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End Of Life
<p>Ella Rubeli/The Global Mail</p>

Ella Rubeli/The Global Mail

THE WAY OUT: Friday morning traffic in the Intensive Care Unit of John Hunter Hospital.

What Happened To Going Out In Style?

In a single generation the way we die has changed beyond recognition. Do we want to live longer if it just means more old age?

IT’S FRIDAY MORNING at Newcastle’s John Hunter Hospital and intensive-care doctor Peter Saul is on the phone to a surgeon, advising him how to deal with 87-year-old Charlie*, who is trying to kill himself. The overdose Charlie took yesterday didn’t work and now, after stabbing himself several times with a kitchen knife, he is in a critical condition. The surgeon is calling to ask Saul whether he should overrule Charlie’s wishes to die and try to sew him up.

“He doesn’t want to take any medication,” the surgeon says.

“He doesn’t want to have a blood transfusion… he doesn’t want to go into ICU [intensive care unit], he never wants to be ventilated…”

<p>Ella Rubeli/The Global Mail</p>

Ella Rubeli/The Global Mail

Dr Peter Saul

One after another, the surgeon’s heroics cards are trumped, and the thought of breaking the life-saving mantra drilled into him since his university days has him huffing into the phone.

Saul puts down the phone and tells The Global Mail, “This old guy is terrified that he’s going to end up in a nursing home — which he will — so he’s trying to kill himself rather than have that outcome."

Charlie also doesn’t want to end up in ICU, that section of the hospital that increasingly lives up to its nickname, “the departure lounge”. Spending your last days in ICU, as one in 10 Australians do, means dying in an unfamiliar bed at the flick of a switch, while tethered to a feeding tube, a dialysis catheter and a breathing machine — “machines that go ping” Saul calls them. Most of us don’t want to end up in this situation.

In today’s developed world, dropping dead, dying in your sleep or being defeated by an infectious disease is unusual. The healthier and longer we live, the longer it takes us to die. Dementia is the third leading cause of death in Australia, and it takes, on average, seven years for a person to die of it.

<p>Ella Rubeli/The Global Mail</p>

Ella Rubeli/The Global Mail

One nurse takes records as the other two do the ward rounds. Immobile patients must be turned regularly to prevent bedsores.

John Hunter Hospital provides care for the densely populated region of Newcastle and the Lower Hunter Valley, on Australia’s east coast — an area the geographical size of England. Half the deaths in the Lower Hunter occur within the walls of this hospital, Saul says.

He tilts his head behind him towards the maze of fluorescent-lit corridors that branch off towards acutely ill patients in curtained cubicles, all in a state of collapse, strung up to tubes like marionettes. It’s a scene repeated in every other large hospital in Australia. In fact, most hospitals in the developed world look like this. Increasingly, the beds are occupied by patients who have lived very long lives and whose bodies and minds are only slowly dwindling. Our extended life expectancy has brought with it a new condition that doctors, patients and families must cope with together. It is not a disease, but a combination of the symptoms of ageing and a variety of medical problems: frailty.

Saul emphasises that greater longevity just means more old age, not more youth. Before antibiotics, the ‘Father of Modern Medicine’, Sir William Osler, described pneumonia as ‘the old man’s friend’, because it allowed death to come quickly and helped the elderly avoid other illnesses that would cause a more painful or drawn-out demise.

In the past 100 years of medical progress in developed nations, doctors equipped with life-prolonging technologies have changed the very nature of how we die. Around the mid-1960s, it even became possible to die without ceasing to function. Machines were invented to replace the function of a failing heart, bones, lungs, liver, gut and kidneys, and intensive-care doctors were trained to perform miraculous, life-saving operations. Mortality rates dropped and death, because it now occurred mostly in hospitals, became a less significant part of our daily lives. According to Saul, at least six in 10 Australians will die of frailty.

IT IS THE END OF THE WEEK and, sitting in his austere office, Saul seems drained. With a career in intensive care spanning 30 years, he has seen a lot of death. Seven of his patients have died in the past 10 days, all of frailty.

Most intensive-care doctors of his generation, he says, went into the business for the challenge and reward involved in performing life-saving operations. Many are disillusioned by emergency calls to elderly patients who have only months to live anyway.

“We run there with gear, and we find this incredibly old person who’s incredibly frail and incredibly thin and, you know, 90-odd, and can’t breathe, and you go, 'Seriously?’” Saul says.

ICU wasn’t designed to prop up frail patients and facilitate dying, and its doctors and nurses haven’t been trained to deal with this ever more frequent situation.

“The stress created in families by dying is enormous.” Saul says. Having a family member hospitalised in ICU can cause symptoms of post-traumatic stress disorder in those closest to them.

When Saul asks families if they have talked to their loved ones about dying he is often met with a heavy silence, followed by distress. Families are ill-prepared and their decisions fogged by grief and fear; they frequently say, “We always thought there’d be more time.”

<p>Ella Rubeli/The Global Mail</p>

Ella Rubeli/The Global Mail

At first glance, apparatuses for mobilising patients make the intensive care unit look like a gymnasium. The older and larger the patient, the more this equipment is required.

Families want everything possible to be done to extend the life of their elders, even if it’s just for a month. If their loved one is drifting in and out of consciousness, it is the family’s decision, made in consultation with the doctor, that determines what happens to them.

“Dying has become a private thing and a shameful thing and it’s not the public domain at all any more,” Saul says. “You no longer just die in your sleep, you die in a managed way.”

Saul estimates only 10 per cent of the Lower Hunter region’s elderly die at home, while 70 per cent of Australians die in acute care. “It’s reached a point that your home could be declared a crime scene if you die there now, it’s so rare,” he says. But in a recent survey conducted by Palliative Care Australia, 74 per cent of people who had thought about it said they would prefer to die in their home.

<p>Ella Rubeli/The Global Mail</p>

Ella Rubeli/The Global Mail

A patient lies wired up to a stack of what doctor Saul calls ‘machines that go ping’.

The survey also revealed that almost two in three Australians believe death and dying aren’t discussed enough in the community. But doctors and nurses are not inclined to broach the subject.

“Doctors will [discuss treatments] with you [when you have] a cough, or a broken leg, but when you’re 85 and can hardly breathe, for some reason they don’t feel self-confident enough to say, ‘What do you think is going to happen with your breathing?’” says Saul.

Australian palliative care and sociology academic Dr Allan Kellehear, currently based at Dalhousie University, Nova Scotia, has published several books on death and dying, including A Social History of Dying (2007). He agrees that society has some catching up to do with the medicalised way in which we are ending our lives.

“You can’t blame people for not rushing to understand how complicated intensive-care situations are, when the public information about intensive care is minimal to nothing.

“That does not mean we’re death deniers, it means we’re cautious,” he says.

<p>Ella Rubeli/The Global Mail</p>

Ella Rubeli/The Global Mail

An elderly female patient wails as nurses change the dressings on a leg wound.

“Current generations have been brought up with a good understanding of their own health,” he says. “We know basic anatomy … that smoking causes cancer, asbestos can kill you … we know the difference between if we eat pizza, fish and chips and KFC or fresh vegetables and salads.

“But we don’t have the death-and-dying equivalent.

“Let’s do the public education first; let’s get governments to encourage schools, universities and workplaces, to think about death and dying policy,” he says.

Saul agrees: “Most medical students never see anybody die at all.”

In an email a week later, Saul reflects on his suicidal patient Charlie. “This is modern dying,” Saul writes. “We are old and in poor health, and often do not want a lot of intervention. Then we encounter an inflexible system that is set up only to intervene aggressively.”

Because of his suicide attempts, Charlie was taken over by a psychiatry team, who spent five days and nights sitting by his bed to ensure he did not attempt to hurt himself. Eventually they decided he was completely sane. Because he had spoken with his wife about dying, she supported him in his wish to die and pushed the doctors to avoid surgery. Charlie went to a palliative-care hospice, where he was given drugs to help manage the pain he was experiencing, but nothing to prolong his life.

Saul says Charlie was lucky to encounter a surgeon who was prepared to listen, ask others for advice and be bold enough to take an unconventional route. Charlie was lucky to have a wife who stood by his wishes, however hard for her that was.

“He will die at much the same time, but better,” Saul writes.

*Not his real name.

35 comments on this story
by Ron Bowden

This article affected me profoundly. At 73 I still have my marbles (I think) but the body is beginning to cost society more than it can ever repay and possibly more than it ever contributed.
I suspect I'm one of a very great number in this situation and I believe this to be grossly unfair. Unfair to the society that must, because of some warped values, spend increasing amounts to keep alive people who probably don't want to be kept alive.
Unfair to the old and infirm who, if they were to be asked, and if they were capable of a rational answer, might opt for assisted suicide, but what difference would it make? In most cases, I suspect, very little.
Those compassionate medical people who lean toward the proactive must have regard for the consequences.
I'm not yet at the stage where I'd rather be dead but I intend to ensure that when that time comes, as it will, I do not end up like poor Charlie of the story. Neither will I become a burden on my wife and family.

December 6, 2012 @ 2:38pm
by Geoff Webster

Makes me realise how lucky we were to be able to support my sister at home through her final months because of the work of Karuna - a Brisbane based palliative care service (it's free) that assists patients to die with dignity at home amongst those they love. Every form of support is offered - physical, emotional, psychological - for the patient and family without tying up an expensive hospital bed. It works so well - why can't it be duplicated elsewhere?

December 6, 2012 @ 2:42pm
by Gail Abbott

Another aspect of the dying process not often considered is the effect on the family of having a member's dying "managed" in a hospital, and thus largely removed from sight. It can certainly be difficult for a family to manage a death at home, but it is also an immensely enlarging experience and a privilege for the caring members. Death, after all, is a part of life, and we need to know about it and accept it. It's not always possible, but where it is, it's an experience to be embraced, not avoided, I consider. So good that you have opened this subject for consideration, Ella. Thanks!

December 6, 2012 @ 4:02pm
by Tom

Really great article.

December 6, 2012 @ 4:44pm
by Matthias

Errr... "A patient lies wired up to a stack of what doctor Saul calls ‘machines that go ping’". Please, those syringe drivers are empty, the dialysis machine is on stand-by with no circuit in place. And no ventilator in sight. Please avoid such obviously stage-managed (and done so badly) photographs which only serve to showcase an ignorance of the subject at hand and a willingness to insult the intelligence of the audience.

December 6, 2012 @ 8:38pm
by Maria Hendriks

Very good Ella to tackle this subject. Is also shows how different cultures are in this respect. If an elderly in Holland is in hospital they will want you to go when it becomes clear they can do nothing to cure you. You either have to go home or into a hospice. Just as well, who wants to die in a beeping environment that frightens your relatives and friends. The article itself is good and clear, nothing I would change.

December 6, 2012 @ 10:24pm
by Tom

I think you might be missing the point, matt.

It's about highlighting how artificial the setting is to most people. They won't recognise a dialysis machine, it's just a jumble of machines that go ping.

December 6, 2012 @ 11:16pm
by Helen Neville

I watched the video of Saul's lecture and found myself applauding at the end like his audience. I was so pleased to hear his opposition to Euthanasia - it was a relief to hear his point of view because the "Dying with Dignity" movement (a silly description in my view) has been given too much media attention and oxygen. If the same attention could be given to the reality of how our society treats dying, and attention given to practical information about how we die, the fear of dying would truly be addressed. Then perhaps death would no longer be the taboo subject that it is. Thank you Ella for being one who is willing to get it "out there".

December 7, 2012 @ 10:10am
by jason thompson

I have been working in research and health promotion for the best part of 20 years and I've often thought to myself, "OK, so we are trying to stop people dying of this (whatever it is), but what are they supposed to die from, instead?".

Every effort and thought is geared toward stopping the death - like to die is wrong. But dying is required - it's absolutely necessary for people to die so that new people can be born and have room to live.

You see it in research circles as a sign of success - "Everyone used to die from my disease but now they're dying from something else - We've been successful!" Well maybe they haven't - Maybe the 'other disease' is worse?

I think we need to have a discussion around engineering the 'least worst death' for people instead of just pretending that it should always be from 'something else'.

I choose 87 years old. Stroke. In my sleep.

Can someone help me with that?

December 7, 2012 @ 1:44pm
by Julia Fountain

As the doctor said to my dearest elderly relative, the one with a terminal illness, "I’m so glad we’re having this conversation about palliative care and the arrangements you want at your home. So often people leave it too late".

Thanks Ella and TGM for publishing this story.

December 7, 2012 @ 5:57pm
by Christine Bolt

An important story. Alzheimer's Australia has two discussion papers that aim to encourage people to inform themselves and their families/carers of their rights, and to plan early to hopefully alleviate some of the stress and confusion at later stages. They are called Planning For End of Life for People With Dementia written by Prof Colleen Cartwright. I hope these can help your readers.

December 8, 2012 @ 10:15am
by James Fitzgerald

A great and timely (for me) story which I will encourage my wife and daughter to read. Thanks to Ella and The Global Mail.

December 8, 2012 @ 11:03am
by Barry le Plastrier

The writing on the wall next to the man on the right says it all.

December 8, 2012 @ 2:04pm
by Annie

This is an important article.
It behooves us all to think about the 'end time' and to talk about it with those firstly, who will be there ( spouse, children) then our doctors.
My mother and father believed in voluntary euthanasia ( never mentioned in this article but heavily implied). My mother had severe MS for the last 6 years of her life. She asked me that 'when the time comes, you will help won't you'? I said; I wish I could but I can't.

We were lucky enough that 'when the time came' and she had finally contracted pneumonia we had a doctor in the public system who listened to me ( my father gave me the nod to speak for him ..a rare thing for his baby child) and my dad's wishes and announced; We will make her comfortable. You know what THAT means? He asked? Yes I said with relief. She died in hospital.

My father lived for another 10 years after her gradually become demented, his greatest fear. Before he stopped talking and recognising me he said; You won't let them put me in a dementia unit. You will help me won't you when I am no longer me. I said;; I wish I could but I can't.
He died in a Aged Care Facility..slowly after many falls and multiple 'fluid on the lungs' infections. With no 'being made comfortable'...
I was there for both of them.
I saw my brother in law die at home of AiDS related illnesses.

I know where I would wish to be if asked In hospital being made 'comfortable' at my own request and done asap I had made the decision. I do not want my family standing by and watching me slowly seep away at home. I want professionals to take care of the cleaning and turning and administering the final dose.

My husband has been chronically ill for over 20 years. We both know what we want.
In all this I have seem the insides of many hospitals, ICU's and A & E's. Also 'aged care facilities.
We know what we want and now it is up to us to argue, fight and demand it for the future, when we are ready.
I am not hopeful especially with the interference of the religious.

December 8, 2012 @ 3:47pm
by Peter Warwick

This is one of the best stories I have read on aging, living and dying. The statement by SAUL “that greater longevity just means more old age, not more youth” is as true as it gets.

I realized that under no circumstances would I allow myself to be “managed to death”. I am a member of Exit International and have my supply of the good gear for when I am ready to die.

It does help being an atheist. One has no fear of death, other than a nasty, pain filled one, tethered by machines that go ping, and attended by a battery of health professionals (who I admire in the greatest degree) determined not to let the patient die.

Congratulations Ella on a fine and compelling piece of journalism on a very important subject.

December 8, 2012 @ 5:39pm
by Donna

What a beautifully balanced and insightful piece of journalism. As a nurse in the early years of my career I worked in ICU and High Dependency Units that were populated by "younger" patients. I hadn't realised how far the pendulum had swung. I've spent the past 28yrs as a midwife when a baby born at 28 weeks gestation was a miracle to now when we work to save 24/40 infants. Families at both ends of the spectrum are reluctant to give up the fight for life. It takes someone as wise as Peter Saul and the caring Neonatal ICU doctors to gently help relatives see the light.

December 9, 2012 @ 6:36am
by Kathleen Fahy

Thank you Dr Peter Saul; you are an angel of compassion and wisdom. Thank you for bringing the important issue of how we die to a much wider audience.

December 9, 2012 @ 7:35am
by Pamela Crockett

This is the first article I have read that has really nailed the act of modern dying in one. Congratulations Ella for being able to bring what has become a chasm between what the person concerned wants and what everyone else needs in order to complete the paperwork, avoid litigation and have "closure".

A frail, relative in a nursing home used to insist she had lived a full and productive life and it was time to move on her own terms. She just made it happen through sheer will power, wore out naturally. She simply didn't wake up one day.

December 9, 2012 @ 9:11am
by Vivienne Goldstein

A very thought-provoking article! Actually I didn't read euthanasia into it - just simply an invitation to consider the difference it would make to find ways to care for our elderly and/or ill family members at home and not prolonging life by taking any drastic scientific means. I would refer anyone interested to the website:

December 9, 2012 @ 11:49am
by Peter

I like the article for the questions it raises. But, purely from personal experience, it is off the mark. The real world is different from the picture painted - personally speaking.

December 9, 2012 @ 10:57pm
by Deirdre Ryan

Medical Students are NOT trained in so many NECESSARY areas these days and this is yet another very important one! The "powers that be" in the Medical World MUST ASK PATIENTS and not assume that they "know it all" in their technology fuelled medical approaches. The Medical World is not doing what one considers basic training & treatments that cured or ameliorated illnesses in past years, they are SO reliant on Blood Tests & "Evidence-based Medicine" - NOT necessarily reliable for a number of reasons and this adds the exorbitant costs and unsuccesful treatments that are now prevalent.

December 10, 2012 @ 12:33pm
by Robin

Having seen my father tied up to the ping machines in between having repeated sectioning of his gangrenous bowel , unable to speak but his intelligent face showing absolute horror at what was happening to him, I absolutely agree on the need for this change. Families used to be at home with their elderly and dying to manage their discomfort, keep them company, and share their fears. Now we can do so much better than isolating ourselves from this in the name of "better pain management"... we can accommodate both that and the collaboration between staff and caring families..about time!!

December 10, 2012 @ 1:33pm
by Penny Abbington

so we all need to talk with our families and friends, encourage the discussion about the benefits and burdens of medical treatments at a time when the patient themselves are unable to indicate their preferences. Having had discussions with probably close to 350 older and younger people in our community I have met only two who have said they would want everything done to stay alive. Most indicate they want to be kept comfortable painfree, and to live their last days with dignity, with those they love with them and most defineitely they do not want their dying prolonged, for them that would be a huge burden and totally unacceptable.

December 10, 2012 @ 7:42pm
by Terry

Saul estimates only 10 per cent of the Lower Hunter region’s elderly die at home, while 70 per cent of Australians die in acute care. “It’s reached a point that your home could be declared a crime scene if you die there now, it’s so rare,”

Having tried to save my mother in laws partner, at his home, I was made to feel that I was in the wrong, the Police, the ambulance, the coroner all came along and questioned me, Daryl died from a massive heart failure,.

December 10, 2012 @ 8:59pm
by Thomas McLoughlin

As a solicitor In New South Wales, Australia, there are five legal documents you want to have organised for the medical emergency situations, and this probably applies whether young or old:
1. An Advanced Health Care Directive for end stage medical treatment probably via a solicitor and in consultation with your medical practitioner as to the treatments you do/don't want.
2. Similarly an Enduring Guardian appointed for health and lifestyle decisions on your behalf where incapacitated.
3. Similarly in anticipation of incapacity, an Enduring Power of Attorney for financial and property matters to take effect according to strict conditions.
4. Arguably the most important - a will.
5. Last and definitely not least - a binding death benefit nomination every few years for your accumulated superannuation (because superannuation may not be bequeathed in a will).

December 11, 2012 @ 9:35pm
by Robert Gunter

I was a doctor for 55 years. I have only recently become aware of how our ICU resources are being misused in this medically and ethically wasteful and idiotic way. Surely it is time for the ICU Specialists and ward staffs to stand up and say NO when requested to admit such people, and encourage the referring doctors to think a bit more about the realities of life, which include the reality of death, and not just about prolonging life at any cost. Medical and ethical training need to be addressed here and continued in the professional lives of the Medical and Nursing Practitioners.

December 13, 2012 @ 2:39pm
by Helen Ferguson

Congratulations Ella, a timely and explicit reflection on death our time.

I am a member (aged 87) of the major, dying generation (Gen-D perhaps), with the ingrained frugal habits inherited from the post world war one depression years. Permit me to suggest that one factor guaranteed to reduce the use of hugely expensive ICU and hospital facilities has been largely ignored (in true baby-boomer style & post BB style). That is, the cost to the consumer.

By quoting at the time of consultation with elderly and frail patients for these hideously expensive, life-extending facilities, combined with sympathetic advice about alternative, immediately available, imaginative, inviting, palliative care places doctors should quickly convince the careful, money-saving D-generation to opt for a much cheaper and incidentally more comfortable end to life.

Of course, as always some of the rich and the sentimentalise will try to manipulate the system for their own relatives' 'ends', but in this materialist society money - or lack of it - talks loudest and both the hospitals and the aged can be the winners, both economically and sociologically.

A purely personal plea - for 'Heavens sake' drop those awful commercial and condescending titles such as palliative care, aged care facility' and nursing home etc. How about DYING TO LIVE Club, LIVING TO DIE League or just TO DIE FOR!

December 15, 2012 @ 6:08pm
by Helen Rubeli

Recently I attended a First Aid Course where we were advised to ignore any tattoos we found on the casualty's chest stating "Do Not Resuscitate" as that may no longer be their wish. I wondered if "I Really Mean It" tattoed in red underneath would hold up in court.

December 31, 2012 @ 5:14pm
by Hazel Cotton

Well done Ella. My husband and I have discussed this situation at length and both agree we do not want our life extended unnecessarily. We hope, when the time comes, those around us will honour our wishes. Alieviate pain, yes, but let us die with dignity.

January 1, 2013 @ 10:50am
by Peter Warwick

Just a note from personal experience. My mother was dying of cancer, and was prescribed morphine for pain relief. After her usual morning dose, she called me close to her and told me that she had had a wonderful life, and was ready to go. She said that should the good nurses make a silly arithmetic error, like adding a zero to the end of the calculated dosage, tell them not to worry.

I mentioned her “request” to her supervising physician, who told me that he receives three such requests per day. He said that he was not opposed to it, but could not assist in any way. He said assisting in any way was a criminal offence, and given that he was at the top of his profession, that he thoroughly enjoyed his profession, and that the risk was too great for his family to endure, he could not assist.

He did say that the practice of overdosing is fairly common. The nurses give a tip and wink, and pass whispered messages to those who seek such assistance, and by manipulating the drug register, are able to do it.

I will be carrying in a super dose (for everyone to see) of morphine when I go the hospital, with clear instructions that when I am terminally ill and have said goodbye to everyone, I am to be overdosed with morphine.

I do not have a death wish, but when I am ready to go, I will flatly refuse to be “managed to death”.

January 3, 2013 @ 12:38pm
by Caitlin Boulter

A really moving piece. We try to avoid this issue for so long, but it's probably going to affect us all in one way or another, and sooner than we expect.

January 14, 2013 @ 1:49pm
by Robyn Rawson

Peter, manipulating the Drugs Of Dependence register is an offence and any nurse knows this and knows that if discovered their registration will be withdrawn. No one will inject you with your own personal supply of morphine, or any other drug for that matter. Interesting that the photos of nurses accompanying this article focus on the caring rather than the clinically complex and pivotal role played by nurses in ICU.

February 26, 2013 @ 7:25pm
Show previous 32 comments
by Peter Warwick

Robyn, I think I was able to work that out. I will not be taking in an inject-able drug, but a bottle of Nembutal (kept at home, and brought in when I call for it).

No doubt, you are right about the legals, but just because something is illegal, does not stop people from carrying out a an illegal act for what they perceive as a just cause.

I suspect you may have missed the whole point of the article. It was not a discussion of clinically complex and pivotal role of ICU and the professionals therein. No doubt ICU is complex, and those in ICU are to be applauded for their work.

It was an article about the choice of exiting in a graceful and dignified manner, without the overbearing intervention of modern medicine. Hence the title "What Happened To Going Out In Style?"

Have you ever noticed that everyone is in the business of business these days. There are, no doubt, highly motivated health professionals who have a dedication to the task, but they have made their task of keeping a terminally ill person artificially alive, until there is not a milligram of life left, no matter what the cost (and I am not talking money here).

I suspect, in the case of my mother, the doctor really wanted to tell me "Your mother will die in her own good time, with a little morphine to ease her pain". And I could tell from his voice "and we do not intend to tether her to multiple machines that go "ping"."

He did say that my mother was lucid and rational and had clearly considered the end of her life. She had reconciled everything, was very happy, but simply wanted to die.

The physician said he had seen many deaths, and those who went peacefully and with grace were those who had reconciled that death was imminent, and was not going to be painful.

April 20, 2013 @ 9:12pm
by Robyn Rawson

Dear Peter,

No I didn't miss the point of the whole article but like Matthias in the comments above I thought the choice of photographs was unrealistic and from my point of view, patronising. So if the writer is happy with those visuals, then I am sceptical about the depth of understanding. I also have a problem with the characterisation of a good death as going out in style. Not sure why, but that grates on me.

I stand by my comment about the unlawful administration of any drug, let alone opiates. Your physician seems to think nurses don't value their ethical and legal obligations as highly as he does his own. Nurses do not make executive decisions about drugs, they do however advocate for their patients and request better symptom management when needed.

At the hospital where I work our (ex) ICU director has made an excellent film with ABC TV on the futility and indignity of much of end of life care in ICU. That pathway to ICU has many different starting points in culture, family dynamics and medical practice. There is an excellent video called "critical palliative care" from a recent American conference . Dr Ashley Shreves is both an Emergency and Palliative physician and has some concise and passionate education for Emergency physicians on communication and decision making.

I have worked in aged care, a short stint in palliative care and am now on a cardiology ward. I nursed my father in the last few days of his life. My mother is 90 years now and still independent. I have a deep interest in the palliative process and in particular how we look after people in the acute setting. Our hospital has an excellent Palliative care team. I, like everyone else, grapple with the individuality and complexity of decision making towards the end of life at work and at home..

And if you do take the Nembutal or whatever, please, don't do it on my shift!!!! And make sure you have an Advanced Care Directive AND an inpatient Not for Resus order.


April 24, 2013 @ 5:37pm
by Tim Hooper

G'day Ella,

Congratulations on a profound and thoughtful article.

It seems dignity will be the second rarest commodity after privacy in this century.

July 16, 2013 @ 1:39pm
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