesh. This somewhat predictable and slow dying process in old age provides people an opportunity to think clearly and well ahead of time and then decide where they would like to stay during their very last few days.
The rise in at-home deaths reflects that perhaps Americans are honoring people's wishes and helping them pass away in a place most familiar to them.
Are we ready in Bangladesh to give our loved ones an option to choose?
Dr. Hasnat M Alamgir is Professor and Chair of Public Health at International University of Business Agriculture and Technology (IUBAT), Dhaka.