The juggernaut of intervention

Time was, when facilitating a ‘natural’ death was a given

With reports of questionable interventions being carried out on dying patients, Dr Muiris Houston finds invasive testing and treatment can be a significant side effect of modern medicine.

Dr Muiris Houston

Is modern medicine shooting itself in the foot when it comes to over-treatment and dying? Has it actually got more difficult to die in Irish hospitals? In particular, has it become more difficult to die simply and humanely in an acute care situation?

Time was, when facilitating a ‘natural’ death was a given. However, in the past few months I have come across a number of cases where an alarmingly gung-ho approach has been taken.

Typically, this involves a questionable acute intervention, usually in someone with an existing life-limiting condition, which in turn leads to admission of the person to intensive care, at which point a number of iatrogenic issues such as kidney failure arise. Even then, with a family practically shouting ‘stop’, the juggernaut of intervention continues.

It seems, however, the problem isn’t confined to Ireland. In a really interesting analysis in the British Medical Journal recently, US journalist Jeanne Lenzer described the case of a 73-year-old man with metastatic lung cancer who told his doctors he didn’t want invasive testing and treatment.

They in turn brought in a psychiatrist, who said the man was ‘in denial’ about his illness. After some pressure from his doctors, the man and his family agreed to further testing and treatment. He was ultimately subjected to 47 days of painful and invasive treatments before dying.

Lenzer argues it is us doctors who are in denial. “Physicians are trained to believe that staving off death, even if only for days, is their overriding mission, and all available technology should be employed to achieve that goal.” She says that with 65 per cent of all deaths in the US occurring in hospitals, the frequency with which unnecessary care is being given is likely multiplying.

She then points out the harms of over-treatment are not restricted to dying patients. In a meeting on over-treatment convened in Massachusetts last April, the participants listed examples, such as the overuse of screening tests, to the numbers of questionable operations, such as tonsillectomies. In one study of elective angioplasties, almost half were either inappropriate or of uncertain benefit.

Why over-treat?

The meeting concluded that there were many reasons why doctors and hospitals over-treat: these include malpractice fears, biased research, profit motive and patient demand. Other problems include the rapid uptake of unproven technology and a failure to fully inform patients of the potential harms of elective treatments.

Lenzer says the growing over-treatment movement will have to respond to charges that it is encouraging rationing. But one participant offered the following explanation: “Rationing means that you are limiting necessary care. What we are proposing is limiting unnecessary, harmful care.”

Jerome R Hoffman, Emeritus Professor of Medicine and Emergency Medicine at the University of California, Los Angeles, suggests no amount of denying will prevent the message from being distorted by those whose interests it threatens. He told the BMJ: “Advocates shouldn’t be afraid when opponents try to demonise making wise choices by labelling it ‘the R-word’. Of course we should budget resources — as we do everywhere in our lives. In addition, there’s already lots of rationing in healthcare; wouldn’t it be better for us to decide what should be available, based on what’s best for our health, rather than having insurance companies decide, based on what’s most profitable for them?”

Bottom line

He says the new movement is going to have to address the elephant in the room. “Physicians and nurses have a fiduciary responsibility to put the needs of patients first. But the fiduciary responsibility of companies selling healthcare services is very different; it’s to the bottom line of shareholders,” he says.

“Whenever there is tension between what’s best for the public health and what’s most profitable, these companies must choose the latter. Ultimately, after we agree on which interventions are useless and wasteful, we’re still going to have to tackle the more difficult question… of whether or not profit-driven healthcare is an oxymoron.”

It’s a point that needs debating here at home. The continuing squeeze on health budgets may perversely make it easier to have this discussion than it would be in times of plenty.

But in the meantime, can we please stop interfering in the natural decline that occurs at the end of a person’s life?

Let’s work at making dying easier, not harder.