Quarterly Essay 57 Dear Life

On Caring for the Elderly

Karen Hitchcock

• Publisher: Quarterly Essay
• Year: 2015
• Print ISBN: 9781863957168
• eBook ISBN: 9781925203189
• Topic: Social Sciences
• Subtopic: Gerontology
• Index: Social Sciences

In this moving and controversial Quarterly Essay, doctor and writer Karen Hitchcock investigates the treatment of the elderly and dying through some unforgettable cases. With honesty and deep experience, she looks at end-of-life decisions, frailty and dementia, over-treatment and escalating costs.Ours is a society in which ageism, often disguised, threatens to turn the elderly into a "burden" – difficult, hopeless, expensive and homogenous. While we rightly seek to curb treatment when it is futile, harmful or against a patient's wishes, this can sometimes lead to limits on care that suit the system rather than the person. Doctors may declare a situation hopeless when it may not be so.We must plan for a future when more of us will be old, Hitchcock argues, with the aim of making that time better, not shorter. And we must change our institutions and society to meet the needs of an ageing population. Dear Life is a landmark essay by one of Australia's most powerful writers.'The elderly, the frail are our society. They are our parents and grandparents, our carers and neighbours, and they are every one of us in the not-too-distant future … They are not a growing cost to be managed or a burden to be shifted or a horror to be hidden away, but people whose needs require us to change …' —Karen Hitchcock, Dear Life 'In Dear Life, Hitchcock has laid out her most important work to date in the type of clear, rational, respectful prose that the topic demands. As much as our natural instinct may be to avert our gaze from death, to push it from our minds at every opportunity, this essay is inspirational and aspirational in its scope. It is highly recommended to all those who hold life dear, and especially to those whose professional lives are devoted to helping us through illness and death with dignity.' —Weekend Australian 'Hitchcock's essay is not comfortable reading, but it is compelling' —Saturday Paper 'One of the most compelling and powerful ever published in the Quarterly Essay series' —Sydney Morning Herald 'A sensitive, rigorous, and moving account that exposes the prevailing ageism in our medical services and in Australian society as a whole.' —Australian Book Review Karen Hitchcock is the author of Quarterly Essay 57 Dear Life: On caring for the elderly, the award-winning story collection Little White Slips and a regular contributor to the Monthly. She is also a staff physician in acute and general medicine at the Alfred Hospital, Melbourne.

SOURCES

Thank you to all of my family, colleagues and friends who shared their stories with me and helped immeasurably with my thinking. I offer my particular thanks to Dr Michael Currie, Dr Lisa Mitchell, Dr Michael Oldmeadow, Leonie Oldmeadow, Professor Paul Komesaroff, Michael Cathcart, Dr James Olver, Professor Alison Mudge and the Feik family for your careful (often repeated) reading of drafts, and for your thoughtful comments. I am hugely indebted to you.

The names and identifying details of the patients mentioned herein have been changed to preserve anonymity. The clinical stories are from public hospitals I have worked in across three states of Australia.

“We elders have learned a thing or two”: Roger Angell, “This Old Man: Life in the nineties,” The New Yorker, 17 February 2014.

“Butler outlines”: Robert N. Butler, Why Survive? Being old in America, Harper & Row, 1975.

“Simone de Beauvoir published”: Simone de Beauvoir, La Vieillesse (The Coming of Age), Gallimard, Paris, 1970.

“The swelling ranks of ‘greedy geezers’”: Linda Marsa, “The longevity gap,” Aeon (online), 2 July 2014.

“One of the most-read articles in the Atlantic”: Ezekiel Emanuel, “Why I Hope to Die at 75,” The Atlantic, October 2014.

“The outcome was a report”: Baroness Julia Neuberger (chair) et al., More Care Less Pathway: A review of the Liverpool care pathway, UK government, July 2013; Raymond J. Chan, Joan Webster, Jane Phillips and David C. Currow, “The withdrawal of the Liverpool Care Pathway in the United Kingdom: What are the implications for Australia?”, Medical Journal of Australia, vol. 200, no. 10, 14 June 2014, p. 573.

“a tick-box exercise”: Margaret McCartney, “Talking about death is not outrageous—reducing it to a tickbox exercise is,” British Medical Journal, vol. 349, 29 August 2014.

“the declaration of futility, is neither simple nor clear”: P.R. Helft, M. Siegler and J. Lantos, “The rise and fall of the futility movement,” New England Journal of Medicine, vol. 343, 2000, pp. 1575–7.

“as in the UK”: Nat Lievesley, Ageism and Age Discrimination in Secondary Health Care in the United Kingdom: A review from the literature, commissioned by the Department of Health, carried out by the Centre for Policy on Ageing, 2009.

“Diligently taking ten different prescribed medications has made them very sick”: David G. Le Couteur, “Pharmaco-epistemology for the prescribing geriatrician,” Australasian Journal on Ageing, vol. 27, no. 1, March 2008, pp. 3–7; Doron Garfinkel and Derelie Mangin, “Feasibility study of a systematic approach for discontinuation of multiple medications in older adults: addressing polypharmacy,” Archives of Internal Medicine, vol. 170, no. 18, 2010, pp. 1648–54.

“a satirical novel”: Samuel Shem, The House of God, Richard Marek, New York, 1978.

“the frail elderly do better in wards dedicated to their care”: Michael A.H. Cohen, “Integrated care results in fewer elderly people dying in hospital,” British Medical Journal, vol. 345, 16 July 2012; Alison Mary M. Mudge, Charles P. Denaro and Peter O’Rourke, “Improving hospital outcomes in patients admitted from residential aged care: Results from a controlled trial,” Age and Ageing, vol. 41, no. 5, September 2012, pp. 670–3; A. Mudge, S. Laracy, K. Richter & C. Denaro, “Controlled trial of multidisciplinary care teams for acutely ill medical inpatients: Enhanced multidisciplinary care,” International Medical Journal, vol. 36, no. 9, 2006, pp. 558–63; L.Z. Rubenstein, K.R. Josephson, G.D. Weiland, P.A. English, J.A. Sayre, R.L. Kane, “Effectiveness of a geriatric evaluation unit: A randomised clinical trial,” New England Journal of Medicine, vol. 311, 1984, pp. 1664–70; I. Scott, “Optimising care of the hospitalised elderly: A literature review and suggestions for future research,” Australia New Zealand Journal of Medicine, vol. 29, no. 2, 1999, pp. 254–63; A.E. Stuck, A.L. Siu, G.D. Wieland, J. Adams, L.Z. Rubinstein, “Comprehensive geriatric assessment: A meta-analysis of controlled trials,” The Lancet, vol. 342, no. 8878, 1993, pp. 1032–6.

“The single most important aspect of care”: C.P. Denaro and A. Mudge, “Should geriatric medicine remain a specialty? No,” British Medical Journal, vol. 337, 12 July 2008.

“One reason aged patients do poorly”: Jan Savage and Cherill Scott, “Patients’ nutritional care in hospital: An ethnographic study of nurses’ role and patients’ experience,” RCN Institute, final report, May 2005.

“inappropriately prescribed far too many drugs”: Denis O’Mahony, David O’Sullivan, Stephen Byrne, Marie Noelle O’Connor, Cristin Ryan and Paul Gallagher, “STOPP/START criteria for potentially inappropriate prescribing in older people: Version 2,” Age and Ageing (online), 4 July 2014.

“Twenty to thirty per cent of all hospital admissions”: Libby Roughead, Susan Semple and Ellie Rosenfeld, Australian Commission on Safety and Quality in Health Care Literature Review: Medication Safety in Australia, August 2013.

“three things the hospital environment specifically hinders”: Alison M. Mudge, Prudence McRae and Mark Cruickshank, “Eat Walk Engage: An Interdisciplinary Collaborative Model to Improve Care of Hospitalized Elders,” American Journal of Medical Quality (online), 22 November 2013; NHS, Five Year Forward View, 23 October 2014.

“hospitals precipitate adverse outcomes”: Morton C. Creditor, “Hazards of hospitalization of the elderly,” Annals of Internal Medicine, vol. 118, no. 3, 1993, pp. 219–23.

“concept of futility”: P.R. Helft, M. Siegler and J. Lantos, “The rise and fall of the futility movement,” New England Journal of Medicine, vol. 343, 2000, pp. 1575–7.

“reams of data show”: Terri R. Fried, John O’Leary, Peter Van Ness and Liana Fraenkel, “Inconsistency over time in the preferences of older persons with advanced illness for life-sustaining treatment,” Journal of the American Geriatrics Society, vol. 55, no. 7, July 2007, pp. 1007–14.

“reams of data”: E.P. Cherniack, “Increasing use of DNR orders in the elderly worldwide: Whose choice is it?”, Journal of Medical Ethics, vol. 28, no. 5, October 2002, pp. 303–7.

“good data on treatments such as cardiopulmonary resuscitation”: S. Cooper, M. Janghorbani and G. Cooper, “A decade of in-hospital resuscitation: Outcomes and prediction of survival?”, Resuscitation, vol. 68, no. 2, February 2006, pp. 231–7; P.S. Chan et al. “Long-term outcomes in elderly survivors of in-hospital cardiac arrest,” The New England Journal of Medicine, vol. 368, 14 March 2013, pp. 1019–26.

“Take, for example”: Louise Aronson, “The human lifecycle’s neglected s...

Table of contents

• Front cover
• QUARTERLY ESSAY 57
• Contents
• Dear Life
• Old and Sick
• Fragments
• Hospital Is No Place for the Elderly
• Best­Laid Plans
• Separate and Solitary
• Death
• We, The Living
• Sources
• Clivosaurus: Correspondence
• Tad Tietze
• Paul Cleary
• Geoff Robinson
• Mark Bahnisch
• Dennis Atkins
• Malcolm Mackerras
• Grant Agnew
• Response to Correspondence: Guy Rundle
• Contributors
• Copyright
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