Saturday, 25 August 2012

Can we ignore true despair?

For those of you that have missed me over the last few weeks, I apologise for my absence. My inaugural spell of fatherhood took its toll on my creative juices. It’s not that I haven’t had any good ideas, it’s just that a lot of the issues that I would previously have got on my hobby horse for seem less important when holding your first child.

But through all the hours that I have spent staring at my beautiful baby, the world has continued to turn, and lives have continued to have been lived. In some important cases, lives have come and gone.

Who was not moved by the grief shown by Tony Nicklinson when his right to die appeal was rejected? (http://www.youtube.com/watch?v=tpxeGY4JLdg). The law by which our society abides ought to be logical, consistent and representative of the values of society, and we as a society have yet to really come to an agreement about how we feel about assisted suicide.

Sometimes though, the strength of need shown by people you come across transcends your own moral code. However you feel about assisted suicide, we can be quite clear about how Tony Nicklinson felt about it, and we can be quite clear about the impact that the rejection of his case had on him. The only blessing from his death days after the second biggest disappointment of his life (his original stroke surely counts as number 1) is that his suffering ended. That his final days were blighted by disappointment and frustration is something that we cannot now undo. But perhaps we owe it to him to delve further into the issue.

Lots of people assume that I have a well-developed thesis on the role of assisted suicide from my work with the elderly. This however is not strictly true: I don’t think that euthanasia has much of a role with my patients, as inevitably, they are people who are reaching the end of their natural lives. The majority of my patients are frail. There are a great many fit and active elderly folks around, but they tend not to need the services of hospital-based physicians very much.

The issue that I find myself tackling is the honest communication to my patients and relatives about what they can expect from the treatments that we have to offer. In many ways, we have over-achieved, and have created an expectation of full recovery, when that is often not possible. The new frontier for geriatric medicine, I think, is in the communication of the message that often, less is more: by doing less to patients, we often achieve a better quality of life, lived outside of hospital.

If we put aside the rather tired philosophical argument that we are all dying, many of the elderly people I meet in hospital really are dying. By that I mean that they are in their final 6 months of life. This can be difficult to communicate, as I never know with any certainty how long any particular individual has left. But recognising the reality of the end of life when someone is coming up to it can really frame the discussion about what the best care for them is. By accepting the supposition, you change the goal that you are aiming for, from saving life, to protecting quality of experience. It involves doctors taking a back seat, and only intervening when it will improve the qualitative experience of the patients.

Thus my goals as a doctor to the elderly oscillate between two main objectives: on the one hand, I advocate for elderly patients to receive the same standard of care that younger counterparts receive when they have the same condition. Ageism is much less of a problem than it used to be, but we still need to be careful about how we ration access to care in these straightened times. And on the other hand, I advocate for a hands off approach when an elderly patient is reaching the end of their natural life. This is the beauty of geriatrics, as what we really try to specialise in is truly patient-centred care, with full use of up to date care, but also with a healthy dose of judgement and compassion.

And it is this reality which separates geriatric medicine from the assisted suicide debate. In general, we have no recourse to euthanasia: to over-simplify the issue a little, my patients either have a decent crack at a fully recovery, or we accept that they are reaching the end of their natural lives, and adopt a symptom-control approach. While we often find ourselves unable to cure a great many conditions, with the help of my palliative care colleagues, we can offer patients comfort and dignity in their final days, weeks or months.

The assisted suicide debate centres around slightly younger patients who have either suffered a catastrophic illness, or are staring down the barrel of a scarily progressive disease, which will inevitably take them somewhere they do not want to go. For these people, with locked-in-syndromes, or with motor neurone disease, choosing the time of their own death is the last defiant act that they can take.

And through all the complexities of ensuring the protection of the vulnerable from coercion and exploitation, as a civilised society, we owe these desperately unlucky people our support, our attention and our honest endeavour to relieve their despair.

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