HOSPICE care - the end-of-life care provided by health professionals and volunteers - is not a topic oflen discussed due to it's sensitive nature.

But,  it's a topic that Singaporeans will need to address. With the country's ageing population, hospice care is fast becoming an urgent area of concern.

The latest statisics show the median age of Singapore's resident population is 37 this year - way up from just 20 in 1910. The post-war baby boomers - aged five to 24 in 1970 - have now moved up to the age group 45 - 64. And almost half of Singapore's population is in the 35-64 age group.

All this means that in the next few decades a large proportion of the population will be much older, and issues related to their care will become paramount.
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Singapore's population hit 4.99 million in 2008. Of thal number, 3.73 million are residents here. And out of that number, some 1.66 million are aged belween 35 and 64, up from 1.3 million a decade ago. This age group makes up 44.5 per cent of the total resident population, up from about 40 per cent just 10 years ago.

Compare these numbers to the fact that there are just four hospices in the entire country with 125 beds between them - and the concerns about supply begin to make sense.

The Singapore Hospice Council - the umbrella body incorporating all organisations that actively provide hospice and palliative care here - estimates that about 70 per cent of people with terminal illnesses are dying without hospice palliative care in Singapore.

An increasing sophisticated and educated population will also begin to demand better hospice care, as well as palliative care - which includes any form of medical care that concentrates on reducing the severity of disease symptoms and on improving the quality of life for those with serious and complex illnesses.

Hospice care
Palliative and hospice care aren't just about housing a patient in his last days. They're about managing his pain and discomfort, providing him with psychological and spiritual support and helping him maintain a decent quality of llfe - something everyone would need and appreciate when and if the time comes. And caring for terminally ill patient can be emotionally and physically draining for a family member.

Hospice care comes in the form of day care and in-patient care at hospices, home care - where trained professionals provide palliative care to patients in their home - and acute care at hospitals. Dover Park Hospice (DPH), Assisi Hospice (AH), Bright Vision Hospital (BVH) and St Joseph's Home and Hospice (SJH) are the only fuIl-time, in-patient hospices in Singapore. All four are voluntary welfare organisations, depending on public donations - with subsidies from the government - as their primary source of funding.

Palliative day care is provided by HCA Hospice Care, AH and BVH, while home care is provided by HCA. AH, BVH, Metta Hospice Care, Agape Methodist Hospital and the Singapore Cancer Society.

Palliative care services have also been established at all acute hospitals.

The acute shortage of beds here means that in-patient hospice care is limited to those who do not have care-giver at home or those who need special nursing or medical treatment.

It was reported In the Today newspaper in October last year that of the 17,000 deaths in Singapore in 2007, only 26 per cent received some form of subsidised hospice or home hospice care - indicating a sizeable unmet need.

AH, which has 35 beds, says it has a waiting list for its in-patient service almost all of the time. BVH's 32 hospice beds are usually fully occupied at anyone time. Over at SJH, half of its 22 beds are for hospice patients - and those are also fully taken-up, most of the time.

Speaking for DPH, lawyer Stefanie Yuen-Thio,  who sits on its governing council says: "We almost always have a waiting list of anything from two to 10 patients who have been referred by the hospital. Our occupancy rate is always very high but we have to keep at least one single-bed ward free in case we need to isolate a patient."

DPH has 40 beds and recorded 437 patients in the last financial year.

The Health Ministry bas indicated that it would like to see a 50 per cent increase in hospice beds by 2015, and has encouraged DPH and AH to expand their capadty. There are also plans for hospice beds in the new nursing homes and community hospitals scheduled to be sat up in Singapore.

Specialist care
There is also a need to boost the level of training and specialist care that can be provided. While palliative medicine has been recognised as a specialty in much of Europe, the UK, the US, Australia and New Zealand, it was only recognised as a medical sub-specialty in Singapore In 2007.

Health Minister Khaw Boon Wan, in a 2007 ,speech, spoke of the need to ramp up manpower to support the growing demand for palliative care. "This is a labour and skill-intensive service. We need to train many more nurses, counsellors, medical social workers and therapists. We need  to support  them with long-term career paths and meaningful salary schemes to attract and retain them," he said.

R Akhilesh, HCA's chief executive, estimates that his centre looks after more than 900 patienls on any given day, all over Singapore, compared with 300-350 patients in 2001. HCA cared for more than 3,200 patients in FY08/09.

"Although the number of doctors and nurses interested and willling to work in home hospice care has increased in the past few years, we are still helow the required number of nurses and doctors needed to look after these patients. Currenlly. HCA Hospice Care look after 35·40 patients at any given time. The ideal nurse 10 putient ratio would be 1:25. The supply has not kept pace with  the demand," Dr Akhilesh told BT.

The Lien Centre for Palliative Care is working to train healthcare professionals who work in nursing homes to enable them to provide basic palliative care to the residents when the need arises. It also sees the need to educate and train healthcare professionals working with patients with cardiac, respiratory and renal failure to provide palliative care.

Broader forms of hospice care, not limited to terminal care, are also included. The Health Minister, in that 2007 speech, said palliative care needs to be extended beyond oncology to other terminal-stage chronic conditions, such as chronic obstructive lung disease and heart failure.

HCA has been reaching out to support non-cancer patients requiring hospice care. These days, some 10 per cent of its patients are non-cancer patients, compared to1.5 per cent in 2001.

The KK Women's and Children's Hospital's Palliative Care Unit (KKH), which provides hospice care for children, believes care is also needed for children diagnosed with life-limiting illnesses like celebral palsy, neurological diseases, and congenital chromosomal or metabolic disorders. It explained that these children are not necessarily terminal and may live for many years before they die of their disease and its complications.

KKH believe, home hospice care is desperately needed for children in need of palliative and hospice care. KKH says this need is not being met, with a lot of children who require such care either not being recognised or not referred because many organisations are not comfortable with looking after such children. Only KKH and AH have the capabilities to do so at present.

KKH also sees the need for an extension of paediatric palliative care to prenatal/neonatal palliative care. These are for expecting mothers who are going to deliv'er a child who is not expected to live long, or who may be a stillbirth, or for newborns who may have medical conditions that will cause death within a few weeks.

DPH would like to be able to provide more acute care in its in-patient facilities. "This would allow us to handle more medically complex cases than we are currently set up to deal with, which will allow us to help a larger pool of patients who have more complicated needs," Ms Thio says.

Home care
Increasing the numher of hospital beds and improving the type of in-patient care at hospices are longer-term goals. Over the nearer term, the more immediate need is to have more home hospice care.

The Health Minister, in his 2007 speech, said that of the 17,000 Singaporeans who died last year, 55 per cent died in acute hospitals. "Twenty-eight per cent died at home, but I suspect many more would prefer that," Mr Khaw said.

A recent study by the Lien Foundation found that 80 per cent of those surveyed said  they were not open to the idea of being in a hospice if they were dying, preferring to spend their last days with their family.

Ms Thio says, "Many patients fret that their final days have to be spent in a hospice, away from their families and ultimately at the mercy of strangers. They would like to spend their last moments in their own beds, with the comforting presence of their loved ones close by.

"We are hoping that if we can successfully roll out specialised hospice care delivered to the home, more of our patients will be able to make the most of those last precious moments."
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In the US, hospice-at-home care forms the bulk of hospice services, with in-patient care being a form of acute hospital care.

Ms Thio says: "I believe many patIents would like to see that model available as an option. It makes good business sense too, as the cost of looking after a patient at home is generally less than on an in-patient basis."
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The Health Minister has also recently changed its healthcare financing policy so that CPF funds can be used for home palliative care.