Saturday, 23 May 2015

How far to go with medical intervention remains a question

New Yorker feature writer and medical practitioner
Atul Gawande is in Sydney (photo: Quentin Jones).
In her story on Atul Gawande, the world-famous New Yorker feature writer who is also a medical practitioner, Sydney Morning Herald reporter Amy Corderoy evinces some surprise - as does the subject himself - when she discovers universal acclaim among Sydney Writers Festival attendees for the man. I first came across Gawande as a postgrad journalism student because one of his feature stories was included in our coursework, and I also fell under his thrall. So I can understand their reactions. It is rare to find a professional such as a doctor who is able to write with such flair and confidence about his or her vocation.

Gawande is here to talk with Sydneysiders about his new book, Being Mortal, which looks at ageing and health. Because my mother is currently in a nursing home and I have cared for her for the past six years this is something I have some experience with and I admit to being a bit surprised when reading Corderoy's story because she said nothing about Australia's advance health directive (AHD). This is a document prepared with the subject's GP when the individual is still competent to have such discussions, in which the extent of medical intervention in the case of terminal illness is documented and signed off on. You might want to limit the extent of intervention, for example, as in the case of my mother, and not go "the whole hog" in every situation.

Perhaps Corderoy didn't raise this matter because she doesn't know about it, or there might have been space constraints in the story. But I think the AHD goes to the heart of what Gawande discusses in his book - which, admittedly, I have not read yet, though I will read it - and that makes it seem like an obvious candidate for inclusion in her SMH story.

There is no doubt that quality of life has to be considered when you are deciding how far to take the medicine, and that's why AHDs are recommended to family members and subject individuals by lawyers, for example, when a person is also discussing their Will with them. It is I think a routine part of the succession process in Australia. To apply Gawande's own words, the AHD is an effective way for medicine to work with the individual. Of course, nurses in nursing homes will always consult with family members about types of care to provide when a crisis arrives, as it eventually will in all cases. The subject's GP might also go beyond the actual words of the AHD and talk with family members about specific details of the case in order to find out definitively where to stop. As in the case of organ donation - where an individual might sign up for the program at some point during their lives - the consent of family is still sought despite the existence of the AHD.

Which means it's not always specified how far intervention will go, but at least the people involved in the case have some sort of guidance to fall back on when questions about intervention arise.


Janine & Steve said...

Have you read Karen Hitchcock's "Dear Life", the Quarterly Essay published earlier this year? She's very critical of the push to get elderly people to write Advanced Care Directives while they're in hospital, a time when emotionally and cognitively people (especially elderly people) are fearful of being a burden and pessimistic about being able to get back to normal life. These directives are not revisited once they're signed, even though once back home the person may feel quite differently.
I do believe strongly in Advanced Care Directives written in good health and mind (although I haven't written one myself) but her observations did make me wonder about the morality of some of the means used to encourage people to write them.
The correspondence in the following Quarterly Essay has been interesting- especially Inga Clendinnen's contribution from within a nursing home herself- a rare perspective.

Matthew da Silva said...

Thanks for that. I will look out for the issue. As I mention in the blogpost, it's probably best to do an AHD early as part of the normal succession planning process, when everyone is in a good place physically and mentally and emotionally. A rational choice, then.