But standards have improved since study done in 2007, authors note
IT IS an agonising life-or-death decision. Should doctors resuscitate a terminally ill patient who is nearing the end anyway? Understandably, they are not always able to get the person’s consent. But a study has found that even when patients are alert and able to talk, this issue is still rarely discussed with them. And many terminally ill people are given aggressive treatments during their last 24 hours, which may cause unnecessary pain while merely postponing the inevitable.
The study by a team of doctors concludes that the quality of end-of-life care in public hospitals is “suboptimal”. However, the study’s finding was based on data from four years ago, and its authors say that standards at the National University Hospital (NUH), where it was conducted, have since improved. Researchers studied the case notes for all 683 people who died in NUH’s general wards in 2007. Their paper was accepted for publication last month by the United States-based Journal of Palliative Medicine.
It found that while in the West, patients are usually consulted if possible before a decision not to resuscitate is made, this seldom happens in Singapore. Of those not resuscitated, only 4 per cent had been asked about it – though some may have been unconscious or not capable of understanding. Doctors were more likely to make this choice with the help of family members, who were consulted in about 80 per cent of cases. And more than 17 per cent of the time, the decision was made by the doctor alone, though in some of these situations there may have been no next of kin. The team noted that in Western countries, “excluding a competent patient from such decisions is unjustifiable since it demeans the patient by barring selfdetermination and allows others to shorten the patient’s life”.
They said the findings might reflect Asian cultural biases. In Singapore, the practice has always been to consult the family, especially when the patient is unable to make such decisions, said Professor Lim Tow Keang, head of NUH’s Respiratory and Critical Care Medicine division. He was part of the team of seven doctors who produced the paper, helped by a Ngee Ann Polytechnic researcher. Prof Lim’s comments reflect those in a study released recently by the Lien Foundation, where doctors said they often discuss elderly patients’ conditions with the families.
The report on NUH was initiated by respiratory physician Jason Phua, who wanted to improve care for the dying at the hospital. It found that many were still being given aggressive treatments right up to the end, which “probably inflicted pain and certainly did not avert death”. This may have happened because in 28 per cent of cases, no decision was made about how patients were to be treated, and 43 per cent of the time neither they nor their families had been consulted. The team suggested that hospitals should use “integrated care pathways”, which provide a framework for decisionmaking and care of the dying, and that instead of carrying out “excessive burdensome interventions”, more doctors should be trained in palliative care to make patients’ last days more bearable.
Since 2007, changes have been made to improve the standard of care for the dying, said Prof Lim. NUH has introduced a “pink form” which provides a checklist of things to discuss with the family and can be used to document any discussions and decisions made. He said that last year, discussions with patients or family were held in 90 per cent of cases where a person died in the general wards, and a decision on how to treat the patient was made 80 per cent of the time. Those who are clearly dying are also now less likely to receive aggressive treatments. Although the way they are cared for has changed, there has been no increase in the number of deaths, he noted. The report’s authors also noted that NUH’s palliative care has improved: “Such a service is associated with cost savings, better quality of life, and even improved survival for the terminally ill.”