This was the question posed by UNSW medical researchers investigating whether hospitals should move away from aggressive life-saving treatment for older patients nearing the end of their lives and instead focus on providing comfort and dignity.
The study, led by UNSW Adjunct Associate Professor Magnolia Cardona and published in the Joint Commission Journal on Quality and Patient Safety, reviewed the medical records of 733 admitted patients who received calls for medical emergency teams during hospitalisation. The median age was 68 years but a third of the patients were older than 80 years.
About 40 per cent of those 80-plus-were subjected to aggressive procedures such as intubation, intensive monitoring, intravenous medications, transplants, and painful resuscitation attempts.
Cardona said that hospitals and emergency staff were offering invasive treatment when a close look at the patient’s history would suggest a gentler approach could be more appropriate.
She said these often-costly and aggressive treatments bring about unnecessary suffering for patients by admitting them to the ICU, and questioned the benefit to the patients, their families and the health system.
“Some risk factors such as a history of presenting to the emergency room or several hospital admissions in the past few months, as well as not-for-resuscitation orders are clearly linked with poor clinical prognosis and impending death,” Cardona said.
“Such high-risk flags could be used as a guide to refrain from using the emergency team. If hospital staff were trained for earlier recognition of when death is inevitable, patients could be spared such aggressive treatments and allowed a less traumatic and more dignified end.”
Cardona said patients or families can discuss their values and preferences before a health crisis takes place and before they lose ability to make choices.
“If patients put these in writing in an Advance Care Directive explaining how they wish to be cared for towards the end, clinicians will be better equipped to guide shared treatment decisions,” she said.
She added that there is also a need for patients and their families to recognise that requesting intensive interventions for elderly people going through the natural end-of-life is likely to introduce more pain and discomfort while unnecessarily prolonging the process of dying.
“If hospital staff were trained for earlier recognition of when death is inevitable, patients could be spared such aggressive treatments and allowed a less traumatic and more dignified end.”
Half of the deaths in the study occurred within two days of the medical emergency call, while all patients with a not-for-resuscitation order died within three months. Cardona said this suggests the prognoses of the patients would have been somewhat predictable.
“Our findings strongly indicate that admission to the ICU and invasive procedures for elderly people dying of natural causes need reconsideration,” Cardona said.
“When death is inevitable, other more appropriate pathways of care can be offered such as symptom control, pain relief and psychosocial support.”
The study mirrors the findings from surgeon Atul Gawande in his book Being Mortal, which found that a ‘good life right to the end’, rather than more time for time’s sake, is the desired goal for patients and families.
Learning how to give our elderly the self-determination to make decisions for themselves, instead of over-treatment and safety at all costs, is an important conversation we should all be having.
As Gawande points out, “We have the room to act, to shape our stories, though as time goes on it is within narrower and narrower confines. A few conclusions become clear when we understand this: that our most cruel failure in how we treat the sick and the aged is the failure to recognise that they have priorities beyond merely being safe and living longer; that the chance to shape one’s story is essential to sustaining meaning in life; that we have the opportunity to refashion our institutions, our culture and our conversations in ways that transform the possibilities for the last chapters of everyone’s lives”.