Issue 7 / 4 March 2013

DESPITE much development and increasing complexity in health care, humankind’s mortality rate remains at 100%.

Given the ubiquity of this experience, it could be argued that an important, universal health outcome measure is a “good death”.

In the late 1990s, a qualitative study identified five things that people want when they approach the end of life: avoiding suffering; avoiding the prolongation of dying; achieving a sense of control; and relieving burdens on, and strengthening relationships with, loved ones.

More recently, Australian researchers involved with the Respecting Patient Choices Program in Victoria conducted a randomised controlled trial that objectively demonstrated that advance care planning — “whereby a patient, in consultation with health care providers, family members and important others, makes decisions about his or her future health care … should the patient become incapable of participating in treatment decisions” — improved end-of-life care and patient and family satisfaction and reduced stress, anxiety and depression in surviving relatives.

In the latest issue of the MJA, several contributions examine end-of-life care from different perspectives.

Since 1995, adults in Tasmania have been able to appoint and legally register a substitute decisionmaker (known as an enduring guardian) to make health care decisions when they lack capacity to do so themselves. A report shows the uptake of this option from 1995 to 2010 in the eligible population was only 2.7%: a missed opportunity, considering the authors’ belief that the process of advance care planning is just as beneficial as the legal documents arising from it.

Another Tasmanian project, the Healthy Dying Initiative, seeks to improve care and decision making in and out of hospitals at the end of life. It includes a “goals-of-care” framework for clinicians to state whether goals are curative, palliative or terminal, and advance care directives.

We are getting better at planning care at the end of life for cancer patients, but what about the many Australians who will die from chronic disease? Authors of a Perspectives article say this scenario holds particular challenges.

As patients with multiple morbidities slowly deteriorate, they require active disease management, but they also need help to control distressing symptoms, and emotional, spiritual and psychological support for themselves and their families.

The authors call for a system that allows and supports both these needs simultaneously.

Some doctors believe we should go a step further in assisting patients at the end of life. The position of Doctors for Voluntary Euthanasia Choice is explained in another Perspectives article. Under current health care provisions and professional ethics guidelines, the authors are concerned that some patients still have unrelievable forms of pain and others may be forced to endure a wretched but ongoing existence.

The authors call for voluntary euthanasia to be legalised, following the precedent set in several other countries.

As pointed out in the introduction to the journal’s new occasional Ethics Series, we have some way to go before our conflicts about the big issues in medicine — such as how far we should go to assist in a good death — are resolved.

Three principles are offered that might help guide the way: universalisability (could we apply to ourselves what we are proposing to do to others?), consistency, and a willingness to be guided by the wishes and values of the individual most affected by a decision.

When it comes to the third principle, some of the advance care directives analysed indicate that, for many, the wishes for end-of-life care are simple, practical and clearly articulated: “I do not want to be force fed” or “When I am unable to walk outside by myself, I would like to be taken out to the sun for a few hours every day whenever possible”.

These wishes, at least, we should be able to grant.

Dr Ann Gregory is acting editor of the MJA. Dr Ruth Armstrong is senior deputy editor of the MJA and medical editor of MJA InSight.

This article is reproduced from the MJA with permission.

Posted 4 March 2013

4 thoughts on “Ann Gregory

  1. kathy kastner says:

    I am so glad this came my way via #EOLchat founder, Ann @DrBeckerSchutte . It is one of the most enlightening and enlightened end of life perspectives I’ve read (and I’ve been reading as much as I can, and blogging on

    Hugely important – necessary – to wrap collective heads around the trajectory of dying with (dying of?) multiple health conditions.
    Thanks, too, for great links.

  2. Steve Flecknoe-Brown says:

    During my time on the AMA (NSW) Ethics Committee it became obvious that the three things that are critical to the success of an Advance Directive (“Living Will”) are:
    1. It should be presented in a legally-binding form; signed, dated and independently witnessed and an original document.
    2. It should use unequivocal language, and
    3. It must be able to be instantly understood (the “3:00 am rule” of clear wording)
    When Government and lawyers get involved in the process, the last of these three things usually suffers. I am happy to share with readers a document template which satisfies all.

  3. George Burkitt says:

    Advanced care planning should begin early and be a routine part of general practice from as early as say age 60. Proformas need to be developed in a digital form that enable people to create their own detailed directives specific to their needs. Most current directives are too general in their description of what is desired. Directives could be reviewed with the help of GPs as often as required as the patient ages or refines their needs.
    Advanced directives need to be supported by uniform national legislation and be available on line so as to be accessible as soon as a person engages with the health system.

  4. Anonymous says:

    The RACGP has recognised the important role general practice can play in advance care planning and has recently released a position statement encouraging its integration into routine practice:

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