Jane McCredie: Are we headed to the right directive?

IT’S hard to argue with the theory behind advanced care directives: allowing people to specify the level of medical care they wish to receive ahead of time should help to prevent unnecessary interventions and improve their chance of a peaceful death.

But few things in life, or its ending, are that simple.

How much can doctors really trust an advance care directive when making treatment decisions?

It is, after all, impossible for a directive to cover every scenario that may later arise. And if the document has not been updated for some time, how can the treating clinicians be sure the patient’s views have not changed?

A healthy 60-year-old might declare he wouldn’t want to keep going with any level of physical impairment — 20 years on, he might be more focused on simply having a few more years with his grandchildren.

A recent article in the Journal of Medical Ethics goes further, suggesting that promotion of advance directives might align a little too neatly with moves to contain health costs as the population ages.

Medical ethicist Dr Phillipa Malpas, from the University of Auckland, argues older people are already discriminated against in the health system, with evidence suggesting they are less likely to be offered cardiological investigations or joint replacements than younger patients — despite having more clinical indications for both.

Without careful management, she writes, advanced care directives could make things worse by providing a justification for denying expensive treatments to the elderly.

When ageist attitudes are prevalent in the medical setting, it is not difficult to imagine older individuals being encouraged to articulate (clearly) that they do not want “this” or “that” medical treatment. Rationing health care to older patients could then be justified on the basis that “this is what the patient requested in their advance directive”, Malpas writes.

She also questions the ability of time-poor GPs to provide the information and ask the necessary questions to ensure any directive is made by a truly informed patient.

The GP would need to discuss likely future scenarios and explain possible interventions with their associated risks and benefits, as well as exploring the patient’s personal values and goals, she writes.

So, all that in a level B consult? I don’t think so.

If we really want advance care directives to deliver on their promise of increased patient autonomy and control, it looks as though there may be a bit more work to do.

Jane McCredie is a Sydney-based science and medicine writer, and author of Making girls and boys: inside the science of sex, published by UNSW Press.

Posted 7 March 2011