Can we afford to keep people alive?

WHEN my 79-year-old mother died peacefully in St Vincent’s Hospice, we were thankful we were with her. At home until just a few days earlier, she remained in control as much as anyone dying from cancer could. In the hospice, the morphine made the last few days bearable – and killed her. This is what ethicists call double effect: the intention is good but it has a foreseeable bad outcome.Hospices help people die with dignity. My mother was lucky she was not in hospital – they are not designed to help people die but to keep them alive.The earliest hospitals treated injured soldiers in Roman times. Perhaps this is why we like military metaphors in health so much. We fight diseases and lose the battle against them when we die. Until recently – the past 50 years – most people died in the company of family, friends, priests or faith healers. Today, if we die in hospital, we are more likely to die alone or in the company of strangers.In the 19th century, people were expected to live for half as long as they do now. Most families would mourn the death of at least one child, sometimes more. Medical advances and a better standard of living mean we are no longer reminded of death each day.Hospitals with advanced technology and medical specialisation still fight diseases and frequently win. But there is one fight they cannot win: the one with death.Hospitals are filled with elderly patients at the end of their lives. People over 65 make up an eighth of the population but comprised about 37 per cent of all patients in public hospitals last year. Twenty per cent were over 75 and about 5 per cent over 80.Doctors always include age in an oral summary of a patient but other factors are also important, such as lifestyle, psycho-social factors and a capacity for relationships. Some people in their 70s are fitter and healthier than those in their 50s.I was at a public lecture last month when a 95-year-old woman spoke wise words from the front row. She was as sharp as a tack. If she got sick, she should have all the medical care needed to get her well – but only if she understood the risks and was able to state a preference. A person’s capacity to enjoy life and make decisions is what counts.Because hospitals are designed to treat and save patients, healthcare professionals follow protocols designed to maintain and sustain life, often without considering the patient’s circumstances. The sanctity of life underpins the ethics of hospitals. They use expensive, often invasive, treatments when basic, humane medical and nursing care is more appropriate.The full range of interventions – heart monitors, ventilation machines and other vastly expensive technologies – are given to patients admitted to intensive care units. Expensive imaging equipment, such as MRI machines, can range in cost from $1 million to $3 million, with each scan costing between $500 and $3500.Whether a patient wants any of this is frequently unknown. Patients may be unconscious when admitted, or deteriorate suddenly. The miracles of medicine allow life to be maintained even in the frailest humans. Many die during treatment and the lucky ones have palliative care for their remaining days. Many who recover are incapable of interacting with others and unable to say what they would like to happen. They are incapable of enjoying life or relationships. Is this how we want to die?While affordability is a big consideration, my arguments for limiting treatments for the elderly at the end of their lives are based on the potential for harm from those treatments and avoiding unnecessary suffering – be it for weeks, days or hours.If an elderly patient’s heart or lungs stop working, they will usually be given cardiopulmonary resuscitation by an ”arrest team”, regardless of how likely they are to survive. This is the default treatment. Only patients who have expressed a preference and had it recorded in their medical records are not given the treatment.Many doctors and nurses who are critical on ethical grounds of the requirement to revive elderly patients will go through the motions of CPR. Others give it their best and keep the patient alive, only to wonder later if they did the right thing.The fallback position of extending life seems proper but is, in fact, tragic. Until the mid-1990s, patients in NSW had red or blue codes inserted into their records to show whether were to be resuscitated. Often, neither those patients nor their relatives knew which colour applied to them. They didn’t know that doctors had already decided not to resuscitate. Such information should be shared with patients and carers – a necessity for both them and clinicians.Confusion about policy regarding treatment of the elderly in hospitals means many terminally ill patients are kept alive unnaturally and suffer unnecessarily. It allows the personal biases of doctors to dictate treatment. Some doctors may act on their own moral and religious convictions and try to save every life. Others will not offer treatments when they should on the basis of the patient’s chronological age alone.Why are we reluctant to talk about caring for the dying? Some patients worry that if they refuse high-tech treatment, they will be left without any care. Some doctors see little that’s heroic in caring for the dying – their skills lie, and are better used, elsewhere. Patients need a warm hand and comfort rather than a scalpel.Notwithstanding the clinical complexities of treating the elderly, who often have multiple problems, surely the goal of treatment is to relieve pain and reduce symptoms while not over-treating or causing undue suffering by prolonging life.Palliative care clinicians should be discussing the options with patients and carers to determine what is best for them. Sadly, they are often called only after more invasive treatments have failed – perhaps because palliative care is not well understood by the community.In 2006, for instance, the government report Community Attitudes Towards Palliative Care found it was raised by just 1 per cent as a health issue. While hospices are the alternative to hospitals, palliative care is the alternative to life-saving treatments. A palliative approach treats the whole person by focusing on their quality of life, not just treating the disease. Yet it was not specifically mentioned in the health and ageing budget statements for this financial year. The government did allocate $500 million for more sub-acute care services, which enable many older people to leave hospital earlier. But we need to keep them out of hospital in the first place. Hospitals can be dangerous for the frail elderly, who are at risk of over-treatment, infection and adverse events. If a family member wants ”everything done”, doctors are likely to agree – the fear of litigation ensures that. Doctors respond to family demands, even when the patient will suffer.Yet the cost of treating the elderly in hospital is enormous. This year, $64 billion was allocated to public hospitals and reducing pressure on emergency departments. A disproportionate amount of that money will be spent on those in the last few months of life. This money could be better spent on patients who would benefit and on health prevention.In a NSW hospital, one bed costs about $450,000 a year – $1233 a day. The average cost nationally for each admission to a public hospital is about $4500. Older patients generally stay longer than younger ones – 7.3 days compared with 4.5 for the rest. Apart from toddlers under the age of one, patients over 75 stay longest. Most elderly patients are admitted to hospital for circulation problems, then cancers and tumours.Coronary heart disease and stroke account for 30 per cent of deaths of those over 65. Surgery and general anaesthetic are too much for some. About 10 per cent of aged patients are transferred from hospital to a residential care facility, including those who were admitted with only a broken bone.Where should the elderly go when dying if not to hospital? If a person cannot die at home, the next best place is a hospice.We arranged for my mother’s admission to the hospice when she had difficulty breathing and strong pain. There are too few hospices; of the 78,000 elderly people now in nursing homes, a significant number are transferred to hospital for symptoms similar to those experienced by my mother. Yet the average cost of an aged-care bed is about $100 a day – less than a tenth of the cost of a hospital bed. The cost of a hospice bed is also significantly less than a hospital bed.Keeping the dying out of hospital is better for family, friends and the patient. It’s much easier to have meaningful conversations in a hospice.In the past half-century, we have handed over responsibility for dying to doctors – and we’ve incurred the costs. Accepting death as natural is necessary for imposing limits on treatment. We need more discussion on how we die, how we care for those approaching death and on whether the goal of medical treatment for the dying is to relieve suffering or extend life.This problem is not one of medicine’s making; it is a conceptual one about how we use medicine on the inevitable journey to death.Merrilyn Walton is professor of public health at the University of Sydney.
Nanjing Night Net