Dr Ian McPhee, Anaesthetist at the Tweed Hospital. Photo: Nolan Verheij-Full / Tweed Daily News
Dr Ian McPhee, Anaesthetist at the Tweed Hospital. Photo: Nolan Verheij-Full / Tweed Daily News Nolan Verheij-Full

The conversation we’re dying to avoid

DYING is looking different. And it's time to talk about it.

Of course, the end result is unchanged, but what of the route taken? And just when does the journey begin?

In response to the latter, every medical student learns that there is a constant and inexorable cycle of cell destruction and renewal, and that ultimately, well, we know which of these forces wins!

Death is the inevitable failure of one or more vital organ systems as they wear out in the course of doing their job, or in the face of disease or injury. "Pumps, filters, drains and circuitry" are all susceptible - nothing in the human body escapes the consequences of one or more of these phenomena.

While a billion-dollar, international "beauty" industry has emerged around slowing the visible effects of ageing, propping up failing organ systems remains the province entirely of 21st century, mainstream Western medicine.

And just as we in medicine have grown comfortable with instituting life-prolonging measures, so too have our patients grown to expect that we will offer them at every juncture.

Somewhere there has been allowed to creep into the patient narrative the presumption that life is no longer finite, that old age, overwhelming disease and major physical trauma are no longer, necessarily, threats to existence. There has evolved an expectation that the ravages of time (or misadventure) can and will be held back by the liberal application of science and technology.

With such expectation has come the belief that there is now only one place to be while dying - a hospital. And then with as much gadgetry attached as possible, as if to signal that no one has failed to offer a dying soul every last chance. But, chance at what?

Dying in hospital is a phenomenon of recent history. Just as it remains in large part the case in many Eastern and less developed countries, so too it was for our forefathers that death was a shared experience and a part of the household everyday. It was also not necessarily associated with advanced age.

Infirmity, disease and death were dealt with in the home. Carers were family members who were on hand to minister whatever might be available to them to assist with an individual's suffering.

For the most part, this was basic care and comfort, and had nothing to do with science. There were likely potions and salves, and as opiates, morphine in particular, became available, soothing syrups and tinctures that could be purchased and applied without medical direction.

But today death has been medicalised. It has moved from the natural consequence of a life, well-lived or otherwise, to a challenge for modern medicine to overcome, as if medicine genuinely, and in all cases, had the power to do so.

Lives now are placed in hospital beds where they can be "saved".

People at the end of their days are not necessarily afforded the peace and dignity of a passing free from the drama of futile treatments and heroic resuscitative measures.

But where has this disconnect between the expectation and reality been generated? How is it we in medicine have created end-of-life scenarios for our patients that we would not want for ourselves?

It is not all the fault of popular culture's portrayal of doctors and nurses responding, fleet-footed, stethoscopes flailing, to "codes" that invariably are successful.

Somehow, in our own day-to-day communication with patients, their relatives, and with each other, the myth of the success of what are for the most part crude interventions is perpetuated.

How many, even of those who work in hospital-based medicine, know that survival to discharge following an inpatient cardiac arrest is little more than 20%?

The order "Do Not Resuscitate" has, in many jurisdictions, been changed to "Do Not Attempt Resuscitation" to better reflect this reality.

And so it is, when questioned about interventions at the end of life - their life! - senior physicians report that 90% would not want CPR, 87% would not want artificial ventilation and 80% would not want surgery.

Who and what is driving them then to offer these interventions to their patients?

This is the discussion that we simply must have.

End-of-life should not be the beginning of an expensive, perhaps painful, pointless journey exploring the very limits of modern medicine.

Instead it should be a dignified and meaningful transition, not just for the departed, but for those who might be left to grieve.

Dr Ian McPhee

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