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Tackling end-of-life issues in community

Clinical ethics support needed in treating end-stage patients outside of hospitals

The Straits Times (26 May 2017) - Does a bedridden patient suffering from pain and being sustained through tube feeding have the right to refuse such sustenance?

Yes, said Associate Professor Chin Jing Jih, a senior geriatric specialist at Tan Tock Seng Hospital (TTSH).

While fluids and nutrition are basic needs, tube feeding is not natural and is considered medical treatment. Patients have the right to refuse it even if it leads to their death, he said.

Hospitals have ethics committees that can help doctors make such decisions. But as Singapore shifts its focus from hospital to community care, this and other problems facing people at the end of their lives need to be addressed in situations outside of a hospital.

Associate Professor Benjamin Ong, the director of medical services at the Ministry of Health (MOH), said similar clinical ethics support is needed for decision-making outside of hospitals.

“Clinical ethics is also relevant and should have an important role in the decisions made in areas such as advanced-care planning, and long-term care and management plans for the aged and the infirm,” he said.

Speaking at the opening of the three-day 13th International Conference on Clinical Ethics Consultation at the Grand Copthorne Waterfront hotel yesterday, Prof Ong added: “We should start to make clinical ethics support more available to clinicians practising in these (community) settings.”

With Singapore’s rapidly ageing population, there is also some urgency for the population to talk about what it wants done in such cases, said Prof Ong.

He announced that the National Ethics Capability Committee, set up in 2014 to design a framework to equip healthcare professionals with “a good understanding of clinical ethics that will inform and guide their professional practice”, had just submitted its report to the ministry, which is reviewing it.

Speaking at the same conference, Prof Chin said some doctors in hospitals do not recognise that sometimes quality of life can be more important that quantity of life.

This is because most doctors have a “professional bias towards rescue and survival”, he said. But aggressive medical treatment may not be in the patient’s best interest.

Today, most patients suffering from end-stage organ failure spend the last six to 12 months of their lives “undergoing multiple rounds of invasive investigations and interventions”, said Prof Chin. This results in an inevitable trade-off “in their already marginal quality of life, as well as limited lifespan”. Some doctors continue prolonging life because they fear legal backlash should they not do so.

Doctors have also asked him: “Even if this were end of life, how do I know if this is the right time to change the therapeutic goal from one based on quantity of life (or survival at all costs) to one that is focused on achieving the best possible quality of life and comfort?”

His answer is, there are no absolute rules.

To help both doctors and patients, hospitals here are putting in a process where such patients’ conditions and needs are reviewed periodically, since their condition can deteriorate subtly. Regular reviews ensure that treatment is aligned with the best care for the patient.

Decisions on the course to pursue should be discussed with the patient or family, before a crisis occurs, so doctors would not automatically treat the patient aggressively to keep him alive, he added.


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