Issue 39 / 20 October 2014

LAST week the New York magazine published a short but enjoyable interview with Boston-based surgeon and writer Atul Gawande.

In giving some background to his recently published book about aged and end-of-life care, Gawande told the interviewer: “… what we’ve really lost sight of, both in medicine and society, is that … people have priorities besides just living longer. We all have things we care about; we all have reasons we want to be alive. And preserving those reasons is fundamentally important.”

That individual priorities matter is not a startling observation but it’s something that can be forgotten in health care as we try to keep people safe, and rightly use mortality as an end point to measure our success.

In this issue of MJA InSight we’re thinking a bit about death and priorities, both separately and as they interact.

Our first news story looks at the very clear reductions in mortality that appropriate surgery can offer to patients with localised non-small cell lung cancer, after a study published in the MJA found large variations across NSW health districts in the rates and types of surgery performed for such patients. An oncologist who spoke to MJA InSight called the disparities “disturbing”, and said misplaced fatalism about prognosis might be robbing patients of lifesaving options.

Another study in the MJA found that, in the Top End of the Northern Territory, most people who developed hepatocelluar carcinoma (HCC) were diagnosed late, and only 28 of 80 patients diagnosed were alive a year later. Indigenous people had much higher rates of HCC than non-Indigenous people, mostly on a background of chronic hepatitis B. For our news story we asked experts how these “unacceptably high” rates of HCC incidence and mortality could be curbed.

Unlike mortality, priorities are difficult to quantify but addressing them is essential to effective health communication.

Drug and alcohol specialist Wayne Hall’s recent review on the harmful effects of cannabis has been depicted in the media as a damning condemnation of the drug. In a comment for InSight this week he sets the record straight, explaining that the review was not done to support prohibition but to encourage the wider community to consider where cannabis sits in our priorities for drug regulation.

A recent article from Australian academics, the subject of Jane McCredie’s blog this week, demonstrates the important role patient priorities play in the choice of health practitioner. The authors say the view that homeopathy is unethical “… fails to account for either the moral worth of care and of relationships or for the perspectives, values, and preferences of patients” but Jane is not convinced.

Earlier this month The Economist also ran a review of Atul Gawande’s new book. The reviewer observed that, as dying in hospital has become the norm, “… more people spend their last hours exactly as they wished not to: hooked up to machines under fluorescent lights, surrounded by strangers”. Hospital becomes an alienating place to die when patients, families and medical teams do not share the same priorities and expectations.

Another InSight news story follows up an article in the MJA about a new framework called “goals of care”, designed to be completed for all patients on hospital admission to transparently record if the goal of care is curative or restorative, palliative or terminal. The idea is to save practitioners, patients and their carers from having to make crucial care decisions during times of crisis.

If done well, initiatives like goals of care will take into account patients’ priorities about what would make them choose lifesaving treatment over death should the situation arise.

Gawande, when asked in the New York interview about his own priorities in this respect, nominated that he would want to keep living as long as he had the ability to think and communicate, but his wife’s answer is also appealing.

 “… if I look happy, that’s good enough. Keep me going.”

 

Dr Ruth Armstrong is the medical editor of MJA InSight. Find her on Twitter: @DrRuthInSight
 

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