In April 2023, Dr. Blair Bigham delivered a presentation based on his book “Death Interrupted” in Toronto. You can watch that presentation here. Dr. Bigham answered as many questions as he could at the time, but, as with most compelling speakers, there is never enough time for all the Q&A. In this blog post, Dr. Bigham addresses all the unanswered questions from that day. 

---

Advance directives 

Do you have advice for phrasing advance directives to create the best chance for having our wishes honoured in the way we want? 

I think it’s hard to be explicit for all the unknowns of why people end up in hospital. What’s more useful is making sure your Substitute Decision-Maker (SDM) has a very clear understanding of how you live your life and what quality of life you would find acceptable should be become critically ill. For specific wording, many people consult a lawyer as part of the process of preparing a power of attorney or will.  

Any suggestions on how to word an Advance Care Plan document in light of what you have said so that we’re not using absolutes, e.g. around antibiotics, oxygen, CPR? 

See above. Wording is hard. Generally, people exclude certain technologies, like ventilators and defibrillators and dialysis, while accepting “medical treatment” which would include antibiotics for example. But others would exclude even antibiotics and prefer only to be made comfortable. These wishes may change as the trajectory of illness improves or declines, which is why it’s more important that your SDM be able to discuss your prognosis and the impact various treatments will have on your prognosis so they can make decisions if you’re unable to.  

Death dilemma 

Are there things that families should be aware of when helping a loved one die comfortably? You mention ‘age’ and ‘chronic condition’ as factors in whether to offer technology to preserve/prolong life. How do you decide that either of these is relevant? 

Rely on the medical team by asking for the expertise around prognostication and the chances a particular treatment will lead to a benefit.  

I’m curious how the narrative that health care providers are ‘professional life savers’ facilitates the perceptions for patients that we don’t have to think about death or end of life. Is there a way for physicians and health care providers to shift the narrative of ‘professional life saver’? 

That is a grand challenge that we can each start to address locally using our own influence and leadership. It’s very tough, though.  

I am an independent health care navigator. I find this discussion to be equally difficult in long term care when antibiotics keep on being ordered and the resident is spoon fed even when they have no awareness of their surroundings. Do you have any thoughts on bringing this up with residential care physicians? 

I would start by bringing it up with families and understand what their expectations and hopes are for the patient. When people are unable to appreciate the world around them, families sometimes choose to focus on comfort and stop things like feeding and hydration. When we exclude food from goals of care, and focus on comfort, a natural death can be achieved.  

Do you think that by improving preventative medicine regarding goals of care and encouraging people to have these difficult discussions early would help to ease the death dilemma? 

Yes, but it’s not the only answer. There are so many unknowns that are hard to plan for; a lot of the tough discussions need to happen during critical illness, but they are made much easier if there have been prior discussions. 

It is easy to accept that ICU physicians are approachable and thoughtful about ‘pulling the plug,’ but what about oncologists? Is a new perspective needed in that area of medicine? How can families get more help in that area? 

Different specialties are certainly known for different ways of approaching serious diagnoses. Sometimes it’s helpful to ask to meet with a palliative care physician who can assist the other specialist in helping plan a treatment regimen. Prognosis is hard, and often treatments are not curative but only meant to prolong life, and it’s important that this is well understood by families and patients so that they can constantly re-evaluate the benefits of treatment given their response to treatment and their goals of care. 

CPR/DNR 

As a former paramedic, any thoughts about the ‘grey zone’ or death dilemma prehospitally, both in active resuscitation and in preventative paramedicine (i.e., community paramedicine)? 

In Community Paramedicine (CP) there is an opportunity to build relationships with patients with chronic organ disease. These patients will benefit greatly from medical intervention, but eventually they will likely succumb to their chronic disease. CPs can identify trajectories and help patients and families navigate declines. In the prehospital world, cardiac arrest is often unexpected and requires immediate action. When it is expected, it may well be appropriate for paramedics to have brief conversations with families about the suitability of offering CPR, for example. 

Do you feel that primary care providers should be discussing/establishing DNR orders for people in advance of requiring invasive intervention? 

It’s hard to know the specifics of why someone might need invasive intervention; sometimes the intervention might have a very high likelihood of success, and be desired, while other times it may not. So, it’s situation dependent, which is part of why these discussions occur once a patient is already exposed to technology. The trajectory is important – ask the doctors, “Is it working?” 

Do the paramedics have to resuscitate? Does that vary by province? 

Each province sets out rules for how paramedics deal with end-of-life circumstances, and there is a lot of variability.  

Palliative care 

Can you comment on when a person moves into the experiences of active dying; are there medications you would say should be avoided? 

Yes, there are definitely medications that are favoured and avoided. It depends on the disease and the symptoms that the patient is experiencing.  

Religion 

Could a physician or psychiatrist’s personal beliefs trump your own personal beliefs in relation to how you die? 

Physicians generally follow the wishes of their patients, and seek to understand and respect their religious beliefs.  

Do religious beliefs affect how staff in the ICU react to end-of-life decisions? 

If a patient is religious, we offer spiritual support that can help families find clarity at the end of life.  

Miscellaneous 

I’m curious about your thoughts on whose responsibility it is to address the way society views resuscitation and the dying process in the media (i.e., news, films, tv etc.) outside of Advance Care Planning? 

I think the bulk of the responsibility lies with medical professionals to initiate these conversations at all stages of health care – primary care, acute care, critical care, palliative care.