Opinion Editorial

A matter of death and life

Wael Haddara

For many Canadians, our publicly funded health-care system is a part of our national identity. In 2014, a study of 7,000 Americans and Canadians found that while Americans are deeply divided about the principles that should govern the provision of health care, Canadians are far more united.

But in the midst of that general agreement, some voices like to repeat the mantra that "our health-care system is broken." Proponents of privatized health-care delivery have long argued a publicly funded system is not sustainable.

I disagree. Our health-care system is not broken. And it is sustainable.

There is -- undoubtedly -- much that can be done to make the health-care system more efficient, including effective use of information technology (eHealth, anyone?). And there are areas, such as mental health, where our entire approach needs to be rethought and reconfigured.

And there are other challenges.

As a physician in the intensive care unit (ICU) of a major Ontario teaching hospital, I witness the challenges of delivering high-quality health care in a publicly funded system on a daily basis.

And I have come to believe one of the most significant challenges facing us is a lack of understanding of the meaning of life and death and our expectations of what medicine can do in a technologically advanced era.

I often tell families whose loved ones are on life support in the ICU that there is a fine line between doing things for patients and doing things to them. Often, that line is crossed in the ICU because of the technology that is available to us.

Respiratory failure? No problem, we'll put you on a ventilator. Kidney failure? We'll roll in the dialysis machine. And when all else fails, we can put patients on cardiac bypass machines that suck the entire volume of blood from a person, add oxygen, remove carbon dioxide and put it back into the patient.

But this sense of omnipotence masks a very real weakness. We are not all-powerful or invincible -- neither physician nor patient.

Human beings remain exceptionally frail creatures. In the ICU, what does not kill you, makes you weaker. And that weakness invites further problems: infections, delirium and organic brain dysfunction, and failure to wean from the mechanical supports.

Some of our patients are not unlike Darth Vader -- wholly dependent on technology, but minus the ability to think, walk, act, let alone talk.

And the money that we dedicate to prolonging the dying process is not small. In Ontario, 10 per cent of the health-care budget or $5 billion annually is spent on the care of patients in the last year of life -- of which $1.3 billion is spent in the last month of life.

Why does this happen? I argue it does because physicians and the public are poorly educated on what dying looks like.

We all have a shared vision of what death looks like: heart stops beating, no more breathing, eyes closed, surrounded by family and friends.

But in a technologically advanced world in which we can keep all those organs going, few Ontarians die this way. Instead, dying in today's world, where many people suffer from chronic illnesses such as emphysema, diabetes and heart failure, means a slow process that takes place over weeks, and sometimes months.

When patients come into hospital with severe complications from these illnesses, more than two out of every three Canadians indicate they would prefer high-quality measures aimed at managing their symptoms and comfort rather than technology to keep them alive. This often does not happen, because most of us do not want to have those conversations with the people who matter in our lives.

Most Ontarians say they are afraid to upset the people around them by talking about dying. So they come into hospital with their wishes unclear. And they end up on life support.

There are other challenges, of course. There are patients and families who believe in life prolongation at any cost, and in any form, irrespective of how little quality of life there may be. And there are physicians who have difficulty letting go, because the death of a patient seems to them tantamount to a personal failure.

But the fact remains that most Ontarians are not talking enough to their loved ones about how they want to die.

Go to www.advancecareplanning.ca for resources on how to make plans for that time when life prolongation is no longer possible or desirable. Talk to your doctor and your family about your wishes.

Wael Haddara is a physician and educator in London, Ont.