Quarterly Essay 57: Dear Life

Karen Hitchcock, Quarterly Essay 57: Dear Life: On Caring for the Elderly (Black Inc February 2015)

Like every Quarterly Essay, this one includes lively correspondence on the previous one. Guy Rundle’s Clivosaurus drew thoughtful responses from a number of writers of the left, defensive missives from representatives of The Australian, fascinating psephology from Malcolm Mackerras, and more. Much of it was too technical for my pay grade, but one thing is clear to me: if you get into an argument with Guy Rundle, it would be unwise to let him have the last word – he’s very good at the devastating rebuttal.

A number of people have already tweeted that every Australian should read Karen Hitchcock’s essay on the treatment of elderly people in our health system. She is a general physician who has worked in large hospitals in several Australian states, and so has extensive hands-on experience in working with frail and/or demented elderly people. As she says:

There are two strong narratives in our culture about the ageing population and death. The first is that medicine is keeping elderly patients alive against their will – medicine is denying a death the patient desires. The second is that elderly patients are seeking to stay alive unreasonably – the patient (or their family) is denying an unavoidable death.

The essay takes these narratives on fiercely, and does a brilliant job of unpicking the ageist assumptions and fanciful versions of sickness and hospitals on which they are built. She marshals her own personal and professional experience as well as current research to mount a convincing counter-narrative.

She describes the way modern medicine is fragmented into specialities, a situation that makes it hard to treat elderly people with multiple conditions.

She explores the concept of futility: is treatment futile if it extends a person’s life for just a few days but those few days allow them to say goodbye to family? can a hospital specialist who is as drenched in ageism as the rest of us and has no personal knowledge of a patient be trusted to make a sound judgement about the futility or otherwise of treatment?

She savagely rips into the often heard argument that the increasingly aged population will make the health care system unsustainable.  ‘Sustainable’, she argues, ‘is just a word for “what we are willing to pay”.’ And the real challenge to the health system comes not from the aged but from ‘a population of increasingly poor, obese, diabetic, sedentary young and middle-aged who are the multi-morbid patients of the future and who will require many drugs, doctors, operations (joint replacements, bariatic surgery, amputations, coronary vessel interventions) and hospitalisations’.

Advanced medical directives, documents that spell out ahead of time conditions that are not to be treated if a person is incapable of making their wishes known, are singled out for special opprobrium. Hitchcock is an excellent storyteller, and her story of 84-year-old Fred who came to hospital begging to be allowed to die is enough to win her case without any further discussion: he was wretched, and didn’t want to be a burden (an often heard internalised version of the message with which older people are too often bombarded); she listened to him, encouraged him, treated him, and followed up some time after he was discharged:

I said, ‘Fred , you told me you didn’t ever want to come back to hospital.’
He said, ‘Of course I want to come back if I get sick. I get silly when I’m sick. I hate everything. I say silly things.’

Not all her stories have such cheerful endings. Death does happen. But if we are to have a national electronic system where people’s advanced care directives are recorded, then these directives, she argues, should be reviewed regularly, even monthly, by the people whose lives they concern.

The essay discusses the isolation that is the lot of many elderly people, including those who are placed in nursing homes when their families can no longer care for them. It argues that this is an issue that should be taken up by the society as a whole – ‘if we are to attend to the social needs of our elderly citizens both inside and out of institutions, then we need government interventions and funding, along with the community’s engagement and help.’ What is needed, and what is beginning to happen in some places is

a shift in perspective: the elderly 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 our society. They are those for whom we are responsible and to whom we owe real care.

Another sacred cow the essay takes head-on is the idea that it is better to die at home than in hospital. My own father had himself discharged from hospital in Townsville when he knew he was dying, and was flown and driven the 500 miles to Innisfail because he wanted to die at home. I have no doubt that that was a good decision: he spent his last days surrounded by friends and family, being visited by a doctor he’d known most of his life and a nurse he’d known all hers. He died in bed beside my mother, his wife of more than 50 years. But Hitchcock makes it very clear that his situation was exceptional in the western world today. A hospital death can be a good death.

In short, this Quarterly Essay is a call to arms against the oppressive attitudes and practices which we have insinuated their way into our minds and practices around older people. I’m 68, not yet in the frail and/or demented group that Hitchcock is talking about. I hope I never will be. But reading her essay, I wonder if my GP’s slightly disturbing lack of interest in my symptoms on my most recent visit, which I put down to his having had a long day or perhaps the lack of drama in my presentation, might have grown from an assumption that once you’re past a certain age you just have to put up with a certain amount of suffering. And that’s partly Karen Hitchcock’s point: if the problems she writes about are chickens, then we are all roosts waiting to happen.

This is the fourth book I’ve read for the Australian Women Writers Challenge for 2015.