Second Opinion: Care plans need to be as individual as the person

'Every old man I see", wrote Patrick Kavanagh in his Memory of My Father , "reminds me of my father." In my younger years, I loved this poem. Yet, as I began to train and work as a geriatrician, I became increasingly unsettled with the analogy, for no older man I had ever seen had reminded me of my father, a remarkable individual who defied pigeon-holing as a Stradivarius defies replication.

Indeed, in over 30 years of practice, not a single older man I had seen ever truly resembled another, reflecting the key characteristic of ageing: increasing complexity and individuality. Born as copies, we die as originals, and in every department of geriatric medicine, this formula provides an unstated but rich counterpoint to our work.

The greatest single threat to you and I as we age is a widespread and perverse tendency to respond to this complexity and richness with a deadening simplification. This can be seen in many aspects of healthcare.

For example, “step-down" or "intermediate care" units for care after hospital admission indicate a wilful or unconscious failure to recognise the need for rehabilitation after critical illness. My general advice to older people and their families when such services are mooted is to opt only for a facility which clearly provides rehabilitation (and is designated as such) or for home with support and, as Ella Fitzgerald would sing, not to mess with Mr
In-Between.

Advance care directive
Over-simplification was apparent again two weeks ago during a public relations push in the media on legally binding advance care directives associated with impending, and generally welcome, legislation on assisted decision-making.

A vox pop on RTÉ news was unhappily revealing. One person made reference to becoming a vegetable – disturbing in terms of attitudes to disability and supporting communication in disability.

It also points to a common misperception of loss of capacity as an all or nothing affair, where we go from full capacity in managing our affairs to no capacity in a very short period of time.

In fact, most of us who lose capacity will do so gradually, usually due to illnesses such as dementia and stroke, and we will retain areas of preserved capacity.

Care in a setting with well-trained staff tries to interpret and maximise this capacity.

Advance care planning, near the time when the person has some sense of what their illness entails, in conjunction with a doctor who is expert in the area, and which provides for reasonable flexibility in interpretation in terms of both complexity of the patterns of evolving illness and innovations in practice, is increasingly a part of usual care.

This is supported by the professional bodies (I am on the faculty of an advance care planning course in the Royal College of Physicians in Ireland), and the Medical Council ethical guidelines mandate that we support advance care planning made in this way.

Experience of dying
This approach has been validated by the experience of organ donor cards in Ireland.

The usual practice is still to consult with family after the patient has died, not only through courtesy and respect, but also in recognition that few of us can accurately predict what the experience of dying and death will be like.

An Irish study has shown that the donor's request has been respected in 100 per cent of cases, a very reassuring finding.

So, the push for legal underpinning of advance care planning is puzzling and counter-intuitive in the face of the complex and multiple possibilities of our final months, where rigid prior directions may limit your eventual possibilities and options.

A recent US study illustrated this, whereby the majority of staff in intensive care units described advance care directives as "useless".

For those who still think that a measure of “certainty” in future planning is a good idea, a helpful analogy is those who took out big mortgages at variable rates during the Celtic Tiger boom.

At least they can fight the banks’ position, however unsuccessfully: with impaired capacity, you will be much less able to do so for health choices.

So, for advance care planning, let us develop and enhance current modes of practice without recourse to simplistic legal strictures, mindful of HL Mencken's dictum that for every complex problem, there is a solution that is simple, neat and wrong.


Prof Des O'Neill is a consultant in geriatric and stroke medicine.