Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.
...
Do not go gentle into that good night
Dylan Thomas, 1914 - 1953
The Pap smear is gone. Welcome the CST (Cervical Screening Test). December 1 marks the change over to the new system. General practitioners have been inundated with information about the new test but on page 23 Dr Ruth Tinker gives the one page guide for the busy GP.
Change in medical practice happens slowly but the understanding of the biology of human papilloma virus and the advent of early virus detection together with a nationwide vaccination program will further reduce the mortality from this deadly disease. The management of positive results will be addressed in a subsequent article.
NRGPN Chairman, Dr Nathan Kesteven, has a long standing interest in obstetrics and works two weeks per month as a GP/obstetrician in rural Queensland. On page 21 he reports on the state of obstetric care in New Guinea where he visited Port Moresby General Hospital recently. The terrible infant mortality rate reflects the lack of staff and facilities for even rudimentary antenatal and perinatal care in most of the country.
Training programs to increase the supply of midwives and doctors are in place but resources are very limited. Dr Kesteven highlights the dedication of two Australian obstetricians working tirelessly to improve the situation. Support for this work is crucial and the “Send Hope, Not Flowers” organisation and accompanying video highlight the needs while also providing a mechanism to contribute.
Mental health disorders and substance abuse are frequent fellow travellers. This has long been recognised by psychiatrists and Australian health authorities through their Comorbid mental disorders and substance use disorders model which dates back to 2003. GPs are reminded of the association on an almost daily basis.
This combination of these medical problems is most acute for Aboriginal people. Adding in institutionalised disadvantage can make for a toxic environment which social and medical services have so far been unable to successfully address.
On page 15, we report on a Commonwealth funded trial taking a more holistic approach to this mix of problems. The $100,000 pilot project for Aboriginal clients in the Richmond Valley is being run through Rekindling the Spirit and the Jullums Aboriginal Medical Service, Lismore with support from the North Coast Primary Health Network.
Addressing the social determinants of health is the key to progress in this difficult area. If the pilot is successful there is the option of expanding it more generally on the North Coast. Progress is urgently needed and the results are anxiously awaited.
The Victorian Voluntary Assisted Dying Bill 2017 has passed parliament and is set to become law. However, its provisions will not be accessible to doctors and patients for another 18 months. As in the rest of the community the debate was passionate on both sides and the vote was close. Death of a loved one is a near universal experience for all adults and personal experience shapes one’s views more than politics or religion.
Supporters of physician assisted suicide include many prominent Australians from the law, business, the arts, the media, scientific research and both sides of the political spectrum. Dying with Dignity promotes physician assisted suicide through its chapters in Victoria and other States.
The RACGP features on the home page of the NSW Dying with Dignity website. The College, like all groups in the debate, supports excellence in palliative care and stringent safeguards to prevent coercion of either the patient or the doctor being asked to participate in physician assisted suicide. Support for this within the College is far from universal, however, with the doyen of general practice in Australia, John Murtagh, bitterly opposed and threatening to resign from the College.
Hope Australia is the organisation co-ordinating opposition to euthanasia. It too features prominent Australians with strong views on the subject. The current and two former prime ministers, Malcolm Turnbull, Tony Abbott and Paul Keating, all oppose physician assisted suicide, highlighting the diversity of political views on this most contentious issue.
Also opposed, after some internal debate, is the AMA. It’s position paper recognises that the Australian parliaments will ultimately make the laws on assisted dying but, if passed, the AMA requires regulations and guidelines protecting patients, physicians and the health system as a whole. The position paper also makes the point that requests for physician assisted suicide may be associated with “depression or other mental disorders, dementia, reduced decision-making capacity and/or poorly controlled clinical symptoms” and that these factors must be addressed in the first instance.
Optimal palliative care will go a long way to relieving the suffering that patients, and their families, experience at the end of life and will often obviate the need to consider assisted suicide.
In this issue of GPSpeak well known Tweed Heads anaesthetist, Ian McPhee, puts the yes case for voluntary assisted dying. Ian has seen end of life issues from both sides of the doctor / patient relationship and recounts his own experience of incurable cancer.
Jane Barker, general practitioner and academic, after a life time of primary care, puts the No case and argues for improved palliative care. Giving adequate pain relief and other treatments that may result in a shortening of the patient’s life is to be considered good care and not assisted suicide. However, this treatment is clearly distinct from actively ending the patient’s life which she, like the majority of Australian physicians, still oppose.
Our own experiences shape our views. Improving palliative care, in which general practitioners play a pivotal role, will lessen the burden.
Death of a parent is a poignant event in everyone’s life. On the eve of Easter this year, my father died after a short illness. Throughout his life he was never a rager, until the very end.
