In his latest post for DWD Canada's blog, Dr. David Amies argues colourfully and compassionately why less end-of-life intervention leads to better outcomes for many patients — canine and human alike.
A few days ago, my eldest daughter, a mature, educated, professional woman arrived on the doorstep in tears. She had just come from the local vet’s office. She had taken her 15-year-old Jack Russell Terrier, Tessie, for a check-up and had learned that its blood markers for pancreatic disease were off the chart. Sadly enough, a year or so earlier, the poor dog’s litter mate had suddenly fallen ill with the same disease and had to be put down. That had been a shock for my daughter and she did not wish to be taken unawares a second time — hence the check-up.
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The vets told her that Tessie needed further sophisticated tests that could only be carried out in Calgary, a 500-kilometre, round trip away. My daughter wanted my advice. I asked a few questions:
Was Tessie wagging her tail? Yes.
Was she eating her food? Certainly.
Was she still interested in pursuing balls, in so far as her arthritic little legs would allow? Most definitely.
Was her nose cold and moist? Absolutely.
It did seem, then, that her little doggie was in no distress and that the problem was an abnormal blood test.
Tessie is a very old dog. She does not have long left to live, even under the best circumstances. A trip to Calgary would be stressful and the investigations expensive and intrusive. So, the cleverer vets in the big city might discover a tumour or an abscess. What then? Surgery? In short, I advised a wait and see policy and so far, Tessie’s tail continues to wag and she is still eating her dinner.
Exercises in futility
A few years ago, in Australia, my mother-in-law, a lady in her mid-nineties, who had previously been in splendid health, suffered from a series of small strokes. She had to give up her house and move into a nursing home. She and her two children had decided that she no longer wished for intrusive treatment, and should she encounter another medical catastrophe, she wanted nature to be allowed to take its course. One evening, she had a further attack and was whizzed off to the local emergency room. By the time we assembled there, an eager-beaver young doctor had seen her and was preparing to send her off for an MRI (imaging on steroids and expensive). I asked him what he hoped to learn and he told me that it was important to establish whether she had had bleeding into her brain or just a clot in one of the vessels supplying it. I asked him what he proposed to do for an encore: bore a hole in her head? The poor young emergency doc was doing everything by the book but he did not seem to have read mother-in-law’s chart. Had he done so he would have seen that she was nearly 100 years old and that she had announced that she no longer wanted enthusiastic interventions. Shades of Tessie, n’est-ce pas?
Dr. David Amies.
Anyway, my dear old ma-in-law was allowed to go back to her nursing home, inviolate, where she eventually died just short of her 101st birthday. Her last several months were no fun and on more than one occasion, she asked my wife, her daughter, if there was anything that could be done to help her on her way. At that time, doctor-assisted death was not available in Australia, although today, discussions are going on to consider change.
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This pair of anecdotes illustrate that medical staff are happier doing something than sitting on their hands. Doctors in both Australia and Canada are not paid to sit and think. They earn the most when they get up to -ostomies, -oscopies and other mechanical activities. And who is not beguiled by larger paychecks? Those more reflective specialties, such as internal medicine and psychiatry, are less well remunerated than the intervention heavy ones like surgery and radiology. As well, doctors are inclined to see a medical problem as something to be fixed regardless of the background circumstances in which it has arisen, such as the patient’s age, general health and wishes. Good examples of such thinking are MRIs for one hundred year old ladies and long trips and invasive tests for fifteen-year old doggies!
What can we learn from these stories?
We must be bold enough to ask our medical advisors what they hope to achieve by ordering one more test or one more round of treatment. Will the proposed line of attack lead to a valuable and enjoyable extension of life? Or will it merely lead to a prolongation of distress, agony and strife? Such questions are hard to put and more so in a society where we have all been brought up to believe that those in the white coats are all seeing and omniscient. We have to think again and ask for a detailed analysis of the pros and cons and keep the wishes of the sick person as the first priority. Keeping mother going for another a few months because we are not ready to let her go is not really the thing that matters most. It is our own plight that is uppermost in our minds, not hers.
Dr. David Amies is a retired doctor in Lethbridge, Alta., and a member of DWD Canada's Physicians Advisory Council.