Andy Ho, Senior Writer

Better to die a good death at home

Dying has moved from the warmth of one’s bed to the cold comfort of one in hospital, but might not an earlier death be better than a drug-filled prolonged life? Doctors should learn to recognise medical futility sooner and be brave enough to let pe
Dying has moved from the warmth of one’s bed to the cold comfort of one in hospital, but might not an earlier death be better than a drug-filled prolonged life? Doctors should learn to recognise medical futility sooner and be brave enough to let people go home to die earlier. -- ST FILE PHOTO

MOST Singaporeans would choose to die at home if they could. A Lien Foundation-commissioned survey shows 77 per cent would prefer to do so. But official records show only 27 per cent dying at home last year, a figure that has changed little over the years.

Dying has moved from the warmth of one's bed to the cold comfort of one in hospital.

This is so even when the terminally ill can receive palliative care, which includes good pain control, at home. A team of doctors, nurses and social workers from a hospice will visit the patient at home once a week or more often to provide medical and emotional support. Such care can be had for $1,500 a year compared to hospital care, which is far more costly.

Dying at home means family members can come and go from the dying person's bedroom as the end draws near. So, the person is with his loved ones up to his last breath. But people are denied this when they die in hospital.

There is also a conspiracy of silence about death, which is treated in the culture as something unspeakable. We strive assiduously to keep it out of the public eye, we do not like to talk about it.

This cultural angst about death fits nicely with what we have inherited from the West's science-based approach to health care, which has privatised death by medicalising and institutionalising it.

If death seems imminent, people are rushed off to a hospital and handed over to doctors who cannot know which particular medical crisis will prove the last one for any particular patient. So they persist in their therapeutic ministrations unto death.

In this world of high-tech medicine, neither health-care giver nor patient and family have space or time for a good death. It would appear very strange to us today, but, for a long time, doctors actually had little part at the deathbed.

This was because, up to the mid-17th century in the West at any rate, dying was still considered something profoundly religious. If anyone was to minister, it was the minister of one's religious persuasion, not doctors.

Yet, by the 19th century, doctors had come to dominate the dying context - but not because of significant advances in pain relief or prolonging life. In fact, no such advances in either area would come until the 20th century.

So doctors gained a place in the context of dying despite medicine's inability to offer anything new. One cause was that, with industrialisation and urbanisation, people became less religious.

According to the late British historian Roy Porter who was a professor of the social history of medicine at University College, London, certain developments in medicine, politics and religion began to change notions of the self, from the religious idea of an immortal soul within the body to a model of the self that stressed consciousness, or the mind.

His magnum opus, Flesh In The Age Of Reason: The Modern Foundations Of Body And Soul (2003) showed how changed mindsets led to changed practices.

Instead of regarding death as the portal to eternity, many people had, by the 18th century, come to regard living and dying as two endpoints along one continuum. Importantly, both points could be mastered, it was now said. Most of all, by the late 18th century, the emphasis had shifted to the embodied life: earthly happiness was an end in and of itself.

Also, early in the 19th century, doctors were struggling to set the medical profession apart from widespread quackery. In that struggle, the profession came up with various codes of ethics to boost its own standing in society.

One brilliant move the medical fraternity made was to institutionalise it as an ethical duty for doctors to aid rather than abandon the dying even if no more could be done, medically speaking.

Yet, what would the doctor actually do in that context? It was suggested that he stayed around to calmly provide any little bit of relief that was possible. In this way, the dying would not be bereft of hope until he expired.

So doctors could appear to master death itself by offering a hopeless hope in tiny portions. In this manner, dying was medicalised.

When no more could be done, medical ministrations were continued if only for the sake of trying to master this endpoint of the continuum of existence.

Up to 50 years ago, people in Singapore were quite averse to being hospitalised because we had inherited Western medicine along with this place of the doctor at the deathbed. Our forebears tended to associate hospitalisation with death, so it was strenuously avoided, if possible at all.

But today, with smaller family sizes, there may not be enough support to care for the dying at home. So taking the dying person to hospital helps to domesticate Death for a little while for a people unwilling to talk about it.

It is now taken for granted that it is best to have doctors and nurses around until the end. But this need not always be true, especially in medically futile cases.

For example, for the terminally ill who are in severe pain, narcotics provide relief but also cause the dying person to drift in and out of consciousness. Narcotics also cause intractable constipation, which can be very distressing.

So sometimes doctors will go easy on the narcotics but the pain returns. Then they boost the dose again but the dying person's consciousness becomes clouded again. Might not an earlier death be better than a drug-filled prolongation of life?

If so, doctors should learn to recognise medical futility sooner and be brave enough to let people go home to die earlier: death is not always the greater evil, so the real question is whether it is in any particular case.

Those who are very ill must ask themselves if dying is a greater evil than living on grossly impaired. Each person must answer it for himself as bravely as he can.

Only he who has done so might be able to ask to be discharged from hospital to head home to go gentle into that good night.

andyho@sph.com.sg