Abstract
Death is an inevitable part of the cycle of life. None of us can avoid it. To some, death comes as a release, to others it comes too soon but, in most cases, it will be a moment of sadness for relatives and friends. Given increased life expectancy, many people in industrialised societies now have little personal experience of death of a loved one. This includes medical practitioners, for whom personal experiences cannot be divorced from the professional. Even within the hospital a specialist may have limited personal experience of death of his or her own patients. Take for example Hodgkin’s lymphoma in patients aged over 70 years. With about 400 new cases per year in Australia, any single haematology oncologist will only see one or two new cases per year, so given a 30% five-year survival they will have little experience of managing death from this disease. It is probably hardly surprising therefore that the COVID-19 pandemic has shown us that internationally there is a very unrealistic view of the realities of death and the relationship of ageing and chronic disease to the imminence of death. The daily macabre reporting of death numbers without any nuance feeds the concept that every death is preventable and therefore every death must be somebody’s fault. Professor Teik Oh wrote this short book about ‘end of life’ prior to the pandemic, but its release now is thus especially timely. Professor Oh writes that his book is intended for both health professionals and the lay public, and I feel that he has admirably managed to author a book that is readable to both without being either patronising or overly technical. The book is written from the perspective of an intensive care specialist, and I think that this is valuable given that, as Professor Oh points out, in Australia 13% of hospital deaths occur in the intensive care unit—a fact that may not be well known to our non—intensive care specialist colleagues, many of whom I am sure would therefore benefit from reading this book.
The book is peppered with short vignettes to introduce or contextualise the concepts being discussed. Overall, I feel that these do work well and make the book an enjoyable read; however, many may consider these a little too embellished for their liking! The first three sections of the book, on ethics, advance care directives, futility and communication, plus the section on religion and culture I consider particularly well written. I especially like the chapter on religion, which briefly outlines the implication of the most common religious affiliations on attitudes to end of life and withholding or withdrawing medical treatments. The book also deals very well with the conflict between the incorrect view widely promoted over the past two decades that autonomy has primacy over any other ethical principle in determining priorities at the end of life. The final chapter, on medical mishaps, is also well written, but I am a little disappointed that it does not directly address a not uncommon situation in which clinicians pursue what would be otherwise inappropriate therapy to correct the result of an iatrogenic injury. The book is well referenced and can therefore be used as a resource for more detailed further reading.
At times Professor Oh does appear to allow what may be his personal bugbears to come to the fore, some of which have a rather tenuous link to the subject of the book. For example, pointing out the idiocy of failing to wear cycling helmets or of continuing to smoke, and then expecting the taxpayer to pay for your treatment when your decision leads to a poor outcome. Similarly, personal perspectives on euthanasia may have the consequence of making this section not as balanced as it otherwise might be. Then the issue of distributive justice is touched upon; however, the cost burden of potentially futile care seems to be more prominent than the sharing of burden and benefits within the community. Personally, I think that this is a matter which individual doctors should consider in the treatment of individual patients; however, in my experience of now over a quarter of a century working in Australia I have never experienced any clinician ever mentioning the cost of treatment in evaluating a decision for a patient, as suggested in a few of Professor Oh’s vignettes.
I am also a little disappointed in the vignettes used to introduce the subject of organ donation. In both examples Professor Oh quotes the doctor as saying, immediately after discussing brain death: ‘I am sorry but it’s also my job/I have a duty to raise organ donation’. While I recognise that this is not a book on organ donation conversations, I think it is unfortunate to see the attitude still being promoted that discussing organ donation with a family is something ‘we all dread’ and for which we need first to apologise.
Professor Oh points out that medicalisation of death is only likely to increase. Apparently, most of us want to die at home, yet it’s much more likely we will die in some sort of healthcare institution. He also points out that one cannot write ‘old age’ on a death certificate, but must find a more precise pathological cause, which made me wonder if this could somehow be linked to increasing medicalisation? My grandmother, aged 85 years with Parkinson’s disease and mild dementia, developed a respiratory illness and died at home with all of us sitting around her bed in London in 1978. The GP wrote ‘Senile myocardial degeneration’ on her death certificate. Even as a 15-year-old boy I understood that—it was right, that was what happened. Her heart just got too old to cope with it all. I am pretty sure that for most, when our time comes, that is also how we would want to die.