End of Life Decisions
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Transcript of End of Life Decisions
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End of Life Decisions
Peter SaulNewcastle, NSW
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Be careful, then, and be gentle about death,For it is hard to die,It is difficult to go through the door,Even when it opens.
D H Lawrence
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“There is always an easy solution to every human problem - neat, plausible, and wrong”
H L Mencken 1917
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This talk
• Dying is getting harder– Late, from chronic disease– Technology does prolong life– Decisions must be made for which we are ill-
prepared• There are no simple solutions– “Living Wills”– “Euthanasia”
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Mrs A
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Mrs A age 89yrs
• Long term resident in nearby RACF• Cognitively impaired• Wheelchair-bound with spinal arthritis• Recurrent UTI’s – several hospital admissions• Daughter listed as “next of kin”• Advance care directive in notes
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At 1 am…
• Mrs A became very ill (BP 70)• Mrs A said:– Do nothing– Don’t ring my daughter (she’s on holiday)– Don’t ring the GP– I don’t want to go to hospital again
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GP contacted
• After hours service– “call an ambulance”
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3 am - in the ED…
• BP still low despite fluid and antibiotics• No urine output• Mrs A was clearly disoriented and confused– “I just want to go home”
• Still refusing treatment verbally (but allowing us to do everything)
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In the ED…
• Advance care directive requested from RACF (not sent with patient as it was RACF policy not to)
• 2 years old• “Statement of wishes” form.• No-CPR order• Refused “life support” for any illness from which
she was not expected to make a “reasonable recovery”.
• What do we make of this?
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In the ED…
• Daughter really was on holiday (and had no mobile).
• Niece contacted– “Do everything”
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What did we do?
• We concluded the the ACD did not constitute a palliative care order.
• Mrs A, while refusing treatment was fully cooperative.
• We accepted the no-CPR order, but transferred her (against her will) to a private ICU for limited support.
• She stayed for a week, and was transferred back to the RACF in good spirits
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A goodoutcome
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A goodoutcome ?
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90% of life gained after 2003 is with profound (core) disability
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Change in demography of death
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Everything has changed…
• When we die• What we die of• Where we die• How we die
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The Big Movers• Dementia (7th to 3rd)• Diabetes (9th to 6th)• Falls (41st to 20th)
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7000 deaths/year
4000 of them in acute care hospitals
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Mostly in ED and ICU
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Most are incompetent at the time a decision is made
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The “Do Everything Default”
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The D.E.D.
• Technical imperative• Medical imperative• Defensive practice• Medico-legal mumbo-jumbo• Subspecialisation and the SEP Field• Failure to recognise dying• Unwillingness to go there
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Dysthanasia
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Change in demography of death
Rise of “patient autonomy”
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The rise of patient autonomy
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“Living Wills”
• Uncommon• Legalistic• Vague• Not available• Unsupported by families/carers• Mystifying to doctors• Failed in trials and in legislation
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Living Wills
• Level 1 evidence that you can get people to write them– J Crit Care 2004;19:1-8
• Level 1 evidence they don’t work– Arch Int Med
2004;164:1501-1506
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Hastings Center Report 2004
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Advance Care Directive
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Substitute decision makers
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MOLST medical summaryDiagnosis and co morbidityCo morbidity is increasingly
the biggest predictive
indicatory of mortality
Summary of prognostic indicators
observed over the past 6
months
Identification of advance
care planning discussion and
documentlocation
Medical advice re hospital based life sustaining treatment
Substitute decision maker
identification documented
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MOLST medical ordersAttempt CPR
supports discussion re
success rate of CPR
Accept natural dying reinforces
that dying is anticipated
Clear instructions on
when to transfer to
hospital and use of critical care services
Goals of antibiotic therapy clarified.
Options other then IV administration are identified and
opens up discussion
opportunities
Identification ofartificial feeding and fluids as medical treatment,promoting furtherdiscussion opportunities
Consent for treatment
documented.MO ordering
treatment identified
Any section not completed implies
full medical treatment for that
option
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Only work as part of a community-wide system of care.Health literacy the key first step.
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7 out of 8 elderly patients with a potential for critical illness would not want CPR or ICU support
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(but 7 out of 8 of their children would insist on it)
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Advance care planning – keys to success
• Improve health literacy• Engage the family/carers• Cultural sensitivity• Get doctors on board• Find opportunities• Make sure plans are honoured• Engage the community
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“Dying with Dignity”
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Dying with Dignity
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Dying with Dignity
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Dying with Dignity
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Dying with Dignity
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Dying with Dignity
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Euthanasia
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Definitions
• “An act of euthanasia is one in which one person – Kills another person– For the benefit of the second person– Who actually does benefit from being killed”
Baruch Brody
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“Euthanasia”• Mercy killing of the
incompetent• Mercy killing of the
competent• (Physician) assisted suicide• Terminal sedation• Refusal of reasonable
treatment• Withholding of reasonable
treatment• Unassisted suicide• Refusal of food and water
by the competent
• Withholding of food and water from the incompetent
• Withdrawing treatment from the competent
• Withholding treatment/ANH from the incompetent with/without a plan
• Withholding/withdrawing treatment with no real likelihood of success from people who don’t want it
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“eu” means rightful, appropriate not just plain “good”
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“The great thing about failure is that it requires no preparation”
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Conclusion
• Dying is getting more difficult• We can’t guarantee a good or dignified death• We must stop recklessly inflicting dysthanasia
and avoidable indignities• Doing this is complex and subversive