End of Life care

I’ve just finished Atul Gawande’s “Being Mortal”.  It’s a thought-provoking reflection on ageing and end of life care, and should be read by everybody in the sector, possibly everybody who is growing old. For the first few chapters he paints quite a bleak picture of how modern medicine has interfered with nature and robbed patients of dignity and quality of life. I felt a little smug at that stage because in New Zealand we have made real progress in this area, whereas he was writing mainly about the States. He got very excited about innovations in residential care which I had seen developed here thirty years ago.  It seems we have come more quickly to appreciate the benefits of keeping people in their own homes (with appropriate support) and of other intermediate steps between home and hospital care. And I don’t often see elderly patients demanding high tech and high-risk interventions when they know their time is short.

 But the rest of the book is fabulously insightful. First of all, he emphasizes the demographic realities that our population is ageing, that there aren’t going to be enough doctors and nurses to look after them and that many of us will face a long period of disability before we pass. Many people are comfortable with the idea that they could pop off at any time, and “going in my sleep” or with a sudden heart attack seems not unappealing. But the idea that they will become disabled, dependent or demented horrifies them.

So we all react in different ways.  Commonly there is avoidance and denial.  I’m found myself almost begging patients to consider their options as they become frailer, because I know it’s likely that when a crisis happens the decision will be taken out of their hands.  But we are making some progress with the wider acceptance of advanced care plans. They allow the patient to express their wishes and preferences in a range of scenarios, which is good not only for them but for their loved ones and medical attendants as well.  See www.advancecareplanning.org.nz for more info.

Secondly, Gawande addresses the challenge of autonomy vs safety. Caregivers instinctively want to minimise risk for the elderly, but that sometimes means giving up pleasures, choices, individuality and independence.  For some patients that is too high a price to pay and they fight it tooth and nail.  They might even become “difficult”.

And honestly, when I get to that stage of life I might get a bit difficult myself.