it was in 1972 that i was first rostered to work in an intensive care unit . from the first day
the list of changes and improvements is enormous , but one particular event and its consequence , more than any other , changed both my practice and my life .
the event was a lecture by professor joe civetta in 1982 in sydney . in 1980 ,
i heard joe speak in san antonio about ways of using nurses ' time better .
i had just begun running a ' continuing education meeting ' in sydney that was to focus on things i believed we had not thought about enough .
i invited joe to speak at this meeting in 1981 , and he informed me that the data and work was that of his wife , judy .
i asked what he would like to talk about and he said he had a lecture on ' stress , death and dying ' .
when i queried why anyone would want to listen to such a lecture , joe responded by suggesting that if 1% of my patients developed renal failure and 10% died , then maybe i should know as much about dying as i knew about renal failure .
joe 's lecture in march 1982 totally changed my practice and that of many others who attended .
the message was simple , and is , in a small way , discussed in one of joe 's papers :  intensive care leads to situations where continuing treatment prolongs dying and suffering without producing survival .  to determine when this point is reached involves consideration of objective data and emotive aspects such as patient wishes . 
the patient 's wishes could sometimes be ascertained from speaking to the patient 's family .
 there is a need to create an environment in which both health care providers and consumers could discuss the appropriateness of treatment and a peaceful death could occur when indicated .
 there comes a time when the goals of good medical care should be comfort rather than cure .
the concepts are not as dramatic now as they were then , because today there is a virtual industry surrounding the dying patient and the patient 's family .
withdrawal of care was unusual in our unit at that time , and when it did occur it was often covert . trying to improve
the end - of - life care of our patients moved us rapidly to a situation where only 9% of our patients died when we were still trying to prevent dying with all our resources , and 12.2% became brain dead . in the remainder of the patients , treatment was withdrawn or withheld .
we began to talk to patients and families about appropriateness of treatment and about withdrawing and withholding treatment .
after reading majorie sternberg 's paper ' the responsible powerless ' , we instituted regular meetings with the nursing staff at which the patients and the appropriateness of their care could be discussed in more depth than on ward rounds .
we developed a corporate philosophy that we called ' the same team ' , as the goals of the providers and recipients of care were usually the same .
the same team ' also meant dressing the same , so the white coats disappeared .
our mantra was taken from a paper by dunstan : " you should not judge .
the success of intensive care is not to be measured only by the statistics of survival , as though each death were a medical failure .
it is to be measured by the quality of lives preserved or restored , the quality of the dying of those in whose interest it is to die and by the quality of relationships involved in each death " .
we learned that the deeper and closer relationships with patients and families meant their hurt and grief was shared .
the process improved the relationships between all staff as well as between staff and patients .
we began to attract the interest of our colleagues and were asked to see patients in the ward to assist with end - of - life care .
the hospital changed from a ' blue card ' system of identifying patients who were not for resuscitation to requiring a proper ' do not resuscitate ' order , which stated what treatment was to be withheld , what treatment was to be continued , why the decision had been reached , who was involved in making the decision , and why the patient was not involved ( if they were not involved ) .
our hospital made ' do not resuscitate ' orders a quality issue : 80% of patients who die had such an order when the notes where last surveyed .
we began to be asked to present in other hospitals , and to lecture our new interns on dying , a subject we learned was not dealt with in undergraduate training .
eventually , with some trepidation , we produced three papers describing our activities , including the policy of not providing treatment that would not influence outcome at the request of patients or families .
the papers were taken up by the national press : 98% of the feedback was positive . with the help of joe civetta 's withdrawing and withholding care policy from jackson memorial hospital in florida , we developed a hospital policy on withdrawing and withholding care .
this policy went to the health department , who referred it to the legal section .
their response to the question ' could somebody acting in accordance with this policy be charged with murder ? ' was affirmative .
laws were drafted , and were discussed at a public meeting involving a diverse range of groups , from the right to life to the cryonic preservation society .
all groups were unanimous in believing that end - of - life care was an inappropriate matter for laws , courts , and lawyers .
the morass of case law regarding the ethics and practicalities of end - of - life care in the usa convinces me that this was a very mature attitude for a representative group to take .
one member of the profession at the meeting put the question regarding a charge of murder to the legal expert in a different manner : ' do you think it is likely that a doctor withdrawing life support from a patient in new south wales would be prosecuted for murder ? ' ' if prosecuted , is it likely that a conviction would be entered ? ' ' if convicted , is it likely that other than a derisory sentence would be given ? ' the answer to all three questions was ' no ' .
the new south wales health department interim guidelines for withdrawing and withholding care were released in 1992 .
i suspect they were made ' interim ' because of political fear that they may have caused controversy and cost votes .
there were no dissenting voices from either ends of the spectrum . in two cases ,
the final version , incorporating those comments , is due before the end of 2002 .
the increased awareness of consumers , the diversity of families , and the confidence - breaking patients who threaten our ability to prognosticate by surviving well , against impossible odds , tend to make these processes more complicated today than they were when we first set out on this path .
but there is no doubt that it made our intensive care unit a better and fairer place to work , and almost certainly made those of us who walked the path better doctors and nurses , and better human beings .
we are constantly impressed by the wisdom and dignity of australians from all ethnic , religious , cultural , and social backgrounds in dealing with end - of - life decision - making for those they love , when empowered to be part of the process .
there are studies suggesting to us that this approach may not be favoured in other areas .
the support investigators found that bringing patients ' wishes to the notice of treating physicians did not improve the quality of end - of - life care . in a more recent french study ,
we have no data that the process we have developed is better than any other .
we have received two letters of complaint since 1982 related to withdrawal of care against the families ' wishes , referred by the new south wales complaints unit .
in contrast , we have a vast quantity of mail thanking us for the care and consideration shown .
in 1967 , the art critic john berger addressed the question ' what is a human life worth ? ' .
his answer was : " i do not claim to know what a human life is worth  the question can not be answered by word but only by action , by the active of a more human society " .
we believe there are enormous benefits to both consumers and deliverers of health care in the active creation of a more humane intensive care unit , and this is an appropriate area for our speciality to show leadership .
 in 1982 , the author attended a lecture by professor joseph civetta dealing with the concept that , at times , the goal of care should be comfort rather than cure , and that inappropriate care prolonged dying and suffering . 
 efforts to improve end - of - life care subsequent to this had effects on care at a local level and at a state level . 
 intensive care providers should be leaders in the provision of appropriate and compassionate care at the end of life . 
Introduction
Competing interests