I have been working back in the aged care sector since August 2016, and as many of you know I have been the Chief Executive Officer of Braemar since March 2017. A few weeks back I did seek comment from colleagues and visitors to my blog about these “end of life choice” matters. Thank you to those who have pondered, commented, and otherwise contributed on these things.
Pain, suffering, and distress are existential. The desire to end one’s own life is based on existential circumstances with perhaps the view that there is little hope for any future improvement in life’s outlook. The majority Christian view still is that Christ offers hope for an end to all suffering, but that happens at the natural end of this life – not a life brought to early closure. The endurance of pain and suffering can seem intolerable, and the grasp of hope seemingly so far away. We must develop ways in which we can assist to bridge the perceived gap between the existential pain and future hope by how we manage our pain, symptoms, and suffering and sense of loss; yet contemporaneously offer support to others afflicted by such suffering, grief and loss.
The environment in which approved providers of (residential) aged care operate is one where close to 90% of clients who come into care facilities will die in the facility in which they live out their final days, months or years. This is a complex environment in which to discuss “end of life” matters.
The latest benchmarking in the residential aged care sector informs us that the average length of stay in a residential aged care facility is now just seventeen months. Increasingly, many of our incoming residents are entering into care with greater levels of frailty and several comorbidities. Those with the highest levels of frailty may in fact only be recipients of our care for fewer than six months – entirely in a palliative care like situation. Whilst this changing reality is to be expected as more and more people receive better home care services – a very positive outcome from a health care perspective, many folks really are entering into facilities seeking a palliative approach to care as very frail, mostly elderly people.
Even when in good health we tend to regard very strongly the relationship we have with our local GP. It sometimes feels like that one person is the greatest confidant we can have. We trust our doctor implicitly. In some instances our own doctor sees and hears things that we may never share with any other person – even our life partner. That relationship needs to be strong and built on trust and trustworthiness. Are we really desiring to change the nature of that privileged relationship?
Whilst aged care providers engage with medical practitioners as part of our everyday role in care of residents, unlike hospitals, very few aged care providers in Western Australia employ, or otherwise formally contract with, medical practitioners around the care they provide to their patients. Most residents maintain a doctor-patient relationship with their existing general medical practitioner (“GP”) when they enter an aged care facility.
Some others who move to a suburb too far for their previous GP to continue to visit are allocated to another visiting GP once they enter into care. Whilst the residential aged care provider may facilitate the visiting GPs by providing a treatment room or similar, the resident is the GPs own patient, for whom they claim Medicare rebates etc following visits and consultations with their patients.
A visiting GP will hopefully add into progress medical notes held by the facility any commentary relevant to the ongoing care of the resident, but in every other way, the aged care facility has very little oversight and/or management of the GP’s performance and clinical governance. The GP continues to have a confidential doctor-patient relationship with the residents they visit in our facilities.
An aged care provider is often caught in the middle of complex family dynamics where, if one or more family members are unhappy with the care regime prescribed by the GP, can often take out their angst on the provider. The notion of a GP acceding to a request for end of life options for a resident which might be contrary to family wishes, and certainly against any view that a provider holds, could present significant difficulties for the provider who does not otherwise have a relationship with the GP.
I do not support any introduction of physician assisted suicide. Nor do I support that being an outcome of care delivery to any resident in our facilities. Should physician assisted suicide be legislated I have urged the WA Parliamentary Joint Select Committee on End of Life Choices that relief from any proposed legislation to be supportive of wording, such as the following that you may wish to adopt:
“<<Your organisational name>> does not support the early termination of life through advanced health directives, advanced decisions, or similarly named instruments. Neither will we knowingly support or be party to any overt action by a resident and/or family member, friend, or health professional or agency to deliver any medication that causes the death of a person earlier than the disease process would through natural causes and contemporary palliative care service provision. We are however supportive of a resident’s right to refuse or withdraw treatment for reasons of personal choice due to futility or the potential harm that could occur to the resident. We value the sanctity of life and recognise it is not our right to choose to end life. If a resident were to choose physician assisted suicide (howsoever called) then we will use our best endeavour to relocate them, according to their wishes, to another organisation for the terminal phase of their care, but we will not knowingly participate in any process of physician assisted suicide / assisted voluntary euthanasia as may be approved from time to time by relevant legislation.”
The full Submission that Braemar Presbyterian Care has made can be found here.
Finally, this is not about my express desires or yours. The legislation will be determined by our elected representatives, and will provide for protections. Sadly though we are in 2017 unable to guarantee that those protections will not have slipped by 2027, 2025, or even 2020. If you are concerned for the care and welfare of your clients, please think through these issues and make sure your voice around protection of elderly and vulnerable people is heard.