Liam Butler interviews Dr Alastair MacDonald, Member of Ethics Committee at The Royal Australasian College of Physicians (RACP).
Liam Butler: Dr MacDonald, you are establishing a clinical network in ethics for New Zealand. What are some of the current ethical considerations in the aged care and retirement sector that need to be explored and why?
Dr Alastair MacDonald: I am fortunate to have been asked to comment on a number of issues that I feel are of the utmost importance to all New Zealanders. I am happy that I got my Gold Card almost 7 years ago. I am a retired kidney doctor (renal physician). I have worked in the New Zealand Health service for 40 years. I have had the privilege of working in the first and the best public health system in the world. We have to thank Michael Joseph Savage for his role in this remarkable achievement in 1938. I am now a clinical ethics advisor and am a member of a couple of ethics committees.
In brief I would like to comment on our health services not only in terms of what I expect, but also in the context of what other older New Zealanders should expect. If I have a serious a medical problem; I want to be treated as an individual, with honesty and respect. If my time is limited, if I am going to die; I want to be told this by people who are good at having difficult conversations. This approach respects me as an individual. I also expect that they will use these health services so that others in the future will have the same excellent health care. Isn’t that what you want?
If I reflect on what I said in the previous paragraph, I would like to think that this was how I practised medicine in my career – respect for patients in the context of responsible stewardship of our health services. I have had to have many difficult conversations when it was necessary to impart bad news. Patients are often scared at times like this. A combination of empathy, compassion, respect, honesty, time and occasionally humour will help to achieve a good outcome that enables your patient to face that reality that their life is indeed coming to an end.
In spite of the fact that this is how I would like things to be, I am also very aware that it is increasingly difficult to achieve this degree of sensitivity in decision making. Just imagine how busy nurses and doctors really are. Things like not wanting to be on the front page of the paper, budget deficits, psychological burn out, aggressive drunken patients in the emergency room, demanding relatives, cultural diversity, time pressures and changing expectations.
Having tried to paint a realistic picture of what a hospital is like I’d like to get you to reflect on some interesting data on comparing doctors, lawyers and the general population and how they fared at the end of life (1). Doctors were less likely to die in hospital, less likely to have surgery and less likely to be admitted to the intensive care unit.
Well what might all of that indicate? My interpretation is that the doctors may have experienced less aggressive and more fitting management at the end of their lives. They may have died with more realistic expectations because they would have had knowledge of the burdens of aggressive treatment and the futility of many interventions. They may also have benefitted from more timely palliative care. Dying at home with access to skilled nursing care was more likely. They may have felt more in control of their dying. They may have had conversations with their families which really counted. They may have had more time to plan their funeral. They may have died with more dignity. Dying in this gentler way may have led to a less traumatic grieving process.
From a more pragmatic perspective, might they also have “consumed” less health resources? Could it also have meant that health resources were available for others to be used more wisely and effectively? Please notice that until now I have not used the word rationing of health care!
- End-of-Life Care Intensity for Physicians, Lawyers, and the General Population. JAMA. 2016;315(3):303-305. doi:10.1001/jama.2015.17408