The importance of proactively planning for end-of-life care cannot be overstated, writes Dr. David Amies in this latest blog post. By having honest, in-depth conversations with family members and healthcare providers about our end-of-life wishes, we can give ourselves peace of mind.
Dr. Catherine Calderwood, formerly an active obstetrician, has been the chief medical officer of the National Health Service in Scotland for about 18 months. Her first annual report, Realistic Medicine, has attracted a good deal of notice far outside the borders of Scotland.
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She claims that doctors in general act differently with their patients from how they look after themselves and their own families. She has discovered that 95 per cent of doctors would refuse cardiopulmonary resuscitation (CPR), 88 per cent would refuse dialysis and 67 per cent would avoid admission to an intensive care unit (ICU) for themselves or their families in end-of-life circumstances. She claims that the idea that patients put longevity above all other considerations as they approach the ends of lives is false. According to Dr. Calderwood, they wish to be symptom free and to have good quality time with their families and friends. In fact, they seek precisely the same conditions as their doctors!
Of course, dealing with dying persons is very stressful and might not seem to be the ideal situation in which to discuss what patients want or expect from any proposed course of treatment. It is much easier to issue orders — begin CPR, admit to the ICU — than it is to have an in-detail, heart-to-heart talk about alternatives and consequences of any actions taken. Besides, the doctor who sends a very sick person to the ICU, for example, runs no risk of censure. Discussion about the pros and cons of such an order might later be seen as time wasting by grieving relatives. People prudent enough to have undertaken the business of drawing up end-of-life directives, and who have discussed the possible concerns arising in the last few weeks of their lives, will avoid confusion and dissent in what will be an anxious time for all concerned.
"Good, sound common sense"
Dr. Calderwood's report contains several major points, but chief among them is the idea of shared decision-making. Perhaps, then, everyone in middle life and beyond should make an advance care directive. Family members need to be involved along with the family physician. The process provides an ideal opportunity for all to discuss how they would like their last years, months and weeks to be managed. Adult children may learn, to their surprise, that their parents are contemplating medical aid in dying if certain circumstances arise. Much better to know this several years in advance rather than to be knocked off guard when serious illness intervenes. The business of making wills, appointing enduring attorneys, making advance care directives and selecting alternate decision-makers is, by its very nature, rather solemn, but it is in no way morbid. Dealing proactively with all such matters is good, sound common sense.
Dying With Dignity Canada has assembled workbooks to facilitate these processes and tailored them to cover the procedures province by province. (We live in Canada, after all, and must expect Alberta to behave differently from Nova Scotia, for example!) These materials are available to download here.
Lastly, here are details of a recent encouraging family experience. My wife is recovering from a recent accident, which could have proven to be much more serious than was the case. It got her thinking and caused her to finish her advance care directive, which she then took along to her family doctor for comment and signature. The doctor was favourably impressed with the DWDC workbook and undertook to recommend it to other patients. When all was signed and sealed, my wife asked him if he would provide medical aid in dying if the situation arose. He pointed out that his personal ethics would prevent him from so doing, but that he would not stand in her way if that was her wish. Moreover, he said that he would provide the first of the two necessary medical opinions and would have no hesitation in making a suitable referral.
No one has the right to take issue with the personal ethics of another in the matter of medical aid in dying, so long as there is not mere pig-headed obstruction. My wife was heartened to know that her doctor will be ready to help her at the end of her life if she calls upon him to do so.
Dr. David Amies is a retired doctor in Lethbridge, Alta., and a member of DWD Canada's Physicians Advisory Council.
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