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• When Doing Everything Is Way Too Much
  Joseph Y Ting
  Published on: 19 June 2015

• Published on: 19 June 2015

  When Doing Everything Is Way Too Much

  • Joseph Y Ting, Adjunct associate professor, School of Public Health and Social Work

  To the Editor: It is crucial that hospital staff have ready access to background health care information about patients who come into their care -- including end- of-life care preferences -- that allow better decisions to be made. However, it is important to incorporate the reality that chronically ill and debilitated patients can at best, only achieve a return to the level of health or function they had before they becam...

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  To the Editor: It is crucial that hospital staff have ready access to background health care information about patients who come into their care -- including end- of-life care preferences -- that allow better decisions to be made. However, it is important to incorporate the reality that chronically ill and debilitated patients can at best, only achieve a return to the level of health or function they had before they became really sick. If they were previously housebound with significant cognitive impairment, I would be reluctant to start aggressive treatment and then have to deal with the difficult decision of whether to continue. To do everything for a non- communicating bed-ridden patient confers legal protection to the treating team but does the patient fearful of meeting his maker a gross disservice. Such measures prolong physiological viability at the expense of meaningful life.

  Unlike the inhumanely excessive and overly aggressive treatment demanded by desperate patients, and complied with by the ICU, there is often all-round agreement that symptom alleviation, with a focus on pain reduction, maximising physical comfort and support of the psychological well-being of both patient and family, is the clinically rational and humane course to pursue. Before the acute worsening, and in consultation with their usual treating physician, partners, children and families will have had to opportunity to discuss and contemplate at length a fundamental shift of objective to comfort care, preservation of dignity and symptom palliation.

  There is usually time to come to a realization that premorbid or disease-related quality of life is poor and more aggressive treatment would be futile. Most of us believe that dying at an old and infirm age is not something to be raged against or resisted at all cost. For all of us and every day, life dies at a varied pace. Some race into the abyss of oblivion and the healthy are inching towards the precipice. Alastair Reid yields a truthful rebuttal to Dylan Thomas' "Do not go gentle into that good night." "Curiosity", alluding to a cat's nine lives and a dog's contentment with its allocated years, is an enjoinder to life as the prelude to death.

  "...to tell the truth; and what cats have to tell

  on each return from hell

  is this: that dying is what the living do,

  that dying is what the loving do,

  and that dead dogs are those who never know

  that dying is what, to live, each has to do."

  We need to bear in mind Kafka's "The meaning of life is that it stops." The question arises of health resources wasted in futile clinical care being made available elsewhere, and the substantial opportunity costs entailed in expensively futile critical care.

  The algorithm for equitable distribution of expensive health care should include probability of meaningful survival, quality adjusted life years of remaining alive from medical treatment, and the loss of scarce critical care beds to a competing patient with better prognosis.

  Conflict of Interest:

  None declared

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  Conflict of Interest:
  None declared.

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