Protocol for seniors with Covid-19 is flexible, patients may be cared for at home: MOH

Although it is unclear what the official protocol is, Covid-19 patients aged 80 years and older are not typically eligible for the home recovery programme, and are expected to be transferred to external facilities. ST PHOTO: KUA CHEE SIONG

SINGAPORE - While the existing protocol is for all Covid-19 patients above the age of 80 to be taken to a hospital, this practice is "not rigid", the Ministry of Health (MOH) said on Thursday (Nov 4).

On Monday, The Straits Times reported the case of a 99-year-old terminally ill man who asked to die at home, but he was tested positive in an antigen rapid test shortly before dying. The family kept him at home until his death, according to his wishes.

The man's doctor and family highlighted the lack of clear protocols on what to do during the episode.

The man had earlier made his family promise that he would be allowed to die at home.

The doctor who attended to the case, Dr Choo Wei Chieh, told ST that sending the man to hospital would "increase the burden to already busy hospitals".

Dr Choo, who is co-founder and chief executive of home-care provider Ninkatec, added that given the man's unstable condition, he would likely have ended up in the intensive care unit, exacerbating the workload there.

In a forum letter on Thursday, MOH said: "Where patients prefer to be cared for at home, we have put in place home-based care programmes to support their recovery."

It added that if someone were to die at home, medical practitioners are able to issue a Certificate of Cause of Death for him regardless of whether he was suspected or confirmed to have Covid-19,and in the hospital or the community.

Professor Dale Fisher, a senior consultant at the National University Hospital's Division of Infectious Diseases, told ST that terminally ill patients who test positive for Covid-19 should be provided support to stay at home if they wish.

Emphasising that he was not referring to any specific case, Prof Fisher, who is also a professor of medicine at the National University of Singapore's(NUS) Yong Loo Lin School of Medicine, said: "Now Singapore is in its transition phase, it is not enforcing the isolation of positive cases as strictly, so I believe Covid-19-positive terminally ill people should be provided the support to stay at home. It is better for the individual, families, and for the health system."

An expert from the NUS Centre for Biomedical Ethics, Dr Anita Lim, pointed out that there is no legal mandate for Covid-19 patients to be hospitalised.

"It is a medical decision, based on the clinical condition of the patient and weighing all the relevant factors," she said.

End-of-life conversations for patients who are terminally ill will involve discussions on their preferred place of death and constraints to be addressed, said Dr Lim.

But she added that any flexibility in the decision-making needs to take into account the safety of the patient's caregivers.

Asked who should have the final say in what happens to terminally ill patients, Dr Lim said that while the patient's wishes and those of their caregivers should always be discussed, considered and recorded, decisions should be made by the most qualified caregiver, who is usually the senior clinician.

This decision should be made in consultation with other clinicians, she said, adding that a second opinion may be beneficial at times.

But she acknowledged that in urgent situations, it may not be possible to obtain all the necessary information.

"In these circumstances, decisions should be made according to the patient's best interests, following ethical principles as fully as possible," she said.

The 99-year-old man's daughter had also told ST how two undertakers refused to collect his body as it had not been bagged.

The National Environment Agency (NEA) had earlier told ST that for safety reasons, the bodies of Covid-19 patients are bagged by hospital workers before being placed in sealed coffins.

In its letter, MOH said that in the case of the 99-year-old, the ministry's processes had actually allowed his body to be taken to the mortuary, but the undertakers were reluctant to do so.

MOH said it was working with NEA to address the concerns of such undertakers.

"Although many of our undertakers have undergone infection control training by the National Centre for Infectious Diseases, some may still be concerned about managing those who have died of Covid-19. We are working closely with the NEA to engage the industry to address their concerns," said the ministry.

Prof Fisher noted that as Singapore transitions towards living with endemic Covid-19, it is gradually removing various restrictions.

"Ultimately, management of dead bodies needs to revert to standard precautions. Like everything else, I would be confident that these measures will be normalised in time," he said.

He added that while the risk of infection from a dead body is relatively low, it is not zero.

Covid-19 is mainly transmitted through droplets, such as when a person sneezes or coughs. But the virus could still be on the surface of a body or in its secretions, cautioned Prof Fisher.

Still, he added: "These are certainly restrictions that can be wound back now that we are in a new phase."

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