Bigger health picture

There is suddenly a lot of panic over the number of ventilators available in Australia. Likely provoked by headlines around the world proclaiming there are not enough. But is this really the only thing we need to be worrying about?

It may be that people who ‘miss out’ on a ventilator would not have benefited from it — or may not have wanted it in the first place.

The overwhelming focus on the number of ventilators provokes fear as it conjures images of the frail and elderly being forgotten and forced to die alone.

But it doesn’t have to be like this if we ensure national availability of palliative care and advance care planning.

Last week the median age of the Australians who died from COVID-19 was 81 years. A Chinese study has shown that older age is the greatest risk factor for developing respiratory failure and death. Nearly half of the patients who died in Italy had three or more comorbidities, such as hypertension and diabetes. Generally speaking, those who are most effected by COVID-19 also seem to be those who would be the least likely to survive an ICU admission for any reason.

Facing an extraordinary humanitarian and resource crisis, Italian doctors spoke out about rejecting people from ICU based on “potential survival”. Another has said “[Who lives and who dies] is decided by age and by the [patient’s] health conditions. This is how it is in a war.”

These solemn declarations give the impression that those deemed ‘unworthy’ will be left uncared for. It implies that we cannot do everything for everyone and so must do nothing for others.

But this is wrong. Too often doctors speak of there being “nothing left to do” but there is always the opportunity to relieve suffering. We must ensure that palliative care is available for those Australians who would not benefit from a ventilator or who do not wish to be ventilated. Palliative care is well equipped to treat these patients.

Nonetheless, in the best of times, let along during a pandemic, palliative medicine is easily overlooked. Unbelievably, Australians over 80 years of age, dying from non-malignant disease, such as respiratory failure, are currently the least likely to receive palliative care — partly due to a lack of referral.

But it is not just the medical fraternity who need reminding about palliative care.

There has never been a more pertinent time for all Australians to consider what type of medical care they are — and are not — willing to endure.

Many self-actualised 80-year-olds view pneumonia as “an old friend” and upon its arrival entrust me to ensure their dignity and not send them to the cold clinical ICU to suffer a drawn out death. This is an advance care directive.

In an Australian audit of 2,285 patients over 65 years of age, across six states and territories, less than 30% had an advance care directive indicating a person’s preference for care. Even in aged care facilities, less than 50% of residents have a care directive indicating whether, for example — they want to be transferred to the emergency department, be resuscitated or what consequences of medical treatment they would consider unbearable. This is despite evidence demonstrating that advance care directives promote autonomy.

If we don’t ask, we won’t know how people wish to be cared for if their lives are threatened.

The current lack of integrated access to palliative care and responsible advance care planning is something we need to be worrying about. Many older Australians will forgo a ventilator but we will only know this if we ask and if we reassure them that they will always be cared for — ventilated or not.

Dr Jessica Borbasi is a medical doctor and research associate at The Centre for Independent Studies. She is the author of the research report ‘Life Before Death: Improving Palliative Care for Older Australians.’