End-of-life care not up to standard: Study

SINGAPORE - Terminally ill patients in Singapore are rarely consulted as to whether they wish to continue receiving medical treatment, a study conducted at the National University Hospital (NUH) said.

It was found that many are still being forced to undergo aggressive treatments right until the very end, which often causes unnecessary pain while doing little to avert death.

While in the West, patients are usually consulted if possible before resuscitation is carried out, in Singapore, even when the patients are aware and able to communicate their wishes, this decision is rarely discussed with them. Of those resuscitated, the paper reported that only 4 per cent had been consulted - although this percentage may include those who were unconscious or insensible.

The standard practice in Singapore is to consult the family, especially if the patient is not able to make a decision, Professor Lim Tow Keang, one of the seven doctors who authored the paper and head of NUH's Respiratory and Critical Care Medicine division, told the Straits Times.

The Straits Times reported that in 80 per cent of the cases, the doctors in the study arrived at a decision with the help of family members. More than 17 per cent of the time, the doctor made the decision alone, including cases where no family member was available for consultation.

The team said this may reflect the Asian culture, in contrast to the Western belief that "excluding a competent patient from such decisions is unjustifiable since it demeans the patient by barring self-determination and allows others to shorten the patient's life."

The paper, initiated by respiratory physician Jason Phua with the aim to improve care for the dying at NUH, concluded that the quality of end-of-life care in public hospitals is 'suboptimal.'

The team proposed that hospitals should use 'integrated care pathways' - frameworks for making decision on caring for the dying - and that more doctors should be trained in palliative care to ease the suffering of the terminally ill.

The study's findings were based on the case notes for all 683 people who died in NUH's general wards in 2007. The paper was picked up for publication by the United States-based Journal of Palliative Medicine last month.

However the Straits Times report highlighted that authors have admitted the study's data is old, and the standards at NUH have improved since then.

According to Prof Lim, NUH has taken steps to improve their standard of care for the dying. One of the measures introduced is a checklist of things to discuss with the family. This 'pink form' can be used to document any discussions and decisions made.

Last year, discussions with patients or family were held in 90 per cent of death cases in the general wards and a decision on future course of action arrived at 80 per cent of the time, he said. Doctors are also less inclined to push aggressive treatments on those clearly at death's door.

"Such a service is associated wih cost savings, better quality of life and even improved survival for the terminally ill," the paper noted.

Prof Lim added that although changes have been made to NUH's end-of-life care, there have been no increase in the number of deaths.

yamadak@sph.com.sg