Quality can be more important than just quantity of life for end-of-life care, say doctors

SINGAPORE - Does a bed-ridden patient suffering from pain, who is being sustained through tube feeding, have the right to refuse such sustenance?

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, said medical practitioners at the 13th International Conference on Clinical Ethics Consultation at the Grand Copthorne Waterfront hotel on Thursday (May 25).

Going back to the question of whether a patient has the right to refuse tube feeding, the answer is 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 a 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.

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

"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 clinical ethics conference on Thursday, 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 also 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 now reviewing its proposals.

Speaking at the same conference, Prof Chin said some doctors in hospital 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 , he said, "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.

He said that 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 goals 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: There are no absolute rules.

To help both doctors and patients, hospitals here are putting in place a process where such patient's 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.

He added that 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.