Community needs to discuss death

The chief executive of one of Melbourne’s hospitals says we need to break taboos and have a national conversation to improve the “quality of death” in our hospitals.

He says emotion, high expectations and a lack of communication among doctors and families is leading to unnecessarily extended treatment of some patients at death’s door.

They believe confronting this controversial issue will help reduce the suffering of old people at the end of rich lives.

In a feature article in The Age, intensive care specialist, Dr Bill Silvester says, “So many people are being kept alive in circumstances that they would not want, because doctors don’t have the courage to make decisions”.

“So many doctors give treatment not because it is the best treatment but because the family is demanding they push on,” he says.

“Some families will say, ‘We want Mum kept alive no matter what.'”

Dr Silvester works at the Austin Hospital, which is now setting a template for how these issues might be tackled around Australia. As director of the Respecting Patient Choices program, his role involves acting as a “guardian” against doctors who get lost in the push to prolong life.

Austin Hospital’s chief executive officer, Brendan Murphy, says doctors and clinical leaders must play a role in changing the system, and be ready to stop pursuing futile treatments.

In June last year he told a conference of economists debating health reform that “futile and inappropriate treatment” in public hospitals had to be tackeld. At any one time in his hospital, he said, there would be 20 to 30 patients who were “pushed” there from aged-care homes that did not want the expense of looking after terminal care.

“If you walk around the wards of any major acute tertiary hospital in any capital city or major regional centre, the junior medical staff and the nurses are saying that they are treating a significant number of people for whom their treatment is clearly futile.”

It’s not about saving money, he adds. Those 30 people would be replaced with more expensive elective surgery cases. It is about doing the right thing by the patients under his roof.

Murphy is proud of the Respecting Patient Choices program, led by Dr Silvester, which is now being adopted or adapted by hospitals around the country. Patients are invited to make clear choices about possible future treatment, captured in an “advance care plan” like a living will. The plan goes in the patient’s medical record, so their death can be transformed from a series of desperate medical interventions into a peaceful and dignified process.

“I would like to see it as about promoting the best possible quality of death. There is a quality of death, and we need to give them the best quality death just as we give them the best quality care,” Mr Murphy says.

Dr Silvester says there is a common fear – that the program could prevent someone from getting medical care they want or need. However, an evaluation of the Respecting Patient Choices program in residential aged care found that of 161 residents who died, just over half had completed an advance care plan. Of these, only 18% died in hospital, compared with nearly half without a plan. But there was no difference in the mortality rates between the two groups.

“That answers the critics,” Dr Silvester says.

“It’s not about pulling the plug; they just died in different circumstances.”

Respecting Patient Choices has been rolling out piecemeal in Australian hospitals. Dr Silvester, Mr Murphy and the National Health and Hospitals Commission, which reported recently, say that to be truly effective a national approach to funding and implementation is needed.

Below are results of an evaluation of Austin Health’s Respecting Patient Choices program, of the 161 residents of a residential aged care facility who died:

• 58% were introduced to the RPC program. Of these, 89% completed an advance care plan.
• One-third without advanced care planning died in the aged care facility, while 85% with such a plan died in the aged care facility.
• Residents without a plan who were admitted to hospital had an average stay of 15 days before dying.
• Residents with a plan were in hospital for fewer than seven days before dying.
• There was no difference in mortality between the groups.