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Of death and dying

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The AMA has called for an end to the taboo on talk about death, urging that there be frank and open discussion about end of life care, futile treatments, advance care planning, dying and bereavement.

As a Senate committee holds hearings on proposed Dying with Dignity legislation, the AMA has released an updated policy statement on end of life care that broaches complex and highly emotive issues around how to care for terminally ill patients, including the right to refuse treatment and the pressure to prolong life at any cost.

AMA Vice President and emergency physician Dr Stephen Parnis said caring for people approaching the end of their life was at once one of the most difficult and yet rewarding aspects of being a doctor.

But Dr Parnis said effective, on-going communication between doctors, patients, families and carers was key to making a patient’s final days as comfortable, calm and stress-free as possible.

“As doctors, we understand and acknowledge that most of us will eventually succumb to the effects of chronic disease, and that medical care is as much about disease control and symptom relief as it is about prevention and cure,” he said. “How we care for our patients as they approach their death can be among the most difficult yet rewarding aspects of our professional lives.”

The AMA Vice President said good communication between the patient, their family, carers and the health care team throughout the course of an illness helped “alleviate fear, confusion, and guilt over the patient’s condition, assist with decision-making, and reduce the potential for conflict over the patient’s care”.

Medical practitioners caring for the terminally ill can be confronted with major ethical, moral and legal dilemmas.

In its submission to the Senate inquiry into the Exposure Draft of the Medical Services (Dying with Dignity) Bill 2014, the AMA said it opposed making it legal for doctors to prescribe and administer an end of life substance.

“We believe that doctors should not be involved in interventions that have as their primary intention the ending of a person’s life,” the AMA submission said, adding that activities like euthanasia and assisted suicide breached the fundamental ethical principles underpinning medical practice.

The AMA said it was consistent with good medical practice for doctors not to initiate or continue life-prolonging measures, or to provide treatments that had as their primary purpose the alleviation of symptoms, but which may have the secondary consequence of hastening death.

“Withholding and/or withdrawing life-sustaining treatment allows the course of the person’s illness to progress naturally, which may result in death,” it said. “In addition, the administration of treatment to relieve symptoms which may have the secondary consequence of hastening death is undertaken with the primary intent to relieve the patient of distressing symptoms.

“It is important that these practices, which are ethically acceptable…are not confused with activities that constitute euthanasia or physician-assisted suicide.”

The issue can also be a legal minefield.

A study published in the Medical Journal of Australia last month found “critical gaps” in the legal knowledge of doctors that could expose them criminal charges including murder, manslaughter and assault.

The survey of 867 doctors found that, on average, they correctly answered just three out of eight questions about laws regarding end of life care.

The researchers said that doctors could run foul of the law for withholding or withdrawing treatment, as well as for providing life-sustaining treatment against a patient’s wishes.

Dr Parnis said it was important that patients prepare advance care plans to inform doctors, families, and carers about their preferences in the event they lose decision-making capacity.

“An advance care plan is a process of ongoing reflection, discussion, and communication of health care preferences that may result in oral or written directives, such as an advance care directive,” he said. “Legally competent patients have the right to make health care decisions, including the right to refuse interventions such as life-sustaining treatment.”

He said patients with limited or impaired capacity should be encouraged and supported to participate in treatment decisions, consistent with their level of capacity at the time.

Adrian Rollins