9/15/22, 8:06 PM

Can You Die of Old Age? More Doctors Are Saying Yes - WSJ

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https://www.wsj.com/articles/can-you-die-of-old-age-more-doctors-are-saying-yes-11663234201

WORLDCan You Die of Old Age? More Doctors Are
Saying Yes
In Japan, it is the No. 3 cause of death, and Queen Elizabeth II’s passing prompts
discussion of the term’s appropriateness

By Miho Inada

FollowSept. 15, 2022 5:30 am ET

TOKYO—In announcing last week that Queen Elizabeth II died peacefully at age 96,
Buckingham Palace didn’t give a cause.
It hasn’t been publicly disclosed whether the queen suffered from a particular fatal
ailment, but the circumstances pointed to a debate that has been growing in Japan, one of
the world’s most aged nations. When a very old person dies without any obvious trigger,should doctors try to come up with a cause? Or is it acceptable to say that the person diedof old age?
Doctors are increasingly going with the latter. The third-most-common cause of death inJapan last year was rōsui, a word that combines characters meaning “old age” and“decline.” It is generally translated as dying of old age, and it accounted for more than one
in 10 deaths, trailing only cancer and heart disease.

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9/15/22, 8:06 PMCan You Die of Old Age? More Doctors Are Saying Yes - WSJ

Different Diagnosis
Annual deaths per 100,000 JapaneseCancer
Old age
Pneumonia

Heart disease
Stroke350
300
250200150
1005002011'15'20Source: Ministry of Health, Labor and Welfare“We would say these days, ‘She had all sorts of conditions but since she was old, let’s say
she died of old age,’ ” said Akihisa Iguchi, a gerontologist and emeritus professor at Nagoya
University. He said families are usually fine with that.
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Can You Die of Old Age? More Doctors Are Saying Yes - WSJDr. Iguchi said rōsui could become the nation’s No. 1 cause of death as aging advances.
Japan’s view remains an outlier. Old age isn’t on the World Health Organization’s top-10 listof causes of death globally, nor on the U.S. top-10 list released by the Centers for Disease
Control and Prevention. Heart disease, cancer and Covid-19 were the top three causes ofdeath in the U.S. in 2020.
The debate isn’t just about statistics. It also gets at the choices families and doctors facewhen an elderly person grows frail, perhaps suffering from a variety of ailments that aren’t
individually life-threatening. They must decide how aggressively to treat those ailments
and how to ensure the person’s comfort.
Putting the name of a disease on a death certificate—such as respiratory disease orpneumonia, both on the U.S. top-10 list and common among the elderly—prompts
questions about what was done to treat that disease. Death from old age, by contrast,
suggests a kind of inevitability.
The palace hasn’t described how the queen’s family, including her heir, King Charles III,
addressed these questions.
Some in Japan, as they mourned the monarch’s passing, observed how she remained active
until nearly the end and then, according to the palace’s statements, rested comfortably inher final hours and died peacefully. In her final public appearance, two days before her
death, the queen was standing with a cane and smiling as she appointed the U.K.’s newprime minister.
“It was not a tragic but a natural ending,” said Kazuhiro Nagao, a doctor in western Japan
who specializes in end-of-life care. “It’s the kind of death that would be considered ideal inJapan.”
Dr. Nagao said he writes the two characters rōsui on about half of the 160 death certificateshe signs each year.

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Can You Die of Old Age? More Doctors Are Saying Yes - WSJ

That cause has been given for many prominent Japanese people including Kyocera Corp.
founder Kazuo Inamori, who died in August at age 90. Local media cited old age whenformer Prime Minister Yasuhiro Nakasone died in 2019 at 101.
Still, concern remains about overuse of the term, especially if it suggests that doctors andmedical staff didn’t try to figure out what was wrong with an aging patient or gave up on
treatment that could have helped.
In its manual on death certificates, Japan’s health ministry highlights in red that rōsui
should be named as the cause of death only when no other cause can be specified.
If a patient is unable to swallow food or drink owing to age-related decline and develops
pneumonia—a not-uncommon scenario—both old age and pneumonia should be cited on
the certificate and the death counted under pneumonia, the ministry says.
Dr. Iguchi, who is 78, said that when he was a young doctor, his colleagues considered it
shameful to write down old age on a death certificate because it meant they failed toidentify the underlying cause, which they had been taught must exist behind every deathunder Western medical practice generally adopted in Japan. Dr. Nagao said some doctors,
particularly at university hospitals, continue to avoid the term because it has yet to be
medically defined.
The WHO’s International Classification of Diseases has been growing since the end of the
19th century and now includes 17,000 diagnostic categories that doctors also use whenidentifying cause of death. In January, the latest version of the list, ICD-11, included old age
for the first time.
After criticism that the inclusion of the term stigmatized old people and implied that they
were automatically sick simply because of their age, the WHO replaced the term with“aging-associated decline in intrinsic capacity.”
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Can You Die of Old Age? More Doctors Are Saying Yes - WSJ

Dr. Nagao said rōsui wasn’t a disease but a natural ending. “It’s part of Japanese culturethat could be part of global culture too,” he said.

Write to Miho Inada at miho.inada@wsj.com

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