When Have We Done Enough?

Isobel Tarrant was the greatest Nana anyone could ask for. Every morning of the school holidays she would produce faultlessly poached eggs to a standard that would beguile even the best Wellington cafes. She would look at you mischievously when she caught you with your hand in the cookie jar. And most of all she saw nothing but the best in her 15 grandchildren, and showered them all with a relentless torrent of love.

In 1998, at the age of 75, Isobel contracted ovarian cancer. Three years later she was dead. It was one of the saddest experiences of my life. How then do I square witnessing what happened to my dear Nana with the cold-hearted economic concept of prioritising our health budget, when that raises the spectre of limits to care for the elderly? The fact is that our healthcare spending is a long way from giving us the greatest number of healthy years of life for each dollar invested. My Nana’s story helps us understand why.

Initially things went well. The diagnosis probably took longer than it should have, but Nana responded well to the treatment. She was still strong, and the operation and chemotherapy seemed to take care of the problem. We returned to normality, albeit slightly more aware of her mortality than previously.

And then, in late 2000, the cancer returned. We all knew from the outset that the chances weren’t good, Nana was still weakened from the first bout, and the survival rates from relapses were not high. And so began the long, steady slide.

This time around the operation and chemo really took their toll. This once proud, fiery, red-headed woman took to wearing scarves to maintain some dignity in the face of her hair loss. One complication followed another as the battle raging between chemo and cancer affected the rest of her body. Each operation seemed to blur into the next. Nana was lucky in that she had so much family around her to help during her last days. I shudder to think how someone with a small family (or even none) would handle such a situation.

It is usually in these times that a family will make emotional pleas for everything to be done. This is an understandable reaction borne out of fear of losing their loved one, perhaps tinged with a little guilt that maybe they could have done something differently in the past. The medical system, too, is geared up to offer treatments and solutions. This was particularly the case for Nana, probably because the specialist recognised that they had lost crucial time dithering over the initial diagnosis. Unfortunately, this imperative, the "rule of rescue", ultimately drives most of the spending within our health system. It means we don’t spend money keeping people healthy when they are young, which is far more effective.

Did Nana want to live? Of course she did, more than anything. She wanted to see the next grandchild’s wedding, or birth of a great-grandchild, or Christmas. But if someone had had a frank conversation with her and the family about what lay ahead when her relapse occurred and offered her the choice between better care and chemo, she might have chosen differently. These conversations are of course incredibly difficult, riddled as they are with emotion, especially when you are trying to keep a patient in a positive mindset. We have to normalise death in our culture before we will ever be able to overcome this issue. But instead of making a conscious choice, Nana’s last year was a series of never-ending procedures, each of which made sense at the time, but together they took a brutal toll on her body.

The whole town turned out to honour Nana’s departure. The netball club formed an arch for her coffin, in recognition of the mafia-like grip Nana and her daughters held over the local netball scene. This is ultimately how I will remember her, not as the frail, weak woman besieged on all sides by cancer and chemotherapy.

Knowing Nana, I suspect she would have been shocked to think that the money spent on her last months could perhaps have been spent ensuring long, healthy lives for a bunch of kids living in Porirua. These downsides are not obvious long-term preventative measures like immunisation are not nearly as eye-catching for the media as an elderly patient being ‘denied’ treatment. And the elderly need not miss out by spending less trying to cure old age, we could afford to actually care for old people better in their last days, particularly those not blessed with a large family like Nana was.

"Let us disarm [death] of his novelty and strangeness, let us converse and be familiar with him, and have nothing so frequent in our thoughts as death." Michel de Montaigne

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