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  Dying by inches Transcript GRAHAM DAVIS: Fahima Sharoubim is 79 and lives in a Melbourne hostel. Her doctors evidently think this Egyptian-born grandmother would be better off dead. For when her family insisted they continue the kidney dialysis on which her life depends, the doctors tried to get a guardian appointed, arguing the treatment was no longer viable. Fahima's the face of a whole new health care dilemma for all of us - just when does life cease to be economically viable? She's still here only because her family fought back, refusing to accept the death sentence the system had passed on her. Do you think your mother would be better off dead, yourself? SOBHY GIRGIS, SON: Oh, that's absolute nonsense. GRAHAM DAVIS: Nonsense? SOBHY GIRGIS: Absolute nonsense. GRAHAM DAVIS: That's what they were saying to you, though. SOBHY GIRGIS: Well, that's absolute nonsense. That's crazy. GRAHAM DAVIS: Fahima's son, Sobhy Girgis, is still incensed at the attitude displayed towards his mother by the Monash Medical Centre. SOBHY GIRGIS: They said the treatment just make her life longer for no use. They said it would be a good idea if we just stop treating her and let her go peacefully. GRAHAM DAVIS: The family sought the intervention of the hostel's priest, Father Daniel Ghabriel, who, before joining the clergy, was a medical research scientist with a PhD in pharmacology. FATHER DANIEL GHABRIEL, COPTIC HOSTEL, NARRE WARREN: When I spoke to them, I asked them for a medical reason why they wanted to end the treatment or cease the dialysis treatment. The only reason they forwarded was she didn't have a sufficient quality of life or prospect of a sufficient quality of life. They weren't able to forward me a medical reason. GRAHAM DAVIS: For its part, Monash refuses to discuss the case, but Sunday has obtained this - its application to the Victorian Civil and Administrative Tribunal for a guardian to represent Fahima's interests. "Due to her medical condition," it says, "dementia and end-stage renal failure, she has deteriorated and is no longer able to return to her hostel." GRAHAM DAVIS: That's not true, is it? FATHER DANIEL GHABRIEL: No. GRAHAM DAVIS: Why did they say it? FATHER DANIEL GHABRIEL: I didn't write it. GRAHAM DAVIS: Because she returned to the hostel, didn't she? FATHER DANIEL GHABRIEL: I think within a few days of that being written. GRAHAM DAVIS: And she can eat? FATHER DANIEL GHABRIEL: She can eat. GRAHAM DAVIS: Communicate? FATHER DANIEL GHABRIEL: With some assistance, she can communicate. GRAHAM DAVIS: And even walk? FATHER DANIEL GHABRIEL: And walk with the aid of a walker, yes. GRAHAM DAVIS: To support its application, the Monash Medical Centre said Fahima's treatment: "Was causing her distress as she'd removed her needles during dialysis three times over the last one to two weeks." SOBHY GIRGIS: If that's true, which I doubt it, that is not an excuse to end someone's life. GRAHAM DAVIS: Yet even more disturbing is evidence that far from being voluntary, what the hospital had in mind for Fahima was against her will. Sobhy, could you ask your mother what her wishes are. Does she want to continue getting treatment? SOBHY GIRGIS: Yes. GRAHAM DAVIS: Yes? SOBHY GIRGIS: Yeah. GRAHAM DAVIS: So she definitely wants to continue the treatment? SOBHY GIRGIS: Absolutely, absolutely. There is no doubt about that one. FATHER DANIEL GHABRIEL: She's expressed no will to end her life to me or that she'd had enough. She doesn't refuse to go to dialysis when it comes about. In some ways she looks forward to going to dialysis. GRAHAM DAVIS: So what steps did the hospital take to establish what the medical profession generally regards as paramount - the wishes of the patient? Well, apparently it engaged its own Arabic translator, who contradicted the assertions of both son and priest. FATHER DANIEL GHABRIEL: I think on one occasion she said, "Enough!" and in my understanding she was just saying she'd had enough for that day and they understood that she'd had enough for ever. GRAHAM DAVIS: It all seems decidedly odd given Sunday's own encounter with Fahima. Elderly? Yes. Frail? Yes. But undeniably still enjoying a quality life. SOBHY GIRGIS: She can enjoy her life as an old lady. She can have her own meal, she can have a talk, she can walk, she can welcome me when I come in to visit her. GRAHAM DAVIS: So she knows who you are? SOBHY GIRGIS: Oh, definitely, absolutely. GRAHAM DAVIS: Small wonder that facing such evidence before the tribunal, the Monash Medical Centre quietly withdrew its application. Did they at any stage of the negotiations mention money? FATHER DANIEL GHABRIEL: They did mention that it was an expensive treatment and I said, "All treatment's expensive." When someone says the treatment's expensive and we want to stop it, you can only come to one conclusion. GRAHAM DAVIS: Dialysis for those whose kidneys can no longer clean their blood is now the main reason elderly people go to hospital. And demand for these machines is expected to triple over the next 20 years as the baby boomers enter the twilight of their lives. It costs $50,000 a year to treat the average dialysis patient. But this is just one component of an all-out assault on health budgets as ageing taxpayers demand the latest technology with scant regard for how much it all costs. Dollar pressures on our public hospitals are nothing new. But today, you'll hear some of the nation's most senior medicos break the ultimate taboo - talking openly about rationing health care. DR BOB WRIGHT, DIRECTOR OF INTENSIVE CARE SERVICES, ST. VINCENT'S HOSPITAL, SYDNEY: We've had such wonderful advances in medicine in the last 30-odd years. But in some ways, some of us are a bit like kids in lolly shops - we haven't got the wisdom to apply it, ah, you know, appropriately. And I think it gets a bit out of hand at times. GRAHAM DAVIS: In what sense? DR BOB WRIGHT: I think we are doing too much for some people. GRAHAM DAVIS: In the age of the ventilator, people can be kept alive almost indefinitely. But the debate doctors want is should they be sent here in the first place? PROF MALCOLM FISHER, DIRECTOR, INTENSIVE CARE, NORTHERN SYDNEY HEALTH: A patient in intensive care, there are three things that can happen. They can get better, they can die, or a third option, which may be the worst, where they essentially become people who exist rather than live. In New Zealand they call them "warm cadavers". GRAHAM DAVIS: And how long do you see people living like this in intensive care units? PROF MALCOLM FISHER: Probably the longest in this unit in recent memory is about 50 days. This person, over the course of his period in the unit, would have made it necessary for us to move sick patients to other hospitals. GRAHAM DAVIS: But this debate isn't just about stopping treatment, but starting it in the first place. The treatment train, let's call it, that sets out once an ambulance is called and wends its way inexorably through the system. It's time, say some, to halt that train for some patients, especially before its final destination. PROF PETER CAMERON, THE ALFRED HOSPITAL, MELBOURNE: The problem is, once they end up in a high-technology tertiary hospital with specialists running around, it's inevitable that they get on a treadmill and they go right all the way down, often end up in intensive care, of all places, you know, with machines that go ping and 20 doctors hanging around them having operations and procedures. And that's just not appropriate for some of these people. GRAHAM DAVIS: Which is why some medicos now think we have no choice but to exclude some patients from intensive care altogether. The most radical proposal comes from a most unlikely source. For more than 30 years, Dr Bob Wright has been head of intensive care at the Roman Catholic Church's St Vincent's Hospital, in Sydney. DR BOB WRIGHT: Intensive care is such a limited resource, I think it's got to be rationed. We're putting so much resource into people with a poor prospect of good-quality survival that people who would benefit more are getting neglected. We've only got a certain number of beds staffed and we can't take your young patient at the moment because to take them we've got to, you know... GRAHAM DAVIS: ... take an oldie off a respirator. DR BOB WRIGHT: Yeah. GRAHAM DAVIS: And how do you feel when you have to say that? DR BOB WRIGHT: Oh, I don't feel happy about that. I think it's not right. But this is something the community and government and health departments have got to talk about. GRAHAM DAVIS: And are they? DR BOB WRIGHT: I think they're going to start after this program. PROF MALCOLM FISHER: Our age population is increasing. It's surviving longer and it's losing its marbles. GRAHAM DAVIS: That debate on patient rights to treatment is already well under way in medical circles, like this gathering of intensive care workers in Sydney. PROF MALCOLM FISHER: Our ICUs are full of old people receiving treatment that would be against their wishes, at the request of their children. GRAHAM DAVIS: But there's frustration here that the nation's intensive care units are being left to make the hard decisions no-one else in the system is prepared to make. PROF MALCOLM FISHER: And maybe it is time for a realistic discussion in society about what people are entitled to expect. But the politicians are certainly not going to lead this because it's something they're very afraid of. GRAHAM DAVIS: With an election looming, we'll test that assertion with Federal Health Minister Tony Abbott as we confront him with the crisis of bed blocking in intensive care. Do you think the frail and very elderly ought to be in there at all? TONY ABBOTT, FEDERAL HEALTH MINISTER: We should do whatever we reasonably can to save and enhance life. I would be shocked if any significant sections of the medical profession were saying that there are some people who shouldn't be treated. GRAHAM DAVIS: Right, well, prepare to be shocked, Minister. We're seeking Tony Abbott's response to this - a discussion paper proposed by Dr Wright, at St Vincent's, that would exclude from intensive care patients with the lowest priority, priority three. Anyone who'd require "high-level organ support or have a low probability of long-term quality survival." DR BOB WRIGHT: Because once you get one of these you're often stuck with them for weeks and that's one of your beds gone. And that ... GRAHAM DAVIS: Bed blocking? DR BOB WRIGHT: That's blocked a bed. GRAHAM DAVIS: So priority three - people with low probabilities of long-term quality survival - are bed blocking in the system? DR BOB WRIGHT: Yeah. Because these people usually take a long time to die. GRAHAM DAVIS: Dr Wright specifically cites as an example "frail elderly patients, especially if there are impaired activities of daily living". Their admissions to intensive care have tripled over the past five years. DR BOB WRIGHT: It's a bit like being a mechanic in a garage, you know, and someone comes in with an old FJ Holden, you know, the tyres are bald, only two cylinders are working, the transmissions gone and the brakes, and they say, "Look, I want you to make a new Commodore out of this," and it just can't be done. You're just doing everything you can to try and keep this machine running and you realise it is an exercise in futility. I don't think it's good for anyone to live longer than they should. You know, I think it's best, if you're going to go, to go quickly and as peacefully as you can. GRAHAM DAVIS: This is what he had to say about it. So what does Tony Abbott think about these comments from a senior clinician in one of the Roman Catholic Church's most prestigious hospitals? We played him extracts of what Dr Wright had to say about category three patients blocking the system: DR BOB WRIGHT: And every intensive care in the country you'd go around and find one or two patients in this category, sometimes more. GRAHAM DAVIS: One or two in a ward of how many people? DR BOB WRIGHT: Oh, there might be 10. GRAHAM DAVIS: So two out of the 10 of those people shouldn't be there? DR BOB WRIGHT: Well ... GRAHAM DAVIS: Sometimes? DR BOB WRIGHT: With the gift of hindsight, yeah. GRAHAM DAVIS: How get you get rid of them? DR BOB WRIGHT: That's the first thing. You have to get medical agreement. And often ... GRAHAM DAVIS: You're talking here about topping somebody though, aren't you, effectively, because most of the time when you take them off the respirator ... DR BOB WRIGHT: No. We're talking about stopping treatment that in retrospect might have been inappropriate. GRAHAM DAVIS: The effect is the same though, isn't it, once you take the person off? DR BOB WRIGHT: What we're doing is letting nature take its course. GRAHAM DAVIS: For a Federal Minister and one with a strong Roman Catholic belief, what do you think about that? TONY ABBOTT: Let's leave religion out of it. Let's just talk about ordinary human ethical standards. Decisions are often made to turn off life support machines but they should only be made not just on the basis of a medical consensus but on the basis of a family decision and, if possible, informed input from the patient. GRAHAM DAVIS: The problem is that with many patients in no condition to provide informed input, their families are often not only grief-stricken but divided, fractious and even belligerent. DR GIDEON CAPLAN, GERIATRICIAN, PRINCE OF WALES HOSPITAL: What people often say is, "My brother is a lawyer", or, "I'm a lawyer", "My brother is a barrister". They threaten you with a lawsuit to try to push through treatment which they know is of no benefit. Sometimes family members disagree about that treatment and we've seen cases in the hospital sometimes where different family members come to even blows, physical blows, over the patient's bed, because they disagree about what treatment they want the person to have. GRAHAM DAVIS: Full-on fisticuffs? DR GIDEON CAPLAN: Yes, yes. GRAHAM DAVIS: But while this is mercifully infrequent, there is an assertiveness in the community when it comes to treatment that previous generations would have regarded as unthinkable. PROF MALCOLM FISHER: When I went to medical school patients and the families were expected to do as they were bloody well told. GRAHAM DAVIS: And they don't any more? PROF MALCOLM FISHER: No. And we enjoy intelligent consumers who we can have a reasonable and rational discussion with, but ... GRAHAM DAVIS: But not pig-headed ones? PROF MALCOLM FISHER: It is not always reasonable and rational. GRAHAM DAVIS: The blame for that can be partly sheeted home to television, the medical soap opera shattering the image of doctors as gods and promoting the notion of the miracle cure for every ailment. Even so-called reality television with a medical bent doesn't necessarily reflect the real world of a hospital. SAMANTHA FAITHFULL, NURSE UNIT MANAGER, INTENSIVE CARE, ST. VINCENT'S: A lot of people take everything that's on those programs as gospel and they believe everything that is on them. GRAHAM DAVIS: But these programs have produced a nation of sofa surgeons and nurses, yeah? SAMANTHA FAITHFULL: Yes, they have. GRAHAM DAVIS: People who think they know. SAMANTHA FAITHFULL: Sometimes, yes. GRAHAM DAVIS: But don't? SAMANTHA FAITHFULL: Yes. PROF MALCOLM FISHER: It's not uncommon for them to come in with some article they got from the Internet to say that the doctor said, "My uncle had no hope. He was a coma for 15 years and now he's just translated Lord of the Rings into Sanskrit." GRAHAM DAVIS: And it's invariably in extremis, in intensive care, that family expectation that everything be done collide with the brutal dispassion of a system under intense pressure. PROF PETER CAMERON: There are various cultural groups that are more inclined to not want to relinquish life. I guess the Jewish community is probably the most prominent in that group. GRAHAM DAVIS: Right. So they insist on everything being done, generally? PROF PETER CAMERON: Not all in that community, but some in that community. DR BOB WRIGHT: This is the group in our hospital who are least inclined to let the relatives go, you know, withdraw treatment and let them fade away. GRAHAM DAVIS: But they are insistent you do everything possible. Is that what you are saying? DR BOB WRIGHT: Quite often. GRAHAM DAVIS: And how do you feel about that? DR BOB WRIGHT: Well, we have to go along with it. GRAHAM DAVIS: But you're not happy about it? DR BOB WRIGHT: No. GRAHAM DAVIS: If the Jewish community is notable for often insisting on extreme measures to maintain life, other Australians are notable for being sanguine in the face of death. PROF PETER CAMERON: If you had to sort of pick out a group, it would be probably be the rural people, who are farmers and so forth, who are used to seeing livestock living and dying and so forth, so they have a very realistic view of life and death. I think one of the problems in the sort of highly refined urban community is we just don't see life and death and so when it hits us we have trouble dealing with it. DR BOB WRIGHT: It's not only a good thing for Bluey to go, but it's good for the family as well because there's nothing worse than families having to set up camp in intensive care and every day seeing this dismal scene of the relative dying by inches. It's a horrible way to go. GRAHAM DAVIS: But it's Dr Wright's comments about some city folk that have him on a collision course with much of the community, not least the hospital which he has faithfully served for three decades. St Vincent's is run by the Roman Catholic order the Sisters of Charity, whose specific mission statement is to provide health care to all who seek it, especially to the poor and disadvantaged. Dr Wright says it may be time to consider not allowing into intensive care people with a certain lifestyle, right? This is what he had to say: DR BOB WRIGHT: Cynics would say the average St Vincent's patient, in the public hospital, is a heavy-smoking alcoholic drug addict who's got HIV, and schizophrenic, and there's an element of truth in this. And they also get in a lot of trouble because they're the ones that walk in front of buses and, you know, fall over all the time, so they do, you know, provide a fair bit of work for the hospital. GRAHAM DAVIS: What should we be doing with those people ... DR BOB WRIGHT: Well ... GRAHAM DAVIS: ... when it comes to your rationing plan? DR BOB WRIGHT: Well, they're tending to slip into category three, aren't, they? Priority three. GRAHAM DAVIS: Right. People that shouldn't be in intensive care? DR BOB WRIGHT: Well, while there's other people we feel we can do more good for, yeah. GRAHAM DAVIS: Would you agree that's a pretty remarkable thing for Dr Wright to have said? TONY ABBOTT: Graham, I've got to say I am very uncomfortable with the concept of the deserving and undeserving sick. GRAHAM DAVIS: Drug addicts with HIV, heavy smokers, alcoholics - should they be at the bottom of the pile when it comes to intensive care? TONY ABBOTT: That is not a decision I would be comfortable with. GRAHAM DAVIS: Right. So everybody is entitled to be treated equally? TONY ABBOTT: That's got to be the start-off point for all decisions in hospitals. GRAHAM DAVIS: If the Federal Health Minister is uncomfortable, those who'd find themselves designated in category three under the Wright proposal are close to apoplectic. In part two - where a brave new world of rationing could leave the very sick, like Bruce Ellison. Part 2 BRUCE ELLISON: Where do they propose to put us? On a garbage dump? GRAHAM DAVIS: No, you would go to the ordinary wards, or be encouraged to "be made comfortable", as they say, at home. BRUCE ELLISON: So, in other words, euthanased. And we call this a modern, caring society? Give us a break! GRAHAM DAVIS: In the game of life, Bruce Ellison has been dealt a poor hand. He has muscular dystrophy, sleeps only with the aid of a respirator. But each year marks another milestone in his struggle to beat the odds. I first met Bruce 11 years ago when I did a similar report for Sunday. Even then his was a remarkable story. BRUCE ELLISON: I was rushed to hospital unconscious, almost dead. My lungs had packed up. I remember waking up with a tube intubated down me mouth and being told that, you know, you're not going to last long because you've got weak lungs. DR MALCOLM FISHER, DIRECTOR, INTENSIVE CARE SERVICES, NORTHERN SYDNEY HEALTH: At that stage we didn't think we'd get him off a ventilator. He was unable to breath and should he have been left without artificial ventilatory support for any length of time he would have died. BRUCE ELLISON: They said, "You're not going to leave here. We'll make your life as comfortable as possible and if there's any complications, we'd have to think of," you know, "giving you something to ease your pain." GRAHAM DAVIS: Did that mean killing you off? BRUCE ELLISON: Well, I suppose, in brutal terms, yeah. GRAHAM DAVIS: How did you feel about that? BRUCE ELLISON: Oh, I wasn't very impressed. GRAHAM DAVIS: Bruce was in the intensive care unit of Sydney's Royal North Shore Hospital. Then, as now, Professor Malcolm Fisher was in charge. BRUCE ELLISON: At first I was very shocked and upset because he said it in a very straight manner. GRAHAM DAVIS: What? He said ... BRUCE ELLISON: We'll give a lethal dose of morphine to make your life ... to end it. GRAHAM DAVIS: He said that to you? BRUCE ELLISON: Yeah. And I was upset at first, but then I thought, "Well, bugger him, I'm not going to let him have the pleasure of that." GRAHAM DAVIS: He says you offered a lethal dose of morphine. DR MALCOLM FISHER: No. That's not ... Memory, or the stress of the occasion, that's a slight misinterpretation. The process would have been that he would have been taken off the artificial form of life support, being that that was, you know, inappropriate. If he had become distressed then we would have given him morphine to treat his distress. GRAHAM DAVIS: Right. The result of giving him morphine, though, would have been to depress his breathing. DR MALCOLM FISHER: Yeah. GRAHAM DAVIS: And he would have died. DR MALCOLM FISHER: Yes. GRAHAM DAVIS: But by resisting any suggestion that his life be ended, six months later Bruce had moved from hospital to nursing home. And we were all able to reflect on the extraordinary ethical dilemmas his case presented. BRUCE ELLISON: I can remember quite clearly you said you're quite happy to give me a painless end. DR MALCOLM FISHER: Yeah. BRUCE ELLISON: And I wasn't quite prepared to accept that. GRAHAM DAVIS: Even then, Bruce was only too aware of his status as a bed blocker in the system. BRUCE ELLISON: At one stage I felt like they were sitting over the edge waiting for me to give in. GRAHAM DAVIS: Like vultures? BRUCE ELLISON: Yeah, yeah, like vultures sitting on a cactus. GRAHAM DAVIS: Waiting for you to give in and free up a bed? Is that it? BRUCE ELLISON: Yeah, basically, yeah. GRAHAM DAVIS: And Professor Fisher was remarkably candid for a clinician in parading his priorities in public. BRUCE ELLISON: I have never said to a patient, "We can't afford to continue this treatment for you." I am cognisant of the fact that I have to run a budget and to try and have a unit that stays on budget. GRAHAM DAVIS: The same dilemmas face the same man in the same job more than a decade later. DR MALCOLM FISHER: Bruce was offered a choice, and Bruce said, "Treat me," and Bruce was treated, and with consummate nursing skill. Bruce was unable to get off or get to a stage where he was not critically ill, and then options were found which have enabled Bruce to live another 12 years. GRAHAM DAVIS: One of those options came courtesy of Cupid. Bruce fell in love with his carer, Ursula, and was able to leave the nursing home and move into her house. BRUCE ELLISON: Without Ursula's support and friendship I don't think I'd be here today, and her willingness to share her life with me and that we've been able to have a very good quality of life. URSULA HEFFERNAN: He's got so much to live for. He's got a fabulous family. He's got a good life here. He enjoys his bridge. He loves the computer, television. We go out. GRAHAM DAVIS: And he's got you? URSULA HEFFERNAN: He's got me, yes, and I've got him. I don't know what I'd do without him, honestly. GRAHAM DAVIS: More than a decade of quality living thus far, only because Bruce refused to enter death's door when it was opened for him. URSULA HEFFERNAN: When we were told 11 years ago that he probably would be better off dead, I told Malcolm Fisher that he wasn't God and he didn't know everything. GRAHAM DAVIS: What do you think of Malcolm Fisher and the system now? URSULA HEFFERNAN: I think Malcolm Fisher's great. He's learned a good lesson. I think he'd agree. GRAHAM DAVIS: There's no rancour. Far from it. Doctor and patient are still in regular contact and still sporting enough to canvas publicly the issues at the core of this debate. As they get together again I am reminded of something Malcolm said 11 years ago: He wants to live to see the Olympic Games. Can he? DR MALCOLM FISHER: I don't think he can but I would be happy to push his wheelchair. I'll shout him a ticket to the opening ceremony. BRUCE ELLISON: You're on! GRAHAM DAVIS: And you made the Olympics after all? BRUCE ELLISON: Yeah, and the next ones. GRAHAM DAVIS: Did Malcolm Fisher ever give you the tickets he was promising you? BRUCE ELLISON: No, he didn't, but I think it was by a mutual agreement. We decided it was too expensive when I'd rather watch the opening ceremony at home on TV - it's more comfortable. GRAHAM DAVIS: I guess you guys didn't expect to be here today? DR MALCOLM FISHER: No. It was not something I would have predicted. BRUCE ELLISON: Well, I'm glad I'm still here. DR MALCOLM FISHER: So am I glad he's still here, and I'm still here. GRAHAM DAVIS: Malcolm, do you feel any sense of professional embarrassment you got it so wrong? DR MALCOLM FISHER: No. I don't think we got it wrong. We offered Bruce a choice. GRAHAM DAVIS: Do you wonder what might happen to somebody who wasn't quite as assertive as you under the circumstances? BRUCE ELLISON: Not only do I wonder, I've actually seen people with my condition that have been into the medical system and haven't pushed their way around as much as I did, and they're not here. GRAHAM DAVIS: But Bruce won't be here either if we ever accept the proposals from Dr Bob Wright at St Vincent's in Sydney. Never mind the very elderly and very frail - Bruce also falls into priority three - those who wouldn't make it to intensive care, where his life was saved in the first place. In this brave new world of priorities Bruce wouldn't be alive, would he? DR MALCOLM FISHER: It's the crippled, the old, the addicted, the mentally infirm and the chronically ill who will suffer from medical rationing. There is no question. And the poor. GRAHAM DAVIS: So Bruce Ellison is a pretty good embodiment of the dilemmas we face in this debate? DR BOB WRIGHT: I think we're forced into it unless suddenly there's enormous funds given for health care, which is not going to happen. GRAHAM DAVIS: No. This is the debate we have to have. DR BOB WRIGHT: It is. It has reached the stage where something has to be done. GRAHAM DAVIS: Already, according to Dr Wright, patients with a better prospect of long-term quality survival die because they cannot get into intensive care. DR BOB WRIGHT: Any inappropriate person keeps out someone who you can really do something for. For example, some young breadwinner who has had a motor vehicle accident who has trauma and that sort of thing and you really feel you can put them back on their feet and they'll be able to go back and look after their family, but we can't fit them in. GRAHAM DAVIS: So where do they go? Well, to other parts of the hospital, with less sophisticated equipment and fewer nurses per patient. DR BOB WRIGHT: Well, one nurse may have to look after six, on an average, but in some hospitals and situations it can be more. GRAHAM DAVIS: Well, are there instances where people who should be in intensive care get, you know, six-on-one treatment and die because of that? DR BOB WRIGHT: Look, I don't think it's common, but it does happen, I think. GRAHAM DAVIS: But if the normally healthy are to get preference in intensive care, Bruce is in no doubt what it would mean for him - certain death, if his health suddenly declines. BRUCE ELLISON: You know, I thought the whole thing of our health system and our society was that euthanasia was considered illegal. GRAHAM DAVIS: Look, they're not calling it euthanasia. BRUCE ELLISON: They call it whatever they like. But the essence of the matter is they're asking for you to be left to die. GRAHAM DAVIS: But this is not euthanasia, says Dr Wright. Far from it. It's withdrawal of active treatment rather than intervention to hasten death. And however unpalatable, it must be debated if the community continues to insist on the latest and costliest treatments. DR BOB WRIGHT: The things that we artificially did to the patient, like putting them on a breathing machine, or giving them dialysis or certain drugs that we're using to keep the circulation going, yes, we can withdraw those. GRAHAM DAVIS: And when you withdraw them, that person, invariably, in the state that they are in, in this place, they die, don't they? DR BOB WRIGHT: Not invariably, because sometimes you're wrong, because... GRAHAM DAVIS: But mostly? DR BOB WRIGHT: Nearly always. GRAHAM DAVIS: It was what was offered to Bruce Ellison 11 years ago. BRUCE ELLISON: People in my condition would be the first ones jettisoned out of the system. GRAHAM DAVIS: And what he feared back then he fears even more now. BRUCE ELLISON: I would find it criminally reprehensible of the medical system that they would say, deny me the choice, or the opportunity, especially in a public hospital. GRAHAM DAVIS: This, of course, is only a discussion paper for the NSW Health Department, not a policy document. But the bureaucrats baulked at such a radical proposal. DR BOB WRIGHT: Well, they thought it was a bit too much of a hot potato at that time. GRAHAM DAVIS: In what sense? DR BOB WRIGHT: Well, it's talking about rationing, but it's the nettle that we have to grasp. TONY ABBOTT: He's a very passionate and sincere man, obviously, and he's entitled to an opinion. GRAHAM DAVIS: Do you agree with him or not? TONY ABBOTT: No, I don't. GRAHAM DAVIS: Under any circumstances? TONY ABBOTT: Well, I'm very uncomfortable with the proposition he's put forward. GRAHAM DAVIS: It's not on. TONY ABBOTT: In the context of Australian public hospitals in peace time, I would find it a very difficult and uncomfortable concept. GRAHAM DAVIS: You've said some pretty controversial things today. Do you expect to be whacked for it? DR BOB WRIGHT: I hope not. Because I think a lot of my colleagues would feel exactly the same. GRAHAM DAVIS: They do? DR BOB WRIGHT: Yeah. And he's really in good shape, considering his age. GRAHAM DAVIS: Colleagues like Samantha Faithful, Nursing Unit Manager at St Vincent's intensive care. SAMANTHA FAITHFUL, NURSE UNIT MANAGER, INTENSIVE CARE, ST. VINCENT'S HOSPITAL: I think that it is time given that we have such a shortage of beds. GRAHAM DAVIS: Who should miss out? SAMANTHA FAITHFUL: I think that it is a very hard question. People who need a lot of support, who need a lot of resources, who are perhaps at the end of their life. GRAHAM DAVIS: And lest it be thought that St Vincent's team is out on a limb, dwindling resources have made talk of rationing a dinner party staple in the medical profession. What do you think of Bob Wright coming up with a discussion paper like this? It's dynamite, isn't it, really? DR PETER CAMERON, ALFRED HOSPITAL, MELBOURNE: I think it's fantastic. I think someone needs to get out there and say these things. GRAHAM DAVIS: What? That certain categories of people shouldn't be treated? DR PETER CAMERON: I think you need to put that out for debate and get the community to talk about it. I don't agree with it, but I think it's important that someone says that. GRAHAM DAVIS: Hospitals are now looking for creative ways to prevent inappropriate admissions, and they're putting a lot of faith in what are called "advance care directives". These define in advance what kind and how much treatment patients want in the event of a life-threatening illness. DR GIDEON CAPLAN, GERIATRICIAN, PRINCE OF WALES HOSPITAL, SYDNEY: The Advance Care Directive covers the whole spectrum of treatment, from what kind of feeding do you want - do you want to have tube feeding? And that can be very onerous on people too because it often means that people have to be restrained, in other words, have their hands tied so they don't pull the tube out, through whether they want to have intravenous fluids, intravenous antibiotics, whether they want to have surgery. GRAHAM DAVIS: It's portrayed as an act of choice, even if many hard-pressed clinicians are bound to prefer the elderly and frail to have said no to extreme intervention. DR BILL SILVESTER, DIRECTOR, 'RESPECTING PATIENT CHOICES', AUSTIN HOSPITAL, MELBOURNE: It alarms me that people would think that the prime motivation of this program is to try to save resources. GRAHAM DAVIS: Why would it alarm you, given the pressure on intensive care resources? DR BILL SILVESTER: But that's not what the program's about. It's about providing a higher quality of care and respecting the autonomy and respecting the wishes of patients. GRAHAM DAVIS: Yet even given the sensitivity, it's clear that advance care directives have great bottom-line benefits for hospitals. DR GIDEON CAPLAN: The number of bed days occupied by nursing home residents at Prince of Wales and St Vincent's has decreased by about 5,000 a year, which equates to over half a ward. GRAHAM DAVIS: How much in monetary terms has that saved the system? DR GIDEON CAPLAN: We would estimate, on a back of the envelope calculation, that we are saving over $2 million a year. MEAGAN-JANE ADAMS, 'RESPECTING PATIENT CHOICES', AUSTIN HOSPITAL, MELBOURNE: Have you ever talked to your family about what choices and medical decisions you might want in the future? BRIAN CARLTON: My family, my daughter especially, she's a medical power of attorney. MEAGAN-JANE ADAMS: Good. BRIAN CARLTON: And she knows exactly my wishes as far as if I got to the situation where I couldn't communicate with anybody at all. GRAHAM DAVIS: In Victoria. they're calling it "respecting patient choices", and whatever the economic benefits, there are distinct pluses for individuals like Brian Carlton, who's about to sign one specifically ruling out extreme intervention. BRIAN CARLTON: Well, to put it bluntly, Graham, I'm going to say pull the plug. In other words, don't let me continue on and have no quality of life whatsoever and being unable to communicate or unable to recognise people. I have seen it here in our nursing home and it's just not on as far as I'm concerned. GRAHAM DAVIS: You'll die here? BRIAN CARLTON: Yes, of natural causes. GRAHAM DAVIS: Happily? BRIAN CARLTON: Yes, I would. I mean, I suppose I've got to look at it, Graham, that I've had 81 years of excellent life. I've had a pretty good innings and I don't want to go off tomorrow or anything like that, I hope to stay for quite some time. I mean, I'm telling people what I want and I want my wishes to be respected. GRAHAM DAVIS: Four years ago, Brian lost his wife, Peg. They'd been happily married for 54 years. What sort of a death did she have? BRIAN CARLTON: Very nice, very nice. Very peaceful, and fortunately it went quite OK. She passed away very, very peacefully. GRAHAM DAVIS: And what kind of death would you like? BRIAN CARLTON: Well, I'd like the same, to be quite truthful. To die in your sleep, I think, is one of the good things. GRAHAM DAVIS: Brian belongs to a generation schooled in the dictum that doctor knows best. Would you always take their advice? BRIAN CARLTON: Well, they're the experts. GRAHAM DAVIS: They sometimes get things wrong though, don't they, Brian? BRIAN CARLTON: Yes, everybody gets something wrong at some time or other. But in situations like that you've got to go by what they say. GRAHAM DAVIS: But if Bruce Ellison had done that, he'd have been dead long ago. BRUCE ELLISON: They said I only had three weeks to live, at North Shore, and that I'd never leave that ward. Well, 11 years later, I am out of that ward, and I'm here, and I feel healthier now than I did then. GRAHAM DAVIS: In your own home. BRUCE ELLISON: Yeah. GRAHAM DAVIS: In a partnership with a lady. BRUCE ELLISON: Yep! GRAHAM DAVIS: And enjoying life? BRUCE ELLISON: And enjoying life, that's exactly right. GRAHAM DAVIS: But now Bruce's future looks grim. An aging population, a shrinking tax base, politicians who promise tax cuts and sacrifice services for those who need them most. Will he still be here next time I come calling? Well, who knows. However determined he might be to live, the threat to Bruce is no longer just medical, but economic as well. BRUCE ELLISON: I think there's more trouble in the health system than there was 11 years ago, and I'm sure there's more threat. And we call this a modern, caring society. Give us a break! Click here for a printer-friendly version. |
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