99-year-old had Covid-19 but family kept him at home until his death according to his wishes

The patient made his family promise that he would not be taken to a hospital again, and would be allowed to die at home when the time came. ST PHOTO: LIM YAOHUI

SINGAPORE - Questions have been raised about the protocol for terminally ill patients who catch Covid-19 and die at home, following the case of a 99-year-old man who told his family not to take him to a hospital.

Dr Choo Wei Chieh, co-founder and chief executive of home-care provider Ninkatec, told The Straits Times on Oct 28 that he was called to attend to the patient, Mr Teo, on Oct 20.

He added that Mr Teo had been bed-bound for some time before he saw him, and had suffered from conditions such as dementia, stroke and fractures.

He had been treated intermittently for pneumonia.

Mr Teo's daughter, who asked that she and her father be referred to only by their last names, explained that his throat muscles stopped working several years ago. He was admitted to hospital in 2017 for pneumonia and difficulty swallowing.

Madam Teo, 72, said her father found his stay in the hospital "unpleasant". Upon discharge, he made his family promise that he would not be taken to a hospital again, and would be allowed to die at home when the time came.

Dr Choo, 49, said when he saw Mr Teo on Oct 20, the patient had a chest infection and fluid in his lungs.

As a result, his oxygen level was already low at the time - around 70 per cent to 80 per cent.

A normal oxygen level should be above 94 per cent, said Dr Choo, although he added that this may vary among patients.

"We knew his condition was bad and that he might not have very long to live... The family was prepared for him to die at home when the time came," he added.

He said the likelihood of Mr Teo dying in the next few days was high.

But the situation became complicated when a Covid-19 antigen rapid test (ART) that Dr Choo conducted on Mr Teo on Oct 20 came back positive.

Dr Choo said: "We didn't really know what to do - this was the first time I've experienced a case like this... Patients like him who are 80 and above are sent straight to the hospital. But he had already expressed his wishes and care could already be rendered at home. Besides, if you sent him to the hospital, it would make it more busy."

He added that a patient like Mr Teo would likely be sent to the intensive care unit and exacerbate the workload of the already strained department.

Madam Teo said she told Dr Choo not to take her father to the hospital.

"We saw on TV that the hospitals are very overwhelmed right now - so many people have Covid-19. I told (Dr Choo) that if you were to call the ambulance now and my father were to go in… chances are that he would die there, and we would not be able to visit," she added.

The Ministry of Health (MOH) announced on Sept 22 that no visitors would be allowed in hospital wards from Sept 24 to Oct 23 amid a rise in cases.

Exceptions were made for certain groups, including patients in critical condition, but visitors were still limited in number and subject to restrictions.

Given the situation, as well as the likelihood of Mr Teo dying in the next few days, Dr Choo decided to care for him at home, while getting the rest of the family to take daily ARTs, all of which came back negative.

Mr Teo died in the evening of Oct 22, but another problem arose when the family tried to find an undertaker.

Dr Choo certified Mr Teo's cause of death as pneumonia as no confirmatory polymerase chain reaction test had been carried out beforehand.

But he told the family to inform the undertaker that Mr Teo should be treated as Covid-19-positive as a safety precaution.

Currently, the National Environment Agency's protocol states that the bodies of Covid-19 patients must be bagged by hospital workers before being placed in a sealed coffin.

But since Mr Teo died at home, there was no one to bag the body, and the undertaker said he could not collect the body. He referred her to the police instead.

Madam Teo asked the police to take the body to the mortuary where it could be bagged. The police said they could not do so as the cause of death had been issued and was not listed as Covid-19.

A second undertaker similarly said he could not collect the body unless it was bagged.

Eventually, after further discussions with the second undertaker and Madam Teo, the police came to bag the body.

Madam Teo said her father died at around 6pm but it took until around 4am the next morning for everything to be settled.

"It was very chaotic... I think the various parties need to communicate with each other. Otherwise, people will keep getting bounced around," she added.

She emphasised that she was not upset or angry as she understood all the parties were following protocol, and that she appreciated their help.

But she added: "The chances are that there may be more cases like this in the future… anything can happen, so if MOH is aware of this and the protocol could change a bit or be made clearer, things would be simpler."

Dr Choo said he felt that as Covid-19 becomes endemic, there will be more situations like Mr Teo's, as well as terminally ill patients who catch the virus but wish to spend their last days at home.

"At home, they have the comfort of their relatives around them when they die. It's much more comfortable than a hospital, and a more familiar place. Some consider it a more dignified death as well," he explained.

Dr Choo added that some Covid-19 patients with dementia may also be better managed at home rather than in a hospital or care facility.

He asked: "Can these patients have a way to be cared for at home? Can they be afforded some flexibility from current Covid-19 protocols?"

He added that precautions will have to be taken in the event that the patient is allowed to stay at home, depending on the situation and if other vulnerable people are living in the residence.

ST has approached MOH for more information on the protocols for Covid-19 patients who die at home.

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