One third of elderly patients receive futile treatment before they die
Worldwide, more than one-third of patients aged 60 or older receive invasive and potentially harmful hospital treatment during their last six months of life, according to a recent Australian review.
The interventions continued into the last two weeks of life, with admission to intensive care, chemotherapy, resuscitation and intensive cardiac monitoring potentially preventing patients from having a comfortable death, and prolonging suffering rather than survival.
The analysis of 38 studies included data from 1.2 million patients, bereaved relatives and clinicians in 10 developed countries, including Australia. It was led by Dr Magnolia Cardona-Morell from the UNSW Medicine’s Simpson Centre for Health Research.
Dr Magnolia Cardona-Morell said the tendency to treat is fuelled by family members with unrealistic expectations putting pressure on hospital doctors, and doctors coming from a culture of doing everything possible.
“Doctors also struggle with the uncertainty of the duration of the dying trajectory and are torn by the ethical dilemma of delivering what they were trained to do, save lives, versus respecting the patient’s right to die with dignity,” she said.
The review, published this week in the International Journal for Quality in Health Care, acknowledged that it can be difficult for clinicians to accurately predict which patients will not benefit from active treatment.
“Admission to an acute hospital and prevention of death through clinical interventions are often the default position whether a patient has a reversible component to their disease or whether they are at their natural end of life,” the paper said.
Dr Cardona-Morell told Palliative Matters the research focussed on the experiences of people aged 60 or older because age and advanced chronic disease were the most statistically significant predictors of death. Hospitals, however, were not good at making these predictions or identifying patients who had limited time to live.
She said 80% of 80-year-old patients die within a year of discharge from an intensive care unit and their quality of life is impaired during that last year.
“We see elderly people repeatedly visiting [accident and emergency departments] in the six months before they end up in intensive care. A large proportion die in intensive care within 24 hours because nothing could be done. A significant number of those who survive and are discharged from hospital die within six months,” she said.
“I am totally convinced about the benefit of families having conversations.”
Study co-author and senior intensive care specialist at Canberra Hospital, Professor Imogen Mitchell, said while it may seem odd that interventions are being ordered in a patients’ last days, there are complex reasons underpinning why this occurs. She cautioned that without the benefit of hindsight it is often difficult to be absolutely certain about what the right thing is for a patient.
“So, as an example, as a 90-year-old, I might clearly state that I do not want to be resuscitated but as health care provider would I allow a 90-year-old choke to death on an apple piece or would I remove the suffering by resuscitating the patient and remove the offending piece of apple?” said Professor Mitchell.
“In a young patient who experiences metastatic cancer with little chance of a good outcome who is not ready to die, would you deny them treatment? I think that’s where it all becomes very challenging.”
Professor Mitchell said the research provided a valuable springboard for discussion and highlighted the importance of friends and relatives being made aware of patients’ values and end-of-life wishes.
“I am totally convinced about the benefit of families having conversations. It is so helpful for families who then may be placed in positions where they have to make decisions.”
Families and loved ones could help doctors to interpret patients’ wishes according to their specific circumstances, which could be difficult when relying on advance care plans alone.
Professor Mitchell said a patient might state in an advance care plan that they did not want interventions that would restrict their mobility. However, knowing how to apply that plan was difficult if the intervention’s impact on mobility was likely to be minimal.
“Two things need to happen. We all need to get a bit more comfortable talking about death and dying, and [understand that] dying can be a very long process. Very few people die immediately,” said Professor Mitchell.
“And as health care professionals, we need to be much braver about saying, ‘Actually, what are we trying to achieve here?’”
She said it was much easier for doctors in acute hospitals to take action and intervene than to decide to do nothing. But the long-term consequences of putting someone on a ventilator, for instance, could cause patients and their families significant distress.
Professor Mitchell said senior doctors may not reflect adequately on how long patients are likely to live, often leaving junior doctors to make out of hours decisions, which often presumes all tests and interventions are appropriate. This could mean a patient undergoes a brain scan in their last few hours of life, rather than spending time with their family.
She said it was important to improve hospital doctors’ understanding of palliative care and patients’ access to it. She said most doctors in the acute sector saw palliative care as something that was important only in the patient’s last two days, partly because of limited access.
“But palliative care offers far more than that. It’s about having [palliative care professionals] with you on your whole journey as you’re dying.”
She said every hospital admission should be reviewed as to whether the patients likely to die within the following 12 months. If the patient fulfils this trigger then it is essential for doctors to have a conversation with the patient and family to determine what is important to the patient at the end of life. General practitioners were also well placed to instigate these conversations with patients in order to prevent unnecessary hospital admissions.
For support in working out how to discuss death, dying and your end-of-life wishes with people close to you, visit www.dyingtotalk.org.au
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