Medical specialists are warning that there is a looming crisis in end of life care. There are already shortages of staff, and this will only get worse as the baby boomer doctors and nurses retire in the next few years. Meanwhile, the ageing population means that there are more people dying, and so more people are in need of end of life care. As we discussed in our book Health Cheque, these pressures will only become more common in our health system in coming years.
Labour is debating whether to start a conversation about voluntary euthanasia, but this misses the point. The real issue here is that end of life treatment soaks up a huge part of the health system’s budget. This money could be better spent on prevention, providing end of life care, and focusing treatment on those that have a greater chance of recovery. It is time for our elderly to start talking about what they want – a comfortable, dignified death or an expensive one?
End of life care vs treatment
There is a massive difference between care and treatment. In our health system the focus is very much on treatment – returning people to health. Nearing the end of life returning people to health becomes less and less likely, but often families and medical staff keep pushing for continued treatment anyway. It is a bad look for any hospital to refuse treatment to someone on their death bed, regardless of how useful that treatment would be.
The result is that our health system throws a lot of money and staff time at treatments that have very little health benefit. Lives are extended by a matter of days or weeks, and the quality of that extra life is debatable. We don’t have a lot of information on end of life spending in New Zealand, but in 2011, Counties Manukau DHB found that spending on patients in the last year of life totaled $22,000 – far higher than previous estimates.
Care on the other hand doesn’t make people better, it just makes them feel better. This is usually left to hospices and families, where funding from the formal healthcare system is piecemeal at best. While many nurses see care as part of their role, our public healthcare system tends to prioritise treatment instead.
Voluntary euthanasia is not the real issue
A few years ago the Prime Minister raised the issue of voluntary euthanasia and now the Labour party are debating whether to push for it to be legalized. Euthanasia is a concept that people understand; that people in pain should be able to choose when to die. However, as we have seen in previous blogs, the circumstances where voluntary euthanasia is a possibility are rare. For starters, patients are rarely conscious and rational enough to make an informed choice. Secondly the big issue is not so much a matter of when we actively end people’s lives, and more a matter of when we stop treating them and let them die of their own accord.
Our health sector has limited staff and budgets
The fact is that our health system has limited resources, so like it or not life and death decisions are made every day. The only question is where we put our health dollar in order to get the maximum benefit. The tendency is to focus on the urgent stuff – people that are already on death’s door. However, this is often not the best investment – we would get greater benefit from keeping people healthy. Spending money on prevention usually returns four times the health benefit as hospital treatment. The lives saved through investing in prevention are every bit as real as the life or death decisions in the emergency department, they just don’t appear to be quite as urgent.
So this raises the question of how long we should go on treating someone that is clearly nearing the end of their life? Of course families are going to want to keep their loved one alive as long as possible. However, as we discussed in a Prescription for Change, when people are fully informed about the downsides of treatment, a third of them choose not to be treated at all. Nurses are crucial in playing this role of guiding a patient through the health system in their last year of life.
Some of the savings from reduced end of life treatment could even be used to fund better end of life care. This could make end of life care a viable option for patients and families to consider. That way the health system wouldn’t have to refuse treatment, they could offer a package of care as an alternative.
Time to talk
It is time to talk about dying. As individuals we can talk with our families about advanced care planning – what we want to happen to us in different end of life circumstances. This conversation is difficult, but it is better to happen now than when it is too late.
As a society we need to talk too. There simply aren’t enough resources for our health system to give all baby boomers a big send off. If we want to invest more in end of life care, then we need to find a way to curb spending on end of life treatment. Throwing more money at this problem won’t solve it either – there simply aren’t enough skilled staff to do everything that we might want.