By Dr Joseph Hawkins, consultant in palliative medicine Woking and Sam Beare Hospice and honorary consultant at St Peter’s Hospital; Surrey, England
In the steppes of Kazaghstan a very special launch is happening- the British space craft: End of Life Services by Astroscale is due to start its mission of clearing defunct satellites from earth orbit. Whilst reading this tidbit of news1 I found myself idly wondering- what form of advance care planning have they offered these terminally unwell technological marvels? Probably none, I reasoned, after all it is unlikely to have been a module included in astronaut training schemes, indeed it has only recently cropped up in medical school curriculae.
Questions of advance care planning, (ACP), have been with me for many years of conversations with colleagues-more pertinently- the big question: Why isn’t advance care planning done more? After all- it isn’t rocket science.
Amongst those with whom I speak there is acknowledgement that many guidelines exist to make advance care planning easier. However, despite these excellent guidelines there remains a fear of overstating risk or missing a reversible cause that prevents some from feeling comfortable with advance care planning. This ideology confuses the concepts of equality with equity or to put it another way it is like saying that all patients who might have an infection should receive antibiotics, this is an equalitative approach. As physicians we understand that some of those patients will not have an infection and doing so may cause harm-therefore we say that access is not restricted but that some will not benefit and therefore won’t be offered antibiotics; this is a more equitable approach. Or, to put it another way: In clinical practice it is equitable to increase opioids for people with opioid-responsive pain; while not increasing them in others with non-opioid responsive pain… equitable, but not equal.
When discussing this with colleagues reluctant to engage with ACP conversations considering the scenarios that we all too frequently see, with an eye to ethics, may help to provide a format for breaking down barriers for clinician and patient.
An all too common example is: when a health care professional organises for hospital admission despite the patient’s prior wish for the contrary. A justification for this decision for hospital is to protect the next of kin from the reality of death at home, particularly if they are less accepting of death and dying than the patient. This is an example where perceived indirect harm: the distress of carers, is seen as a partial justification to deny the patient’s autonomous right to decline a treatment. This occurs due to unconscious bias trending toward a desire to preserve life despite potential costs or futility and a sense of protecting the many, the wider social network of the patient, over the few-the patient. This utilitarian thinking is limited when considering autonomy of the individual. An advance care plan in these circumstances can pre-empt moments of ethical crisis and future regret in all concerned.
More to follow….
- Metro; news in brief by Metro reporters. 23.3.2021.