Originally published in December 2012 on the Baycrest.org
A National Post story (Nov. 8) reported that New Brunswick was the latest province to move in the direction of offering patients more choices about end-of life-care, beyond the standard “do or do not resuscitate” policies.
Fast on the heels of this article was a story in The New York Times
(NYT) on Nov. 24 about end-of-life care. The NYT reported that when
advance care planning is done well “there is good evidence that…it can
greatly increase the likelihood that patients will get the care they
really want. And, as a secondary benefit, their choices may help reduce
the cost of health care as well.”
What I found surprising about the National Post article was that one
would think after reading it that offering dying patients more choices
in their end-of-life care was a novel idea. As the NYT article pointed
out, the history of so-called advance care planning dates back several
decades. Canada has played a strong role historically in the
development of the idea of the “living will” – a document used for the
process of stating one`s wishes and values for end-of-life care, which
can be expressed verbally or in writing. In Ontario it is supported
legislatively through the province`s Health Care Consent Act.
The NYT story states, “Many people sign living wills that specify the
care they want as death nears and powers of attorney that authorize
relatives or trusted surrogates to make decisions if they become
incapacitated”. As part of a nation-wide American project, Physician
Orders for Life Sustaining Treatment have been created to ensure that a
patient’s wishes are followed and not misplaced or too vague for family
members to be sure what a comatose patient would want. According to the
NYT article: “With these physician orders, the doctor, or in some states
a nurse practitioner or physician assistant, leads conversations with
patients, family members and surrogates to determine whether a patient
with advanced illness wants aggressive life-sustaining treatment, a
limited intervention or simply palliative or hospice care.”
With the shift toward giving patients more choices about their
end-of-life care beyond do or do not resuscitate, we need to be careful
of the real risk of developing a quick and cheap fix – that is, relying
on a simple form in which people select from a menu of categories of
choices for their final phase of care. This process has been shown by
many in the field of ethics and end-of-life care to be too minimalist to
capture the nuances and emotional complexities of expressing
end-of-life wishes. Many would say the important part of the process is
not a “form” that is filled out, but a robust conversation with those
that you depend on to respect your values and wishes and interpret the
potential treatments offered when the time comes to agree to or reject a
treatment.
Pre-planning one’s future is never easy and can lead to unexpected
and unwanted consequences if not done with careful thought and planning.
The importance of the National Post and NYT stories is that they
support the importance of having the conversation with close family
members or those you might expect or appoint formally to carry out your
wishes when you are no longer able to do so. This personal
responsibility must be supported by public policy initiatives that
promote education and training of those who ultimately will be
responsible for assisting individuals and their families in tackling
this challenge.
Dr. Michael Gordon is currently medical program director of Palliative Care at Baycrest, co-director of their ethics program and a professor of Medicine at the University of Toronto. He is a prolific writer with his latest book Late-Stage Dementia: Promoting Comfort, Compassion, and Care and previous two books being Moments that Matter: Cases in Ethical Eldercare followed shortly on his memoir: Brooklyn Beginnings-A Geriatrician’s Odyssey. For more information log on to www.drmichaelgordon.com