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How not to die alone

Three years ago, I treated a patient who was estranged from his family and lived alone in a one-room rental flat. He suffered from advanced liver cancer, which had made him incontinent and severely reduced his ability to walk.

Despite multiple attempts to persuade him to accept hospice care, he chose to die at home. His body was discovered days later by a neighbour. I could imagine his final moments - alone and fearful. He is symbolic of a growing population of elderly people living in social isolation and struggling with serious illnesses.

As a geriatrician and palliative care physician, I have encountered many elderly patients at the end of their lives. They generally fall into two distinct categories - those who are at peace in spite of dire circumstances and those who remain distressed despite good treatment options. Predicting their responses has become fairly easy. The former are almost always plugged into a strong, caring social network of family and friends, while the latter often feel physically or emotionally isolated.

Strong, fulfilling relationships can be a panacea for physical distress towards the end of life.

Research backs this claim. One of the world's longest-running studies, the Harvard Study of Adult Develop- ment, sought to determine: "How can you live a long and happy life?"

Researchers tracked 724 men over 75 years, collecting data about their occupation, mental and physical health, lifestyle habits and relationships. Happily married men reported little impact to their positive disposition, despite physical pain owing to poor health. In contrast, those in unhappy relationships reported greater physical distress.

Happiness during old age should never be taken for granted. While the concerted efforts of government agencies, VWOs and healthcare providers are necessary to provide a secure and comfortable social environment for our seniors to age with dignity, individuals must also recognise their part in investing wisely - not in financial or material wealth, but in meaningful relationships with their loved ones.

The study also found that good relationships contributed to longer, happier lives. Men who reported being closer to their family, friends or community tended to be happier and healthier. Socially isolated individuals were significantly less happy, suffered declining physical and mental health earlier, and lived shorter lives.

In the face of a rapidly greying population, are we doing enough to promote social connectedness among our senior citizens?

The short answer is no.

According to the 2015 General Household Survey, 15 per cent of resident households headed by persons aged 55 years and over were one-person households. Nearly one-third of persons living alone were aged 65 years and over, up from 20 per cent in 2010. Increased preference for independent living arrangements, both among seniors and the young, may exacerbate this trend. Especially because seniors living alone often lack traditional sources of support, such as smaller social networks, poorer healthcare access and are more likely to feel lonely.

A study under the Singapore Longitudinal Ageing Studies series found seniors who lived alone were 1.7 times more likely to die prematurely, even after controlling for chronic diseases, marital status and functional impairment.

Another study by the National Healthcare Group reported that seniors who lived alone, or with a domestic helper, and felt socially isolated were more likely to experience depressive symptoms.

Staying closer together may help maintain more fulfilling, inter-generational relationships. Current housing policies already encourage children to live close to their parents. However, financial incentives alone are insufficient. Young couples prefer estates closer to schools, transport nodes or places of work, while the elderly benefit from estates with more senior daycare or rehabilitation facilities. In an ideal world, these different needs would not be in conflict. However, reports of people petitioning against geriatric facilities built near their homes are disheartening. They reflect a prevalent negative perception of ageing and death in Singapore.

Our society is ageing. The number of elderly citizens will triple to 900,000 by 2030, when every two working-age citizens will support one elderly person over 65. We cannot ignore the needs of this huge section of society. We must encourage more open conversations about ageing and disease, as well as dispel myths or cultural taboos associated with dying. Society needs to evolve to accommodate seniors and make resources accessible for them to remain healthy, active and socially integrated.

To do this, we should first understand their fears and concerns. A street poll by the Lien Foundation and Ngee Ann Polytechnic found that most Singaporeans identified being a burden to loved ones as their greatest fear at the end of life. More services will be needed to support caregivers of frail elderly persons who require greater supervision and care. Such facilities could also offer extended operating hours, so family members can pick up the elderly folks at the end of a working day.

To further support eldercare in the community, funding for geriatric homecare services must be stepped up. They play a vital role in preventing minor illnesses from escalating into medical crises and help empower children to care for aged parents at home. Reduced caregiver burdens can, in turn, facilitate more fulfilling family relationships.

The elderly of tomorrow will be distinctly different from the elderly of today - they will be better educated, more financially secure and have higher expectations. Community efforts aimed at promoting social connectedness will not only have to match these emerging needs, but will also have to be creatively designed to encourage transgenerational participation.

Happiness during old age should never be taken for granted. While the concerted efforts of government agencies, VWOs and healthcare providers are necessary to provide a secure and comfortable social environment for our seniors to age with dignity, individuals must also recognise their part in investing wisely - not in financial or material wealth, but in meaningful relationships with their loved ones.

I have witnessed many elderly people die in the arms of loved ones, and I believe this did not happen by chance. It took them a lifetime of relationship-building to be loved as an affectionate spouse, a nurturing parent or an endearing friend.

• Dr Neo Han Yee is a palliative care consultant at Tan Tock Seng Hospital and member of the National Healthcare Group, a Regional Health System for Singapore.


Correction note: An earlier version of this article incorrectly stated that according to the 2014 national census, 15 per cent of Singaporeans above the age of 55 lived alone. In fact, it should be according to the 2015 General Household Survey, 15 per cent of resident households headed by persons aged 55 years and over were one-person households.

The information on persons living alone aged 65 and older has also been edited for clarity.

A version of this article appeared in the print edition of The Straits Times on April 13, 2016, with the headline 'How not to die alone'. Print Edition | Subscribe