Emily aged 85 went into hospital. Her home is a nursing care home. She cannot support her own weight and needs a hoist and wheelchair to get her to the toilet and dining room. She is able to sit in an armchair and watches television. She has several diseases necessitating a good deal of staff time and medication. These are Alzheimer’s, rheumatoid arthritis, chronic pain, diabetes, and chronic obstructive pulmonary disease. Her mood is okay and she is able to converse in a limited way with staff and her visitors.
Prolonging life of patients like Emily
However the quality of life changes when she gets a chest or urinary tract infection to which she is vulnerable. At these times she has breathing problems and becomes uncommunicative. These problems have resulted in several hospital admissions in recent months. Only in hospital can adequate treatment be provided eg monitoring machines, scans, medical expertise on hand, adequate amounts of needed oxygen and so on. When in hospital at first she becomes agitated and more confused and then later fed up not being in her own room at the care home where she sees familiar faces.
The question arises: how many times should a very ill and infirm person near the end of life be given repeated inpatient episodes of hospital treatment. When is prolonging life inappropriate?
It used to be said that pneumonia was the old person’s friend because, although it resulted in death, it took away suffering caused by other serious ailments such as from advanced dementia, cancer, or kidney disease.
Even if physician assisted suicide and euthanasia are rejected, end-of-life care for elderly people with chronic diseases involves difficult clinical and ethical judgments. Such conditions won’t easily go away despite the best that medicine can offer. Palliative care means doctors and nurses do their best to reduce discomfort and pain and improve the quality of the patient’s life whether or not there is hope of a cure by other means.
Prolonging life within the context of professional ethics
Doctors and nurses practice within a framework of professional ethics for example principles of informed patient choice, maximising good, not causing harm, and providing what is thought the patient has a right to receive. All medical treatments involve risks and benefits. Health staff try to get the best balance between interventionist treatment that directly tackles disease and palliative care. These however have different goals and sometimes suggest opposing clinical plans.
Good end of life care means neither hastening death nor unnecessarily prolonging life. Unfortunately it seems that sometimes inevitably one of these consequences will result.
Should one decline to give emergency resuscitation to someone where no improvement in their suffering is likely to result from further living? Should hydration and nutrition not be forced via tubes into the body when the patient is unwilling to drink or eat? Should more effective higher levels of sedative be given to patients in pain although this increases the risk of death? This seems suspiciously like inappropriately prolonging life.
To my way of thinking, the trouble is health professionals are expected to try to cure us. Those health care staff practicing palliative care do not always receive support from family members, other healthcare professionals, or their social peers for their work to reduce suffering and follow patients’ wishes for end-of-life care.
Negative attitudes towards palliative care
N.E. Goldstein and colleagues did a survey and found that more than half of doctors who practice palliative care report that a patient’s family members, or another health care professional had characterized their work as being “euthanasia”, “murder”, or “killing” during the previous five years. And so I do wonder if inadvertently doctors err on the side of prolonging life unnecessarily for fear of being criticised for harming patients by not being interventionist.
They practice in a world where anxiety about death is common and where medicine cannot sanitize dying. Fear of death is pretty widespread and so no wonder it exerts a powerful effect on attitudes to end of life care. Does acceptance of death mean one is able to lean towards palliative care rather than towards interventionist treatment?
Psychological research has found that the fear of death is made up of a number of different fears. For example a study by James Diggory and Doreen Rothman found that the following are common fears about death in descending order of importance:
- My death would cause grief to my relatives and friends
- All my plans and projects would come to an end
- The process of dying might be painful
- I could no longer have any experiences
- I would no longer be able to care for my dependents
- I am afraid of what might happen to me if there is a life after death
- I am afraid of what might happen to my body after death.
Emanuel Swedenborg has given a vivid account of life after death from his personal experiences in the eighteenth century. What he says is often echoed since in the accounts of mediums, those having near death experiences (NDE’s), and those receiving brief communications from the other side (ADC’s). All show a continuation of life similar to what we are familiar in the physical world, albeit in a world of spirit where one’s inner life of experience and character are more apparent.
Is difficulty in confronting attitudes to death in Western culture affecting the way hospitals actively treat elderly people with serious illness at the end of their useful life in the world?
Copyright 2011 Stephen Russell-Lacy
Author of Heart, Head & Hands Swedenborg’s perspective on emotional problems