Re: Quality of death

Once more I am justified in my respect for Dr R. Gallagher—I very much appreciated her thoughtful COHP ar-ticle, “Quality of death,” in the July/August issue [BCMJ 2012;54:292-293].

Her comments reflect what I also experienced when I was actively involved in hospital care and palliative care wards. I often wondered at the number of elderly, frail geriatric patients in the ICU/CCU. Do we really practise the ethical principles des­cribed and plan for the future critical management of elderly patients in our practices? 

In the same issue of the BCMJ, the college library cites some 36000 articles on palliative care, 50 quality texts, and even some DVDs, and the topical issue of euthanasia is once again in the daily news. 

I would add to Dr Gallagher’s article that in cases of terminal disease, a combination of family guilt, social dysfunction (always a part of front-line medicine), and heavy impetus for excessive interventions leads us to de­lay consideration of palliative options and overlook respect for the dying process. 

Those in silos of care as specialists are not in a position to discuss such issues in a timely fashion. Now that I am primarily office-based, it is truly a rarity that hospital-based physicians call me to explore what I call “sensible” care of the elderly (i.e., no heroics when the outcome is glaringly obvious). One shining exception oc­curred recently when one of my frail patients ran into difficulties—not un­expected—when undergoing trans­cath­eter cardiac valve replacement and the complicating issue of ongoing treatment with warfarin, the nightmare for post-op care after such a procedure. The specialist and I agreed on simple ASA/Plavix, since Pradax, etc., still require the clearance of hurdles.

The GP is in the optimal position—ideally knowing the patient and family—to address dire possibilities earlier rather than later and to make wise choices in interventional care when complex care of the elderly begins. I try early on to bring up the concept of patient autonomy, encouraging patients to express clear opinions on interventions of a heroic nature, and to document their wishes in the presence of family members.

Now, if we only could get more committed and enthusiastic generalists and GPs—another topic altogther!
—John de Couto, MD
New Westminster

Dr de Couto raises the issue of the importance of understanding and res­pec­ting the wishes of our elderly patients, particularly when it comes to health care decisions at the end of life. Fraser Health’s End of Life program is introducing MOST—Medical Orders for Scope of Treatment—an initiative to improve such care for our seniors. As part of advance care planning, which includes information for patients and guidance for health care providers on facilitating discussions, MOST provides a way to document therapy and intervention decisions in the event of serious illness. The directions for care are available to acute and community caregivers and ensure that we do truly provide the care desired by the patient. —AIC