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Oct/Nov 2017 Reviews & Interviews

A Good Life to the End

A Good Life to the End.
Ken Hillman.
Allen & Unwin. 2017. 296 pp.
ISBN 978 1 76029 481 6.

Review by Ann Skea


Ken Hillman is the Professor of Intensive Care at the University of New South Wales and is also a practicing intensive care specialist at Liverpool Hospital. He has worked in intensive care since its inception in the 1950s. Over this time he has witnessed a major change in the patients admitted to hospital and ICU. In the main they now are much older than when he first began his career, and they are often in the last stages of their long life. He states that a huge majority of people at the end of their lives want to die peacefully at home but somehow seem to end up in a hospital and quite likely in an ICU. There, they are over-treated, given unnecessary operations and life prolonging treatments, and face a death without dignity. There, too, loved ones are often pushed into making decisions not to the benefit of the patient.

One can and should ask why this has come about. Well, in the last 60 years or so, medicine and its practice has changed dramatically. The once general practitioner (GP) who also coped with minor surgery and who knew you and all the family has almost gone. Visit a GP today with other than a minor complaint, and you are likely to be referred to a specialist. Now specialists know a great deal about one particular part of the body but are often less concerned by the overall. For a younger patient this is all to the good. Usually there is only one problem to be treated, and a referral to the right specialist means the best treatment for that condition is provided. However, for the elderly there are usually a whole host of problems, and treating only one often causes further complications. The result is over-treatment, and as Hillman says, "our practice of applying medical miracles designed to make people better, in increasingly perverse and futile ways, often causes pain and torture in the last few weeks of elderly people's lives."

Professor Hillman has set out in this book to illustrate some of these problems and also suggest we ask ourselves what kind of medical interventions we want as we approach the final stages of our own lives. He quotes, as an example, the case of a lady with advanced motor neurone disease who knew she did not have much longer to live. He details the choices she made and calls this "Denise's Manifesto." It describes the arrangements for hospice care the family doctor made to help her at this time. Surprisingly, this hospice care was in the state of Oregon and covered by the US Medicare system and was free.

Professor Hillman says we currently spend at least A$1,500 per day on a standard hospital bed and more than A$4,000 a day for treatment in an ICU. The very best round-the-clock treatment could be provided at a fraction of that cost in the community. So he suggest we ask the elderly what they want at this time of their lives, and just as importantly, what they don't want, and then design a caring and supportive system around their needs.

Will you read this book? Many won't because this is a book about aging and dying and is thought too depressing. Maybe it is more depressing to become frail and near the end of life surrounded by dishonesty and false hope. Anticipating your own end lifts the burden from relatives who would otherwise be asked to make crucial decisions about how you should be managed if, for example, you suffered a major stroke and were destined to spend the rest of your life totally dependent on others.

So read this book. And if you haven't done so already, make a "Manifesto" telling others what you want at the end.

And if you have aged parents who have not yet spoken about their wishes, sit down with them and talk about what they want. Better to be prepared than suffer the guilt of not knowing and perhaps making the wrong choice if you are asked whether the doctors should intervene and try to extend life no matter the pain or distress, or opt for palliative care and let nature take its course.

 

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