The historical Buddha first witnessed the suffering of the real world when he saw a birth, an old person, an ill person and a dying person. He realised that suffering arose out of those conditions and our response to them.
He would spend many years leading a life of extreme deprivation and asceticism, only to discover that the suffering in his life had not been transformed or ameliorated. A point came in which he determined that he would sit and meditate and not cease until his enlightenment. And so, after many years of meditation, it came to be.
Given that we cannot change the reality of the existence of such life circumstances, we are left with our response to them. As doctors, we spend our working lives fighting the effects of an aging body, or aging mind.
We identify illness, choose the most appropriate treatment, and institute it. We also have a real awareness of the inevitable march of time, of the inevitable effects of aging and disease progression. So hopefully this brings us a sense of proportion in the way that we treat patients’ conditions.
The twentieth century brought inconceivable advances in medicine, and public health, that almost doubled life expectancy. Infectious diseases and acute bacterial illnesses were a scourge of a century ago. That we have overcome many of them is a testament to modern medical knowledge and advances in living conditions.
A consequence of such advances, however, is that chronic, degenerative and incurable conditions play a larger role in our lives, especially for the elderly.
Increasingly in Emergency Departments, I see patients with what amounts to a deterioration of a chronic condition, or multiple chronic conditions. I find myself treating the aggravating factors, but without any real expectation of improving quality of life.
Of course, one is free to live with whatever quality of life one chooses, and medical outcomes are very difficult to predict, but many patients are not free to choose.
Some deeply unconscious patients, or patients mute with dementia, have come to me in the Emergency Department, purportedly for life-saving treatment. Sometimes they arrive from nursing homes after years of incapacity.
Often the nursing homes are simply responding to the requests of family or the patient’s local doctor. Sometimes, because there is no ‘living will,’ they are obliged to seek further treatment.
Sometimes also, the intent is for patients to receive palliation and to die in hospital. I genuinely feel that emergency treatment or dying in hospital is sometimes appropriate; but that for many patients, transfer to an unfamiliar, sterile and strange environment does not serve their interests well.
Obviously we live in an era where the extended family is no longer the norm. We don’t care for our family members at home when they are very ill. And, by and large, they do not die with us at home. Death has become a distant event for us, institutionalised and hidden away.
This makes it harder for us to feel comfortable dealing with such issues at home. And that is why, I feel, a societal shift in thinking needs to occur in which we see death as a natural event, and engage with it meaningfully.
There is, I believe, a real alternative for the ill which has been little explored in this era of medical intervention, high technology and institutionalisation of the elderly. There could well be more support of residential care facilities to provide simple medical treatment or palliation where appropriate. This can be said of support to families also.
Another great need is for living wills, or medical powers of attorney, to become widespread. This would help prevent unnecessary or unwanted transfer to hospital, or active treatment, or resuscitation.
We should be more willing in Emergency Departments to discuss resuscitation issues very early with patients, even if not seriously unwell. It helps to normalise the issue, and often patients give vent to something they have wanted to discuss for a long time.
I often see great relief in patients who have the opportunity to talk about the issue of resuscitation, yet just as often see patients who are obviously thinking about it for the first time in their lives. The consequences of having no plan, I feel, are too great to simply ignore through one’s life.
I tell my patients that, even at a mere 38 years of age and feeling perfectly fit and well, I myself have a living will. Simply because the issue is too important to leave to chance or to strangers who do not know my wishes with regards to resuscitation.
Any one of us could die at any time, I tell them, and though unlikely to occur, serious illness demands very important decisions. A medical power of attorney allows one to specify treatment, thresholds for withdrawal of active treatment, resuscitation wishes, and even religious observances in one’s last hours or days.
You might well ask yourself if you would be happy being allowed to die if in a persistent vegetative state, or on the contrary kept alive in the same situation. And if you were suffering a catastrophic stroke and unable to communicate but were aware of the world around you, would you want blood transfusions, antibiotics, surgery?
The potential questions are endless but the general principles of care can, I believe, be readily clarified in most people’s minds.
This article was originally published in Mandala. It is republished with permission. Follow the Emergency Buddhism series on ehospice.
Brett Sutton is an Australian doctor who is the Regional Disease Surveillance Coordinator for the International Rescue Committee, Kenya & Ethiopia.
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