Karen Hitchcock is a dedicated doctor and a brilliant writer. She believes old people face entrenched age discrimination in hospital. She treats the old, sick patients other doctors may write off. She gives them a chance to grab more life. After the doctoring is done, Dr Hitchcock writes passionately about her experiences in major Australian hospitals. In a provocative new essay, she argues doctors are influenced by a culture that discounts the elderly. As a result, they can be too inclined to withhold treatment in the belief it’s futile. Her account from the coalface is in the latest Quarterly Essay which I’d urge you to buy from your newsagent. It’s called Dear Life: On caring for the elderly. (An excerpt appeared in Good Weekend magazine).
The picture Dr Hitchcock paints is quite different from that depicted in recent writing from the US. In acclaimed books by surgeon Atul Gawande, whose Being Mortal is a best seller, and The Conversation by Angelo Volandes, of Harvard Medical School, it’s broadly argued that doctors don’t know when to stop. The very old are denied a peaceful death as one futile treatment is piled upon another. As a result, elderly Americans die with addled brains, tubes in every orifice, and bodies ransacked by treatments that held only a sliver of hope. Dr Volandes writes: “I work in one of the best hospitals on earth, and I’ve watched patients die in ways that are protracted, dehumanizing, and far more painful than they needed to be.”
But according to Dr Hitchcock, the problem is the opposite in Australia: “…the problem is not that we never allow patients to die, but that we may declare a situation hopeless when it may not be so.” Some doctors, she says, seem to view old patients as a different species of human, unrelated in any way to their young selves. They don’t want patients with the multiple problems of old age, and fight not to be saddled with them; no-one wants to feed old patients who can’t feed themselves; and doctors are under pressure to discharge them too quickly.
“In Australian public hospitals, we have not gone the same way as the United States,” she says… “We have already limited the treatment options we are prepared to offer the elderly and the frail in Australia.” The limitations are mostly sound. But Dr Hitchcock says cries for further limitations – based on horror stories from the U.S or a view that treating the elderly is futile or a waste of money – should be opposed. She fears the new focus on advance care directives, the Dying with Dignity movement, even the dying-at-home cause may hasten the rationing of health care to the elderly.
I asked several people involved in end-of-life care if they agreed with Dr Hitchcock’s account, based strongly on personal anecdote. Ken Hillman, is professor of Intensive Care at the University of NSW, and practises at Liverpool Hospital. He’s author of Vital Signs: Stories from Intensive Care. “Over the last 20 years, more and more elderly frail people at the end of life are being put on ventilators and life support,” he told me. “And I’m not too sure that’s what they want.” He said “doctors are trained to keep on treating.”
A 90-year-old patient with many ailments – coronary disease, a previous stroke, a bit of dementia – who came in with pneumonia and a urinary tract infection would be “actively treated….” he said. “I’d rarely see a doctor who’d stand back and be honest with the carer and patient….We need to be more honest with the elderly frail about their prognosis…some might not want to go into an acute hospital the next time.”
Psychologist Sarah Edelman, president of Dying with Dignity NSW, said all the anecdotes in the Quarterly Essay involved people who were grateful to have been treated and kept alive, even if it was for an extra day. “If [a treated patient] had suffered for a week and then slowly died, would that person have been included as a case study?” Dr Edelman asked. “Hitchcock certainly doesn’t describe any cases where aggressive, life extending treatments produced suffering as has been cited in other reports.” Even when a patient was capable of professing a wish to die, Hitchcock implied they’d been influenced by their family. “…whilst selfish relatives do sometimes have their own agenda, it’s frequently more complex,” Dr Edelman said. “When my father was in palliative care, I wanted him to die soon because he was suffering, not because he was an inconvenience to me.”
I also asked Melbourne doctor Rodney Syme, author of A Good Death, and an advocate of voluntary assisted dying, for his opinion. He said the main problem, left undiscussed in the essay, is the failure of old people to make their end-of-life care wishes known. Everyone over 70 should be having that conversation with their GP. “When people come to hospital close to dying, and there’s no information about what that person wants,” Dr Syme said, “in the absence of knowing that person’s wishes Dr Hitchcock quite properly treats them.” However, Dr Hitchcock made a “grave mistake of being rather critical of advance care directives ….A lot of these people, if they’d had that conversation before they’d come to hospital, would not want to be saved.”
What’s your experience of how hospitals treat very sick old people? Please comment.
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