Book Review: “Dear Life. On Caring for the Elderly” by Karen Hitchcock

Quarterly Essay. Issue 57, March 2015. Black Inc., Schwartz Publishing Pty. Ltd. Collingwood, Australia.

Reviewed by Sue Buckley

Karen Hitchcock is a staff physician at a large Australian city public hospital. In this Essay (short book) she describes how social attitudes towards the elderly shape the way rest-homes, hospitals, and health professionals organise and either limit or extend their care of the elderly. Hitchcock addresses a number of ethical issues – futility, over- and under-treatment, burden, euthanasia, advanced care directives – interspersing these with moving stories of real people and events. These stories are not just dramatic devices but beautifully rendered accounts of interactions she has experienced with her own family members and her patients.

The Essay as a whole challenges current pejorative views of the elderly - the ‘oncoming grey tsunami of the sick and frail’, the ‘swelling ranks of “greedy geezers”’ - but it is especially critical of the attitudes towards the elderly held by some health professionals and how these influence treatment decisions.  If you are old, with two or three organs failing, ‘can no longer negotiate your stairs to go and buy food’, then you are seen as having problems that cannot be cured. These patients, described variously as ‘crumbles’, ‘bed blockers’ or ‘gen med specials’ are not just unwanted in acute hospitals, but if they do arrive they are likely to receive different treatment from younger patients as physicians view their treatment as ‘futile’.  Hitchcock provides some captivating accounts of particular patients and how they responded to treatment when ‘futility’ was overruled.

Hitchcock bravely confronts the costs of treatment while challenging some commonly held assumptions. One that we hear often is that ‘the last year of our lives is when the most health-care dollars are spent’. Hitchcock acknowledges that increasing age and increasing health expenditure ‘go hand in hand’, but points out that this is because there is a greater chance of dying when you are old than when you are young. In fact, the same amount is spent on each death, young or old and, contrary to most commentary, hospital costs associated with the last year of life actually fall with age; data from New South Wales indicates that people aged ninety-five years and over incurred less than half the hospital costs of those who died aged 65-74 years. Responding to critiques that claim the public health system is ‘unsustainable’ and that push for a more private, US-style system, Hitchcock points out that as far as treatment of the elderly goes, ‘free markets lead to over-treatment, while publicly funded systems risk sometimes unexamined and discriminatory rationing’.  She concludes that ‘we need to shift our focus to improving care. It has been limited enough.’

The second half of the Essay deals with dying. It begins with stories of patients for whom decisions about ending treatment needed to be made. The first describes Hitchcock’s own father’s death and the burden of having to make a decision to switch off the machines keeping him alive. The second story tells of an elderly man with severe heart failure who ‘hated hospital’ and wanted to die. Hitchcock describes spending time with him, learning why he no longer wanted to live and finding ways of enabling him to be discharged from hospital to an enjoyable life. The third story describes the admission to hospital of an elderly man with mild dementia who had completed an advance care plan, possibly under the duress of a much younger wife. The wish not to be a burden was prominent in the plan and caused concerns for Hitchcock.  She questions the reliance on advanced care plans which might be made by someone in their seventies but no longer reflect their wishes as they reach their nineties. Impairments once thought of as intolerable may turn out to be bearable after all.  She quotes Thomas Nagel: ‘Does autonomy really give your past self the authority to kill off this later self?’

Hitchcock also questions the reality of the ‘good’ or ‘ideal’ death and challenges the notion that dying at home is preferable to dying in hospital. As she points out, the practicalities of dying at home are often too much for family members and besides, there may be no one at home to look after them.

The essay ends with a challenge to ‘we, the living’ to see ‘the elderly’ as the people they actually are: ‘The elderly, the frail are our society …They worked and loved and lived – and can continue to do so. … Right now we need the resources to care better for the elderly in the institutions we have imperfectly built, and we need deep social transformation so that many more people can live on in their communities and homes. We must remain aware of our ageism in every program and policy we implement.’

This moving essay is written with warmth and elegance and discusses some important ethical issues with clarity and practical wisdom. Its questioning of many current assumptions about the elderly and how they should be treated is well-timed given the upcoming challenges to our health and care systems from an aging population.

Sue Buckley is a researcher for The Nathaniel Centre