Neglected to death - is this the Howard Government's aged-care philosophy?

The Commonwealth Government would seem to have found an innovative solution to the shortage of places in nursing homes. In a Commonwealth-supported development by Melbourne's Austin Hospital, elderly people are being offered the, euphemistically titled, "Respecting Patients Choices" program.

This is not, as one might expect from the name, a program to provide a greater range of choices or resources to patients. It is a program whose clear intention is to encourage patients to opt for an advanced directive that would bring about death by neglect in the event that they become mentally disabled or terminally ill.

The program is being distributed to general practitioners and Aged Care facilities. It involves elderly or sick people appointing an enduring power of attorney for medical treatment and completing a "Statement of Choices".

There are two choices that have already been completed on the form. The patient only needs to tick the boxes. The second is a refusal to be resuscitated. The first is worded:

If I reach a point where it is reasonably certain that I will not recover my ability to interact meaningfully with myself, my family, friends, and environment, or I am in the terminal stage of an illness:

I want to stop or withhold treatments that might be used to prolong my life (such treatment may include tube feedings, intravenous fluid, respirator/ventilator, or antibiotics). I only want those treatments which provide me with comfort and dignity as part of a palliative care plan.

Many patients in nursing homes would meet this description of being unable to "interact meaningfully with myself, my family, friends, and environment" as would many people cared for in their own homes. Dementia does that. Lack of adequate nutrition also causes mental disability in ageing people.

The prognosis "terminal stage of an illness" becomes a self-fulfilling prophecy if it means that the person is to be denied sustenance.

Simply expressed this directive means: "If I suffer from dementia or am terminally ill, starve me and let me die of thirst. And if I also get pneumonia, save the antibiotics, let me drown in my own sputum."

There is no stipulation that the refusal is to prevent suffering. There is no limit on what might be refused so that ordinary, non-burdensome care is continued.

When the Medical Treatment Act was passed by the Victorian Parliament 14 years ago, the case that had prompted the need for the legislation was the predicament of Mr John McEwan, a young man who had been forced to endure mechanical ventilation against his wishes. At the time the Parliament was careful to exclude the reasonable provision of food and water from what might be refused. For the purposes of the Act, this was not to be considered medical treatment.

The logic at the time was that palliative care involved helping a person to live with the dying process, managing pain but maintaining their functions as best as possible, including sustaining them. Palliative care did not mean hastening their death. The expert witnesses to the Parliamentary enquiry pointed this out very forcefully. The point was that burdensome treatments could be refused not the ordinary care needed to sustain them.