A GOOD death — what appears at first glance to be an oxymoron is, as all medical practitioners will recognise, a basic human right.
We have all seen examples of a “bad” death, or at least one where the circumstances for the patient and their family could have been better. When a good death is achieved, there is an immense satisfaction in having given our patient the best possible care right up to the end.
To optimise this experience for the patients, family and health care staff involved, appropriate treatments need to be employed, such as giving adequate analgesia where required, but — of equal importance — futile care must be avoided.
Futile care is difficult to define, but is usually easy for a dispassionate observer to recognise — the chances of success of the treatment are low or negligible, and it has an adverse affect on the quality of life remaining for the patient. Our patients deserve the moment’s reflection it takes for us to ask ourselves if a treatment we are considering is, indeed, futile.
Drivers for futile care include medicolegal worries (“will I be sued if I don’t prolong this person’s life?”), the growth in patient/family autonomy (“everything needs to be done, doctor”), as well as unrealistic expectations as to how successful medicine can be in this day and age (how many blunt trauma victims with cardiac arrest in television shows actually die?).
These drivers are surmountable. For example, common law does not force doctors to provide treatment that they consider not to be in the patient’s best interests — and futile care certainly falls into this category.
As is often the case in medicine, communication is paramount. The patient, their family and the other health practitioners involved in the patient’s care need to be included in a conversation about the aims and futility of any treatment being considered so everyone is “on the same page”. This avoids any conflict and misunderstanding as nature takes its course, preventing last-minute “heroic” measures.
This debate is not new. Hippocrates suggested that physicians should “refuse to treat those who are overmastered by their disease, realising that in such cases medicine is powerless”.
Once the potential for futile care is recognised, its implementation can usually be avoided. The resultant “good death” may in fact be the best service we, as medical practitioners, can give our patients at any stage in their lives.
Associate Professor Alan O’Connor is an emergency physician and clinical director of the department of emergency medicine of the Royal Brisbane and Women’s Hospital.
Posted 25 July 2011