More than a third of elderly patients, dying in hospitals around Australia and nine other countries, received invasive or potentially harmful medical treatment in the last six months of their life, an international study released today shows.
The University of New South Wales-led research finds that hospital doctors from 10 countries around the world – including Australia, France and England – are initiating excessive medical or surgical treatment on patients aged 75 and over with advanced and irreversible chronic conditions.
The study, published in the International Journal for Quality in Health Care, reveals that up to 50 per cent of patients with do-not-resuscitate (DNR) orders were still given blood tests and imaging.
Almost 25 per cent of patients with pre-existing ‘limitations of treatment’ and 13 per cent of terminal cancer patients in the last six months of their life were given CPR. Meanwhile, over 90 per cent of elderly cancer patients died in hospital after CPR.
“These behaviours have repercussions not only on the capacity and financial sustainability of the health services...but also more importantly reflect a disregard for human dignity and quality end of life."
The study also details that 84 per cent of patients who received palliative chemotherapy were admitted to the hospital’s intensive care unit instead of being managed at home; 33 per cent of elderly hospital patients around the world were given chemotherapy in their last month of life; and 24 per cent of elderly patients were given unnecessary medications at the very end of their life.
“These behaviours have repercussions not only on the capacity and financial sustainability of the health services, and perpetuate the unrealistic high social expectation of survival at all costs, but also more importantly reflect a disregard for human dignity and quality end of life,” the study reads.
The researchers analysed the data of 1.2 million patients, bereaved relatives and clinicians from 38 studies, conducted over 20 years across Australia, USA, Canada, England, France, Holland, Brazil, Taiwan, South Korea and Israel. Two Australian studies were included in the overall analysis.
One of these studies, released in 2014, shows that DNR orders in Australian hospitals do not inevitably lead to cessation of appropriate medical treatment.
“The same issues that were reported in other countries are happening here."
The paper, summarising the global situation released today, does not present individual country findings. However, the study’s lead researcher, Dr Magnolia Cardona-Morrell from UNSW’s Simpson Centre for Health Services Research, says the Australian studies used shows that “we are good at not administering too much chemotherapy or radiotherapy or offering intensive care admission at the end of life”.
“But we are also offering too much blood testing and unnecessary imaging tests for people who have ‘do not resuscitate orders’,” says Dr Cardona-Morrell.
“This is unnecessary as it does not change prognosis, is an inconvenience to patients and leads to high costs to the health system.”
Chair of the Consumer Advisory Group at UNSW’s Simpsons Centre for Health Services Research, Alexandra Zammit, believes that although the proportion of Australian evidence in this study is small, the results accurately portray the current situation for elderly patients in hospitals, nationwide.
“The same issues that were reported in other countries are happening here,” says Ms Zammit.
“There are occasions where patients in hospitals or residents in aged care receive non-beneficial care or medical treatment.”
Ms Zammit says this is a serious problem because dying Australians have the right to enjoy a good death, pain-free and without trauma. She explains that our death-denying culture, which refuses to consider dying as a ‘normal’ part of life may be partly to blame.
“I’ve had the families of elderly residents, who died aged over 100, ask ‘what did they die from?’ Well I would think that old age has a role there.
“Often, it is people’s perception that we will live forever but we don’t and it is normal to die from old age. People should be able to die from old age.
“We also don’t have comfortable conversations about death and dying. We don’t talk about it enough and multi-factorial issues such as culture, beliefs and [individual] perceptions don't allow us to have those conversations comfortably."
“Technological advances are good but they should be applied for the benefit of the people who have a prospect of survival."
Dr Cardona-Morrell adds that rapid advances in medical technology have also created unrealistic expectations that hospital doctors can ensure a patient’s survival, no matter their age.
“Just because technology is there, it doesn’t mean we should use it,” Dr Cardona-Morrell says.
“Technological advances are good but they should be applied for the benefit of the people who have a prospect of survival.
“…Doctors also struggle with the uncertainty of the duration of the dying trajectory and are torn by the ethical dilemma of delivering what they were trained to do, save lives, versus respecting the patient’s right to die with dignity.”
A 2016 survey, conducted by Palliative Care Australia (PCA) earlier this year, found that 80 per cent of Australians thought it was important to put their end-of-life preferences in writing, even though only 21 per cent had done so.
The PCA survey results also showed that 70 per cent of Australians prefer to die at home but only 14 per cent do. This is in contrast to a 2011/12 Australian Institute of Health and Welfare report, which found 51 per cent of deaths occurred when people were admitted to a hospital.
The paper’s authors calls more community education to reduce the demand for non-beneficial treatments at the end of life and for hospital doctors to be better trained to cope with end-of-life decision making processes.
“More training for doctors will help them let go of the fear of a wrong prognosis, because they will be better able to identify patients near the end of life,” Dr Cardona-Morrell says.
CEO of Palliative Care Australia, Liz Callaghan, also proposes community-wide discussions on death and dying to ensure that conversations about end-of-life care, which need to take place occur in a timely manner.
“Australia is lucky to have one of the best health systems in the world,” says Ms Callaghan.
“However, both the medical profession and the community need to get better at talking to each other about their care wishes.
“…If we don’t talk to our families and doctors about what we want when facing the end of our lives then they have no information, no guidance, on, which to base decisions they may have to make on our behalf.”
Catch up on Dateline's special Allow Me To Die on SBS On Demand: