Angry Doctor

Saturday, September 08, 2007

Death and Other Inconveniences 3

A more in-depth article on the news story yesterday that provides a more realistic view on dying at home. angry doc highlights the bits not covered in yesterday's news:

Dying at home - why not?
Health Minister Khaw wants to make it easier for the terminally-ill
Tan Hui Leng

MODERN healthcare may save countless lives — but it has taken away something precious from the process of dying as well.

Although death is a taboo subject, Health Minister Khaw Boon Wan noted: "There was a time when death was an integral part of family life. People died at home, surrounded by their loved ones. Family members experienced death together, mourned together and comforted one another.

"In a way, modern healthcare has made dying a lonelier process as more people die in hospitals. Their loved ones have less opportunity to be with them and often miss their last moments of life."

Which is why Mr Khaw would like to make matters easier for terminally-ill people who would prefer to die at home.

"If need be, we shall change the rules and processes that currently hinder dying at home," he declared.

"After a full and meaningful life, I would certainly wish to die at home, among my loved ones, in familiar and peaceful surroundings."

Speaking on Friday at the opening of the Children Hospice International's Congress, the Health Minister threw the spotlight on palliative care.

He believes that, like him, Singaporeans would prefer to die at home. But only 28 per cent got their wishes — 55 per cent breathed their last in acute hospitals.

"While dying in hospitals is natural for fatalities due to accidents, heart attacks and other unforeseen events, the terminally ill have time to prepare for their final moments," he said. As such, families and healthcare workers "should strive to meet their final wishes".

The Ministry of Health (MOH) will study the matter in greater detail, said Mr Khaw. One problem could be getting hold of a doctor to certify the death, when it comes, at home.

As Dr Noreen Chan, chief executive and medical director of Dover Park Hospice, pointed out, family members may not know which doctor to call after clinic hours.

And not all doctors would have applied for the necessary Certificate of Cause of Death book from the Immigration and Checkpoints Authority, she said.

Another obstacle could be costs — patients in acute hospitals get subsidies, but homecare and hospice patients are means-tested. And insurance does not usually cover step-down care services such as homecare. So, patients are more inclined to stay — and die — in acute hospitals.

"Distortions" such as these need to be studied and the MOH will hold focus group discussions, Mr Khaw said.

There are other problems. While a patient may prefer to die at home, this is not always easy for the family, said Dr Chan. "Family members may be unable to provide the care, either physically or psychologically, as it may just too much for them ... It can be very stressful on the family, for example, if the patient is in pain or become delirious."

At the Dover Park Hospice, staff counsel and help family members — from teaching them how to care for their loved ones in their last days, to broaching the subject of funeral preparations.

Mr Khaw thinks more public education on hospice and end-of-life care is needed.

As for the bigger picture, the MOH will support and grow palliative medicine as an attractive and effective medical sub-speciality.

It will extend palliative care and benefits beyond oncology — the study of cancer — to other terminal-stage chronic conditions, such as chronic obstructive lung disease and heart failure. Manpower to support the growing demand will also be ramped up.

"We need to train many more nurses, counsellors, medical social workers and therapists," said Mr Khaw. "We need to support them with long-term career paths and meaningful salary schemes to attract and retain them."

Medical director of Hospice Care Association, Dr R Akhileswaran, said this would be a boost to the sector. "In palliative care, we always have problems finding doctors to work in the speciality," he told Today.

"With it being a sub-speciality, there will be a clearer career path and maybe more doctors will look at it as a long-term option."

This will, in the long run, benefit the patients — Dr Akhileswaran estimates that more than 90 per cent of his patients would prefer to die at home.

"It's a basic human tendency that a person in his last days would prefer to spend them with his own family, rather than in a strange place," he said.

It's not easy, it's not cheap, and it's not going to be pretty.



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