AMA Transcript - Advance care planning

JUSTIN SMITH: There was an important discussion that took place at Westmead Hospital yesterday. It was the discussion focused on geriatric medicine. And top surgeons were urging their colleagues to carefully think about how they treat ailing and ageing patients. As in, is it worth going that extra yard to treat the person - or to carry out surgery on the person - when they are already in very advanced years?

Professor Brian Owler is the President of Australian Medical Association. He's on the line. Hi Professor.

BRIAN OWLER: Good afternoon.

JUSTIN SMITH: We saw a lot of comments coming out of this yesterday and most of them seem to, on the surface, be rather cold towards people. Well, what did you think?

BRIAN OWLER: Well, look, I don't think it's cold - I think this is a conversation that we need to have as a community. Because there is an awful lot of our resources used in the last, very last months of life.

And this amounts to what we call futile care. So it doesn't come down to age necessarily, although elderly patients would be more frequently in this group. But sometimes procedures and treatments are conducted on patients, often because they don't have the ability to say for themselves whether or not they would want to have this treatment. But it's done because people feel like it's the right thing to do. And we're, of course, always trying to prolong people's life and when an individual patient is in front of you, it's very hard to say no.

But we know that, I think, there are a lot of patients who, if a discussion could be had, would probably opt, if they were able to, not to have that procedure. And I think as resources in the system are scarce - it's not about saving money - but when we're using scarce resources, we need to be thinking carefully about how we use those resources, and some of these treatments that can be classified as futile is the sort of treatment we need to think twice about.

JUSTIN SMITH: Brian, to cut through this, we're talking about a resources issue here, or is it because of the welfare of the patient? Or a combination of the two?

BRIAN OWLER: Well, I think it is a combination of the two. And, you know, one of the problems that we have, as I say, is that many people haven't had a conversation with their relatives about what they would want to be done in particular circumstances.

So there's a real role here for what we call advance care directives. And these are plans made by people when they're well, when they're able to make decisions. It may be about a disease that they have and what the end result might be. About, you know, how much surgery, how much chemotherapy, or other types of treatments, they should have or when they might want to say, okay, enough's enough.

And so, having that conversation with family up front, and really having an advance care directive in place for some people, is a very important step and allows us to not to necessarily go the whole hog in treating patients with these sorts of illnesses.

JUSTIN SMITH: You know, a lot of this is down to the individual professional, down to the individual surgeon, some of them will never give up. They will fight and fight and fight. And others will see the futility in it.

BRIAN OWLER: Well, that's right. I mean, look, I've used an example today in the discussion at Parliament House about a patient who was 93 that I got asked to see with a malignant brain tumour.

Now, that patient, you know, was confused, she's 93. It would be inappropriate for me to go ahead with a big operation for that patient. Or even giving them radiotherapy. That's the sort of thing that unfortunately, you know, we shouldn't really treat. We should be trying to make that person comfortable, they've had a good life, and we're not going to really extend it by very much - if at all - by doing the treatment.

And so, you know, putting them through a big operation - it's probably not in their best interests. And so sometimes we need to make sure that we take a step back, we say right, what's in the best interests of this patient?

And I agree, for individual doctors - particularly surgeons - very hard when you've got a patient in front of you. The relatives are keen for everything to be done. But sometimes you just have to say, look, that's not appropriate for the patient.

And we need people to be having this conversation over the kitchen table, with their families discussing, you know, what in this sort of circumstance, what would you want to be done? Would you want to be in ICU with tubes? Would you want a big operation? Because it's so much easier to have that conversation when people are clear-minded, when they're well, rather than in the emergency room or at the bedside when someone's in urgent need of treatment.

JUSTIN SMITH: Professor, thanks very much, appreciate it.

BRIAN OWLER: Pleasure.

JUSTIN SMITH: Professor Brian Owler, who's the President of the Australian Medical Association.

21 August 2015

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