On 8th September 2022, Queen Elizabeth II died at Balmoral Castle in Aberdeenshire, Scotland. In the weeks that have followed, there has been debate on what can be learnt from the Queen’s death, her funeral, and the famous queue. In a Twitter thread with over 2 million engagements, Dr Kathryn Mannix (@drkathrynmannix), a palliative care physician and author, reflects how Elizabeth II exhibited ‘ordinary dying’ – a slowdown associated with advancing age, resulting in gradual organ failure. Dr Mannix writes that Queen Elizabeth II demonstrated it is possible to “plan ahead, address the unfinished business in our lives, and die with symptoms well-managed, even in our own bed if circumstances permit.” But how ‘ordinary’ is Queen Elizabeth’s dying, really?
I believe it is important to contextualise the circumstances of the Queen’s death against wider evidence about end of life experiences in the UK to understand why access to such a “good” death may not be as straightforward for the general population.
Queen Elizabeth died peacefully aged 96 surrounded by her family, at home and having maintained good health until the final year of her life. While a person’s lifespan is thought to be a combination of genetics and environment, evidence suggests genetic factors only account for 20 to 30 percent of an individual’s chance of surviving to age 85. Environmental factors, particularly socio-economic status, have a powerful impact on both life expectancy and how long we can expect to enjoy good health. In Scotland, the gap in healthy life expectancy at birth between the poorest and richest areas is 25.1 years for men and 21.5 years for women. Needless to say, longer periods of good health allow more opportunities for advanced planning of end of life arrangements.
A second interesting issue to explore is place of death. Current palliative care policy is underpinned by an assumption that the home is the best place for end of life care. This assumption is grounded in public surveys that report that most people in the UK would prefer to remain at home at the end of life – something that Elizabeth II was able to do. However, statistics from NHS England show that such an experience is atypical – Of all deaths occurring in 2020 in England, 41.9% were in hospital, 23.7% were in care homes, and just 27.4% of death were at home. Again, socio-economic status plays an important role, with people living in more deprived areas being less likely to remain at home at the end of life.
While Queen Elizabeth II’s end of life experience illustrates the benefits of advanced planning and well-managed symptoms, it is important to contextualise her experience against that of millions of others in the UK. The ability to enjoy a long healthy life with compressed morbidity, to be able to plan in advance, and to choose our place of death is inexorably linked to our socio-economic status and the area in which we live. We should therefore exercise caution in using the term ‘ordinary’ to describe the Queen’s end of life experience. Thanks to the privilege associated with her position she was able to have what many would consider an ideal death – but her experience remains far from ‘ordinary’ when viewed against the experiences of the population as a whole.