When a disease starts winning the battle, it is time to make a critical decision: Should one stop fighting death and focus, instead, on a comfortable and dignified final phase of life?
Patients and their family members look to doctors and nurses for guidance.
But here's the bad news. In Singapore, most of these health-care professionals feel ill-equipped to answer this question. They simply do not know enough about palliative care, which would reduce a patient's suffering and make the remaining days of his life better.
The result: Patients continue their futile fight against death, going for chemotherapy sessions and putting up with the pain, even when there is no hope left.
Even when doctors know that the fight is pointless, they don't know quite how to gently tell the family that it may be time to accept the inevitable.
A survey commissioned by philanthropic group Lien Foundation showed that three in four doctors and nearly half the nurses here feel that they do not know enough about palliative care.
Currently, there are only 46 palliative-care specialists among some 11,000 doctors here.
This survey polled 207 doctors and 425 nurses. Only 17 per cent of these doctors and 26 per cent of nurses felt they had enough training to care for the dying.
Take the example of a cancer patient who had to choose between continuing chemotherapy sessions or going on a Haj pilgrimage. An honest assessment of his condition could help him make the most important decision of his life.
"If people know they don't have long to live, goals do change," said palliative-care specialist Noreen Chan, a senior consultant at the National University Cancer Institute, Singapore.
Pang Weng Sun, vice-dean of clinical affairs at Nanyang Technological University's Lee Kong Chian School of Medicine, said: "Very often, you are used to treating a patient with the view of curing the patient...At which point do you say, I should take a step back and maybe change my approach now, because the patient is no longer improving? It's not always a clear area and, actually, not an easy decision.
"The first thing we need to get our doctors to start working on more is, how do you start conversations about what's important to the patient...And that itself is a difficult conversation to initiate."
Medical schools here plan to expand and enhance training in end-of-life care. Currently, the amount of training in palliative care given to students in their entire medical course is about four days to a week.
The Yong Loo Lin School of Medicine at the National University of Singapore (NUS) plans to introduce simulation sessions in which students talk to "dying" patients.
It would help to have a framework to deal with the situation, said Joshua Lee, 23, a final-year medical student at NUS. "But translating that to the bedside, when you have to explain to a patient that he has a few months to live...it's not something you can pick up from the textbooks," he said.
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