Sue Ieraci: What's worse than dying?

WHEN life is coming to its end, we tend to think about quality rather than quantity. But how is this played out within our increasingly risk-averse society where “bad outcomes” are to be avoided?

I have an interesting context here. In the emergency department where I work, we see lots of people near the end of life — especially the very elderly.

We are improving our focus on the wider needs of patients, including physical comfort, and have particularly focused on the comfort of the elderly and small children, such as warmth, alleviation of hunger and amusement.

For the elderly, we are starting to use tools such as “comfort blankets” — lap rugs with buttons, ribbons and zips that can occupy the hands of a “plucky” dementia patient.

Nice idea? But what about the inevitable question — could they hurt themselves? Could they swallow the buttons?

Well, in general, the elderly wear clothes that have buttons and zippers. Would we deny them the comfort of their clothes in the name of safety?

How kind are we being in seeking to restrict their remaining time by limiting every potential risk?

Similar thinking applies when we consider whether to admit elderly patients to hospital. Is our aim just to keep them alive as long as possible?

Does being completely cocooned in “safety” mean that they might no longer feel alive? Why are we doing that?

What should we do with an independent 92-year-old who presents to the emergency department with chest pain? Would that person benefit from a series of troponin tests? Admission to coronary care? What might happen if we relieve the pain and let them go home?

If they died, would we fear being held responsible? But what if we coaxed them into staying in hospital and they died there? Would we then be relieved we had not sent them home to die, or would we regret depriving them of their last few days at home?

Many of the people who are now very elderly grew up in times when health risks were much greater than today, and they lived their lives productively in that knowledge. Perhaps they fear death less than we do. Perhaps their appreciation of comfort is greater than their fear of risk.

By denying the elderly the right to take their own risks when it comes to death, we further erode their dignity.

I’m not suggesting that we abandon them to immediate danger of harm — that is not dignifying.

However, at a certain stage of life, loss of dignity might actually be worse than dying.

Should we ever allow risk aversion to trump kindness?

Dr Sue Ieraci is a specialist emergency physician with 25 years’ experience in the public hospital system. Her particular interests include policy development and health system design, and she has held roles in medical regulation and management.

Posted 7 May 2012