Mortality is the one thing doctors and medicine cannot fix. We are all going to die, yet death remains one of the most difficult things to speak openly about.
On 18 October 2014, the Straits Times reported that the Ministry of Health (MOH) hopes to raise awareness of end-of-life care. DPM Teo Chee Hean, who spoke at the Palliative Care Community Outreach roadshow, said that the MOH wanted to help Singaporeans learn about palliative care and “have these important conversations with their loved ones about end-of-life issues.”
I am glad DPM Teo raised this issue. Most politicians avoid dealing with such difficult matters, for fear of being portrayed as unsympathetic or callous. But given our rapidly aging population, it is clear that we must confront, and not run away from, such questions.
Over the weekend, I asked a number of people how they would prefer to live their end days - 2 years with a good quality of life or 5 or more years with a poor quality one. Everyone chose the former. Yet, when the question is real, how many patients and family members make that choice? Family members in particular often feel it is their duty or feel pressured to keep their loved ones alive for as long as possible, regardless of age, condition or quality of life.
What do people who routinely deal with such issues say? In the last few days, I came across two pieces which are worth a read.
Dr. Atul Gawande is a Harvard trained surgeon. He recently wrote a book "Being Mortal - Medicine and What Matters in the End", where he tackles head-on the difficult issues of treating the seriously ill and the dying. The book deals with his personal experiences in dealing with the illnesses of his loved ones. His father was also a surgeon, who worked until he was 70, until cancer robbed him of his ability to use his hands. Dr Gawande’s argument is simple yet compelling - that the treatment of illnesses should be less about maximising survival and more about maximising well being. The two are very different, but often confused. We spend most of our resources prolonging life, without asking about the quality of that life. Dr Gawande urges doctors to first ask patients about their hopes, their fears and what they are or are not willing to sacrifice. Would you, for example, be prepared to sacrifice mobility or you career? The responses to those questions may help determine the extent and nature of the treatment. It sounds logical, but apparently rarely practiced.
Ezekiel J Emanuel is a director of the Clinical Bioethics Department at the U.S. National Institutes of Health. In his article “Why I Hope to Die at 75” http://www.theatlantic.com/features/archive/2014/09/why-i-hope-to-die-at-75/379329/ , he argues that we should allow nature to take its course. To be clear, Emanuel is not advocating euthanasia or suicide. He rejects those. He, like many of us, is concerned that his disabilities will place an unfair burden on his children and, and more importantly, that they will remember him for the burden he may become to them in his last years, and not the “active, vigorous, engaged, animated, astute, enthusiastic, funny, warm, loving” person he was for the vast majority of his life.
Emanuel’s solution is that upon reaching 75, he will neither actively end his life, nor prolong it. He will, according to him, need a good reason to visit a doctor and take medical tests and treatment. He will accept only palliative, and not curative, treatments.
This is highly controversial and many will find it difficult to agree. It is a course I would seriously consider for myself. Growing old should be about celebrating a life well lived, and not spent suffering or despairing about the inevitable. I do not want to spend my last days confined to a bed, kept alive by machines, being present only in body not in mind.
Ultimately, it for each person to decide what is best for him and his family. However, it must be an informed, rational decision. Discussions on active aging usually revolve around lifestyle issues such as exercise and diet. But it is much more than that. It is also a mind-set that recognises the issues and vulnerabilities that inevitably come with age, and how we should deal with them. Difficult as it is, we need to have frank conversations with our doctors and family members when the time comes. And it will come. Better we do so when we are clear-headed, before fear, emotion and guilt take over, and rob us of our ability to spend quality time with the elderly person in his last days.
Hri Kumar
MP for Bishan-Toa Payoh GRC