Thursday, January 14, 2010

Too Important for Doctors? Who Then?

Peter Beresford has a post up at the Guardian blog that is a mish-mosh of ideas about aid in dying. He writes about the British medical system but as you read this, it might be helpful to ask yourself a few questions about the American medical system:

Why is there a shortage of doctors and nurses?
Why is medical delivery dominated by profit-generating practices before care practices?
Are American doctors compensated with higher or lower salaries than those in other Westernized countries?
Why are doctors not currently reimbursed for end of life care planning?
Who is responsible for discussing end of life care with patients?
And what are the ramifications of neglecting those discussions?
If doctor's shouldn't handle end of life care, who should?
Why is the public so uninformed about what aid in dying really is?
Who are the main opponents of aid in dying?
Why are DNR and living wills often overlooked by doctors?
Why are doctor's palliative skills so variable?
Why does Beresford suggest that regulation and reporting of the use of any aid in dying law will dissipate?
What are the problems in relegating aid in dying to "clinics" or practitioners other than doctors?

The view of GP Ann McPherson, who is herself facing inoperable cancer, that terminally ill patients should be able to turn to their doctor for help in dying, can reasonably be expected to carry weight . But the recommendation of this inspired and committed doctor also needs to be set against the realities of NHS general practice in the early 21st century and our relation with it.

This is no longer the age of Dr Finlay and his casebook. In some GP practices, patients can't even be sure which doctor they will see. You can now expect your GP practice to be an independent business employed by the NHS. Doctors routinely earn six-figure salaries, employ business managers and a range of specialists to fulfil government targets and priorities, and are under-represented in areas of disadvantage. Many GPs contract out out-of-hours home visiting services and, not surprisingly in the current business culture, some are reluctant to take on high cost patients. What managerialist considerations may now enter the arena of choice and decision-making about life? It is difficult to make the "business case" for palliative care patients, but worryingly simple to see the economic advantages of assisted dying. Palliative care patients are time-consuming and their needs complex. Doctors' palliative care skills and commitment are highly variable. All the same problems that people with mental health problems have already highlighted in relation to general practice in terms of its lack of time, social understanding and sensitivity can similarly be seen to apply.

It is difficult to see how GPs will readily find the time for the skilled support and counselling that is likely to go hand-in-hand with having an active role in assisted dying. How can this be squared with 10-minute consultations, declining resources and increasing healthcare pressures with an ageing population? The idealised figure of the family GP is perhaps just another expression of our continuing deference to doctors. They are already powerful enough. Would adding to their power by formalising a role for them in ending life be consistent with the rhetoric of the "active" and "expert" patient, or simply reinforce our traditional passivity? The principle might seem positive, but ultimately it will hinge on the particular doctor. Fine, if it is one who knows the patient and their family well and who avoids easy judgments about quality of life.

We've already seen comparable problems arise in relation to Do Not Resuscitate (DNR) orders and disabled people. GPs, of course, will always be able to say, "I did what the patient wanted". But then, as we have seen with plastic surgery for very young women and early decisions about sterilisation and vasectomy, the patient may not always be in a position to know best. What sort of assumptions might be imported, particularly if there is pressure from the family in the case of someone, perhaps with dementia, living in a care home?

Then there are the practicalities. Will doctors be paid on a per capita basis for assisted dying? Will a new corps of medical specialists develop, or will the job be devolved to some new ancillary role? We can expect pressure for a strict system of checks and balances to operate initially, but how long before this becomes more of a mechanical tick-box exercise and people are more routinely assisted into the next world? Any steps towards legalising assisted dying demand a fundamental rethink of policy and practice. It's time to take this discussion out of an abstract and idealised context and examine it seriously in the real world of modern primary care. It is much too important a matter to be left to medical professionals.

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December 20, 2010 at 10:41 PM  

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