The inaugural Advance Care Planning Australia conference is underway in Melbourne, hosted by Austin Health. Day one saw a launch by Hon. David Davis MLC, who reflected on the Victorian Government’s support for advance care planning and acknowledged the specific contribution of work focused on increasing the concordance between patient preferences, and the actual care delivered, as a marker of success in end-of-life care.
Presentations from Dr Jeffrey Rowlands and Julie Letts, on the implementation of standardised resuscitation plans in Queensland and New South Wales, were followed by a discussion of legal issues in advance care planning, from Dr Nola Ries and Professor Ben White.
The afternoon session culminated in an informative and entertaining debate on the topic of “Turning Off Life Support – Delivering Death or Delivering Care”. Participants included Assoc. Prof. Lynne Gillam (Uni of Melbourne), Phil Grano (Office of the Public Advocate Victoria), Dr Steve Jacobs and Professor Ben White (QUT). The debaters navigated complex ethical aspects of end-of-life care decision making in rapid fire speeches and rebuttals. Both sides acknowledged a utilitarian view, treating withholding or withdrawal of life-sustaining treatment as ethically equivalent. The main argument was fought out in the territory of causation of, and responsibility for, a patient’s death, due to this withdrawal or withholding. Those arguing the negative (that this is delivering care) contended that the withdrawal or withholding of artificial medical interventions in the context of advanced illness is not causative, and that the patient’s underlying disease process is what ‘delivers’ death. They also drew on the doctrine of double effect, arguing that while death is foreseen in many cases, when the intended benefit of a clinical decision is to relieve suffering and provide care, this is both ethically defensible and morally virtuous. Those in the affirmative (that this is delivering death) argued that there is an inescapable causative link between ‘turning off’, and the other factors that contribute to the patient’s death. They contended that instead of denying this causal influence, we should acknowledge that in some cases dying is a good outcome. Thus while the clinical decision may have ‘delivered death’, this too could be ethically defensible, if it is in line with a patient’s preferences or best interest.
Personally I felt both compelled by the arguments of those in the affirmative, and somewhat intimidated by the implications, which call for a more transparent public discussion about the limitations of medicine and the potential causal role of some clinical decisions in the dying process. This naturally invokes the idea of euthanasia and physician assisted suicide, with the related debate and implications.
The debate was collegial, entertaining and artfully delivered by some fine exponents of moral and clinical ethics. I doubt that I have done justice to the quality of their arguments, but would appreciate the chance to continue this discussion – do you have any comments about this issue from your own clinical practice or experiences? #dyingmatters