Today the death was announced of the actor Bob Hoskins.
British actor Bob Hoskins, who was best known for roles in The Long Good Friday and Who Framed Roger Rabbit, has died of pneumonia at the age of 71.The extraordinary breadth of his acting talent is illustrated by those movies. I do not intend to rehash the several obituaries - the one on the BBC site is brief but gives a comprehensive idea of his career. What I would like to comment on below the fold is the circumstances of his death suggested by my title.
Hoskins' agent said he died on Tuesday in hospital, surrounded by family.
The star won a Bafta and was Oscar-nominated in 1987 for crime drama Mona Lisa, in which he starred opposite Sir Michael Caine and Robbie Coltrane. He announced he was retiring from acting in 2012 after being diagnosed with Parkinson's disease.
Now I clearly do not know the extent to which Bob Hoskins' Parkinson's disease had progressed. It can vary from very fast advancing to almost imperceptibly affecting a patient in its early stages and then progress slowly. A distant relative of mine was afflicted by it and it can be a terrible illness for the formerly vigorous. The charity Parkinson's UK is frank about the implications of advanced cases:
You may find that you're no longer able to do tasks such as washing and dressing without help from someone else, perhaps a carer.Yesterday the comedian Billy Connelly told about his diagnoses of both Parkinson's and prostate cancer on the same day.
It may be a time when Parkinson's drugs are less effective at managing your symptoms, or their side effects are outweighing their benefits. You may have a more complex drugs regime.
Living with advanced Parkinson's or caring for someone in the later stages of the condition won't be easy.
He stopped taking the drugs initially prescribed because they made his condition appear worse by giving him an “expressionless” face typical of Parkinson’s.Such circumstances force the patient to confront their own mortality. Many in that situation accept their death but, like this terminal cancer patient, are concerned about their dying.
Symptoms of the disease include tremors, which Connolly is experiencing in his left hand, and memory problems.
It is quite difficult, as you know, to address the prognosis. My speech is now severely degraded, which does not help; as a solicitor, my whole life had involved being articulate.The comment about being left to become dehydrated is a reference to the Liverpool Care Pathway which attempts to make a dying person's last hours as pain free and dignified as possible. Indeed it provides a similar death to that from pneumonia as described to the cancer patient who was seeking to be assured that was a likely outcome:
My oncologist has said I may expect pneumonia, the 'old man's friend'. Why is it called this – is it pain-free?
I am having a medallion to effect 'do not resuscitate', but I do not like the thought that at the end I may deliberately be left to become dehydrated.
Pneumonia is called the old man's friend because, left untreated, the sufferer often lapses into a state of reduced consciousness, slipping peacefully away in their sleep, giving a dignified end to a period of often considerable suffering.Now this anonymous patient and, I hope, Bob Hoskins, had the opportunity to decide in advance that they wished to have this dignified end. Some however are denied it. In 2008 a study of patients with severe dementia found that this was being denied to some:
The study, carried out by Erika D'Agata and Susan Mitchell and recently published in the Archives of Internal Medicine, showed that over 18 months, two-thirds of 214 severely demented patients were treated with antibiotics. The mean age of these patients was 85. On the test for severe impairment, where scores can range from zero to 24, three-quarters of these patients scored zero. Their ability to communicate verbally ranged from non-existent to minimal.The problems for those treating these patients is that few will have made clear if this is the pathway they would choose. Instead the doctors appear to believe that all should "rage against the dying of the light" rather than going "gentle into that good night".
It isn't clear that using antibiotics in these circumstances prolongs life, but even if it did, one would have to ask: what is the point? How many people want their lives to be prolonged if they are incontinent, need to be fed by others, can no longer walk, and their mental capacities have irreversibly deteriorated so that they can neither speak nor recognise their children? In many cases, the antibiotics were administered intravenously, which can cause discomfort.
There are consequences of artificially prolonging the lives of such patients. In the case of Alzheimer's disease, the opinion piece points out the extremely high costs of end of life care and the implications of indiscriminate use of antibiotics. I am not going to conjure up the spectre of "death panels" but there are real problems for nationally paid for health care which many will be entitled to.
Ultimately the choice must be for the patient even if, like my mother, it is expressed at the last minute. She knew she was suffering another major stroke and begged not to be "taken back" to the hospital for another round of treatment and long rehabilitation before she went into a coma. She was fortunate and the family agreed with the doctors to let "nature take its course". Although not expressed as such at the time, the regimen was similar to the Liverpool Pathway and, having stayed at her side for her final 30 hours, I can testify to the peaceful end it provides.
Most of us, I hope, will not be facing an imminent death but life is a terminal condition. What I would suggest is that each of us take a little time to consider how we wish to shuffle off this mortal coil. Write down your wishes or discuss it with your family. Personally a peaceful end like Bob Hoskins', surrounded by loved ones, has great appeal although I am not yet old enough to welcome this friend.