Issue 27 / 25 July 2011

A GOOD death — what appears at first glance to be an oxymoron is, as all medical practitioners will recognise, a basic human right.

We have all seen examples of a “bad” death, or at least one where the circumstances for the patient and their family could have been better. When a good death is achieved, there is an immense satisfaction in having given our patient the best possible care right up to the end.

To optimise this experience for the patients, family and health care staff involved, appropriate treatments need to be employed, such as giving adequate analgesia where required, but — of equal importance — futile care must be avoided.

Futile care is difficult to define, but is usually easy for a dispassionate observer to recognise — the chances of success of the treatment are low or negligible, and it has an adverse affect on the quality of life remaining for the patient. Our patients deserve the moment’s reflection it takes for us to ask ourselves if a treatment we are considering is, indeed, futile.

Drivers for futile care include medicolegal worries (“will I be sued if I don’t prolong this person’s life?”), the growth in patient/family autonomy (“everything needs to be done, doctor”), as well as unrealistic expectations as to how successful medicine can be in this day and age (how many blunt trauma victims with cardiac arrest in television shows actually die?).

These drivers are surmountable. For example, common law does not force doctors to provide treatment that they consider not to be in the patient’s best interests — and futile care certainly falls into this category.

As is often the case in medicine, communication is paramount. The patient, their family and the other health practitioners involved in the patient’s care need to be included in a conversation about the aims and futility of any treatment being considered so everyone is “on the same page”. This avoids any conflict and misunderstanding as nature takes its course, preventing last-minute “heroic” measures.

This debate is not new. Hippocrates suggested that physicians should “refuse to treat those who are overmastered by their disease, realising that in such cases medicine is powerless”.

Once the potential for futile care is recognised, its implementation can usually be avoided. The resultant “good death” may in fact be the best service we, as medical practitioners, can give our patients at any stage in their lives.

Associate Professor Alan O’Connor is an emergency physician and clinical director of the department of emergency medicine of the Royal Brisbane and Women’s Hospital.

Posted 25 July 2011

4 thoughts on “Alan O’Connor: A good death is best medicine

  1. says:

    Although this article was written in 2011, it i still relevant today, and in the future. The question to ask is.. is the patient ready to die, robust enough physically to fight and have we the expertise and resources to support their continued life?

  2. Rob the Physician says:

    The word ‘futile’ does not enter my vocabulary when I refer
    to patients or patient-care…………it covers the whole
    issue with an “umbrella.of.negativism” that you should hand over management to another person!!!
    Death…..good,bad or indiferent…..this is irrelevant!!!
    Death is death………just as pregnant is pregnant,and it is how you manage such!!!

  3. KBO says:

    Thou shalt not unnecessarily keep a dying patient alive.

  4. Peter B says:

    An important rider to this is that these days, palliative care is so good, suffering in pain is not now really the issue, but rather the timing of the death. So often one sees patient’s under such heavy sedation and analgesia, they not only are unable to attend to bodily functions, and had kissed goodbye to all dignity, but are effectively comatose, so sadly unable to communicate with the loved ones who have travelled possibly immense distances to be there. And even then they often still die alone in the wee small hours, when relatives could have been there at the bedside if only they had known when?
    Being able to set a time to go (once it is accepted all other interventions are futile), and be surrounded by ones loved ones, say good-byes, then be drifted off, must surely rate as a ‘good death’…?

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