To accept or reject life-sustaining treatment
Debates about voluntary euthanasia overshadow the more important issue
of palliative care. In reality, good palliative care is about dying
with dignity – the same issue people think they cover when they discuss
euthanasia.
Palliative care aims not to cure but to comfort, relieve pain and
distress for the dying, and help patients, families and friends to
approach death and recover from grief.
One of the objectives of the Palliative Care Council of South Australia
– a voluntary organization of more than 500 members – is to advocate
the needs, rights and interests of people who are dying, and those
who care for them.
Laws about palliative care are found in South Australia’s Consent
to Medical Treatment and Palliative Care Act 1995. This act might
require people to think about resuscitation, or whether, after an
operation, a stroke or an accident, they would want to be revived.
The SA act – the first in the world to contain the words “palliative
care” in its title – has provisions based on the patient’s right to
self-determination. The value of the legislation is that it emphasizes
the obligation of the doctor to respect the right of the patient.
The importance of a good relationship between the patient, family
and doctor is evident when the doctor needs to understand the wishes
of the patient, and what he or she might like to do before something
happens. This is difficult if the patient has had a stroke, cannot
talk, or is unconscious after a head injury.
Some medical conditions can be predicted to leave a patient in that
situation. So the challenge is for the patient and doctor (and, maybe,
the family) to talk about possibilities in advance.
Talking about a possibility of something going wrong can immediately
make a patient feel uncomfortable. “Why are you asking me about being
unconscious? he or she might ask. “Why do you think I will have a
stroke?”
The common medical answer is: “We do not expect something to go wrong,
but what if it did? What if the natural progression of the illness
meant we couldn’t talk about the situation in the future and need
to talk about the possibility now?”
Patients will be able to make advance decisions about the kind of
treatment they want, or do not want, in the event they are not able
to decide for themselves in the future. A decision made in this way
is called an anticipatory direction (Schedule 2 under the Consent
Act). It may be used alone or together with a Medical Power of Attorney,
so that the medical agent can consent to, or refuse treatment, in
circumstances that may not have been foreseen.
Following the discussions about how someone prefers to be cared for
in the event of a crippling illness, the doctor might need to treat
the person in the way he or she believes the patient would want. For
someone unconscious and in pain, a pain-killer injection might be
needed. Knowing in advance of the patient’s preference for relief
of his or her suffering, the doctor might give an injection (commonly
morphine for extreme pain).
A side effect of morphine is depression of the breathing. Large amounts
of morphine can stop breathing altogether. For cases in which a doctor
administers morphine knowing that the patient might die, but also
that his or her anticipatory direction is for the doctor to try to
ease the pain, the act provides an interpretation:
Medical Practitioners and those administering treatment under
medical supervision will be protected from civil and criminal liability
if they administer treatment to relieve pain and distress, even though
an incidental effect of the treatment is to hasten death.
Also true is that the doctor does not have to do everything to keep
the patient alive. Medical practitioners who care for dying patients
are not obliged to use life-sustaining measures if there is no prospect
of recovery.
The issues around dying are difficult to discuss; and the emotions
associated with death add a complexity to the whole subject. So it
makes good sense to discuss some of these things when you are well.
You should think about what you would want done if you could not
speak or were, indeed, unconscious. Then you can ask someone to help
guide you through those times.
If you have chosen someone (a medical agent) to act for you, that
agent, who must be 18 or older, can make sure your wishes about medical
treatment are carried out. Any adult you trust to carry out your wishes
can be your medical agent. He or she must be willing to sign a form
known as a Medical Power of Attorney.
A medical agent can say “yes” or “no” to treatment but cannot refuse
food or water for you, refuse treatment to ease your pain or distress,
or refuse treatment that could result in you becoming well enough
to tell your doctor what you want.
If you want to let people know your views, now might be the right
time to start talking. Also important is to talk to your family and
friends. They might be facing their own mortality and need your support
when they are sick.
If in doubt, talk to doctors or go to the website of the Palliative
Care Council of SA Inc (www.pallcare.asn.au).
