When a death wish is desirable
People should make end-of-life decisions while they’re able to express their wishes.
It would have required a heart of stone not to be moved by the forlorn figure of the grey-haired man, married many years, looking at the frail figure of his wife, hooked up to the medical technology keeping her alive in an intensive care ward.
The moving sequence was part of an excellent Australian documentary called In the End, screened this year by the ABC’s Compass program. It examined the dilemmas – emotional, financial, medical, moral and ethical – that confront people when they, or somebody they love, face the end of their lives.
Filmed at Geelong Hospital, the documentary graphically illustrated the questions that arise as a consequence of ongoing life support for the elderly.
In recent years, increasingly, hospital intensive care wards bear testimony that, for the most part, in Australia we fail to manage dying.
It is upsetting to see elderly patients in their 80s and 90s – most with no chance of recovery – hooked up to modern technology in intensive care beds for which there is growing demand.
The Geelong Hospital senior intensive care doctor, Charlie Corke, put it succinctly when he said: "We can prolong life but (for these people) we cannot restore health."
At the risk of appearing to be unfeeling, there is also the issue of cost. Not surprisingly, increased hospital costs are linked with proximity to death although it’s not quite as simple as that.
Lesley Russell, of the Menzies Centre for Health Policy at the University of Sydney and ANU, reported in early 2009 that, in Australia in 2007, end-of-life hospital care averaged about $13,500 per person, with about 40 per cent spent in the last month of life. The biggest costs are incurred by caring for people aged 65-74.
A critical consideration relating to costs, however, is the estimate that in the order of 10 per cent of all health costs in Australia goes to providing procedures which people nearing the end of their lives do not want. While this should not be seen solely as an economic issue, extending inappropriate care to one person generally delays or denies care to another. It is particularly difficult to accept this when many patients probably don’t want the treatment they’re getting. Any ethical assessment of these issues must therefore take this reality into account.
People plan for so much in life but when it comes to addressing issues of medical treatment and care at end-of-life, they shy away from the subject either because they do not know how or because they would rather put it off. But putting it off often results in treatment or heroic medical enterprise where, given a choice, the patient probably would not want it.
Advanced Care Planning (ACP) is the process by which people write down their wishes in respect of forthcoming medical procedures and treatments, acknowledging they may not be able to be asked when necessary owing to anaesthesia or other circumstances.
ACP is not an irrevocable or a binding process. It merely expresses a person’s wishes with respect to themselves. As such, it is a guide for others who may have to make decisions for them at a later time. In the absence of ACP, carers – be they children or doctors – invariably opt for interventions or procedures which attempt to prolong life. This is regrettable because we know from the experience of those who make plans through ACP that these attempts are generally against the wishes of the patient.
There are other, related issues that must be addressed in respect of this aspect of medical costs – for instance, the lack of trained staff in aged-care institutions.
Many aged-care institutions have only one staff member working at night and their immediate response to any medical problem is simply to call an ambulance, often resulting in inappropriate admissions to hospital of aged-care residents.
For many elderly patients, the Emergency Department offers the wrong facilities, the wrong treatment and the wrong medical expertise. The result is poor patient outcomes and bad experiences for patients and relatives.
Respecting the wishes of the patient is a key ethical consideration and we cannot effectively do that if we do not know what those wishes are.
This blog was originally published as an opinion piece in The Weekend Australian, January 8-9, 2011.
Neil Batt AO is Executive Director of the Australian Centre for Health Research and former Deputy Premier and Treasurer of Tasmania.
The Hon. Neil Batt AO is a health policy consultant. He had a substantial career in politics, having been variously Tasmanian Minister for Transport, Education, Economic Development and Forestry and concluding his political career as Tasmanian Deputy Premier and Treasurer. In addition, he was the National President of the Australian Labor Party, Executive Director of the Australian Centre for Health Research, a Consultant to Australian Unity and Chairman of Residential Aged Services.
Tim
May 2, 2015 at 9:25 am
Live your life.
You only have one life and you need to live it to the bitter end. Current law and practices around end of life in Australia are adequate.