Palliative Care

[zuoom]

S'pore to expand palliative care systems to deal with ageing population
By Pearl Forss, Channel NewsAsia | Posted: 14 October 2008 1601 hrs

SINGAPORE: More measures are in the pipeline to help Singaporeans die with dignity. The Ministry of Health said the number of hospice beds in Singapore is expected to grow by about 20 per cent in the next five to seven years.

The ministry added that resources and expenditure will have to rise in tandem as the aging population grows and guidelines will be put in place for end-of-life care.

As the Health Ministry said Singapore is under-performing when it comes to care for the dying, it has announced several initiatives to address this.

Among them is a pilot scheme next year to bring end-of-life planning into nursing homes.

This will include guidelines on providing patients and families with care options in advance instead of leaving it to the last.

Health Minister Khaw Boon Wan, said: “Underlying these initiatives is the need for us to have more "die-logues", about death and not sweep it under the carpet. We need to overcome taboos about death and communicate better - both among ourselves as well as between doctors and their patients.”

More doctors and nurses will also be trained in palliative medicine while hospice services will receive more funding.

Each year, the Health Ministry provides about S$5 million worth of funding for inpatient hospice and home hospice services. Mr Khaw said this figure will rise as the aging population grows.

Last year, 4,400 patients received such government subsidies.

One legislation that certainly needs better communication is the Advance Medical Directive (AMD).

Implemented 11 years ago, it allows a person to declare that he or she does not wish to receive external life-sustaining treatment in the event of terminal illness.

Mr Khaw said his ministry has been unduly squeamish in the promotion of the AMD, resulting in a low uptake of fewer than 10,000 people.

Going forward, the ministry will promote it more actively, and make the process of signing the AMD less complicated by providing a multilingual registration form in easy-to-understand language.

Currently, some doctors shy away from acting as witnesses to patients signing this document because they don't fully understand the implications of the AMD.

Mr Khaw said he might make legislative changes to do away with the need for witnesses to be doctors.

And while declining life-support may soon be more common, the jury is still out over medically assisted suicides, which are currently legal in three countries.

Mr Khaw said: "I do not know if Singaporeans are ready for euthanasia. But I do know that ageing will throw up many more human stories of agony and suffering."

Experts said that with the right palliative care system in place, few would consider euthanasia. - CNA/vm

http://www.channelnewsasia.com/stories/singaporelocalnews/view/382729/1/.html

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been hearing alot on this over the radio this week.

reminds me of an article i did during college. "Should euthanasia be legalised?"
in short, i have no answer (for the article). just brought across points of should n shouldn't. extreme cases aside, put in chunks of regular cases. of course, cases of religion n GOD was inside also.

personally, it's a yes. it prevents alot of unnecessary grievance when that option is unavailable. as such, the people would have to opt for suicide. usually not as "clinically clean", usually more messy.

problem is basically the abuse factor. similar to the HOTA case.   

anyway, here's the official webby for Singapore Hospice.



http://www.singaporehospice.org.sg/

Hospice does not refer to a particular place or venue. Rather, it is a concept of care comprising comprehensive programmes designed for patients and families facing life-threatening illness. Also known as palliative care, hospice may be given in a patient’s home, at an independent in-patient institution, a hospice day-care centre, palliative care clinic or hospital ward.

Hospice and palliative care is a holistic approach to caring for patients going through the last stages of their lives.

It aims to meet all needs (physical, emotional, psychosocial and spiritual) so as to alleviate suffering and maximise quality of life for patients and their loved ones.

Awareness
The Singapore Hospice Council (SHC), in partnership with
the Lien Foundation, created the first-ever doctors’ and nurses’ palliative care fellowships and scholarships in Singapore, and launched an inaugural campaign to raise public awareness of hospice palliative care in Singapore. Of the S$2m funding provided by the Lien Foundation to the SHC, S$1.2m has been channeled to the scholarships and fellowships, while the other S$800,000 has been channeled to public awareness efforts. This has been a project to raise public awareness and attract more doctors and nurses into, hospice palliative care.

“We are very heartened by Lien Foundation’s support for the ‘cause of the dying’. About 70% of people with terminal illnesses are dying without hospice palliative care in Singapore.

[zuoom]

here's one example on why euthanasia should go ahead.
http://www.celicasg.org/index.php?topic=4131.0

[zuoom]

Euthanasia is immoral 
Catholic Church condemns practice and urges doctors to reject it as it 'violates medical ethics'. 


   
Archbishop Chia yesterday condemned mercy killings, a much debated topic as the Government mulls changes to the laws governing dying, though legalising euthanasia has not been proposed. -- ST FILE PHOTO

THE head of Singapore's Catholic Church yesterday publicly condemned euthanasia, a topic that has grabbed headlines in recent weeks as the Government considers changes to the laws that govern dying.
Archbishop Nicholas Chia wrote a letter on mercy killings that was read out during Sunday services at the country's 30-plus Catholic churches.

In it, he underlined the Church's views on death, describing euthanasia as 'immoral' and also calling on doctors to reject the practice.

'One cannot choose death and ask to be killed. When they do this, they are not only committing the crime of suicide, but also compounding it by making another person a partner in a crime,' he wrote.

Health Minister Khaw Boon Wan discussed the issue of euthanasia last month after it was raised in the press.

The Government has not proposed legalising the practice, but has broached the idea of making changes to the Advance Medical Directive, or living will. The document instructs doctors not to artificially prolong the life of a terminally-ill patient with machines. The changes would make it easier for Singaporeans to turn down that care.

Opponents say that is one step on the slippery slope to euthanasia, which the Catholic Church has long considered taboo alongside other controversial practices like abortion.

Archbishop Chia condemned mercy killings in his letter, which was read out All Souls' Day, the annual day of remembering the dead.

'One must not yield to another's person's request for euthanasia. To yield to such a request is false compassion,' he wrote to Singapore's 320,000-strong Catholic population.

'To have true compassion for the person is to understand (they are) actually feeling lost, confused, hopeless and alienated. Mercy entails supporting such person through care and friendship.'

The archbishop also called on doctors to reject mercy-killings, saying they were a violation of medical ethics. 'No health-care professionals must even contemplate the option of administering euthanasia,' he wrote.

The Head of the Catholic Medical Guild, a group of religious medical professionals, said she wholeheartedly agrees with the archbishop.

'Taking one's life or assisting another person to take his life is immoral,' said Dr Sally Ho.

Most times, people do not want to die, she said. Instead, they want to end the pain they are feeling, so ensuring patients receive proper palliative care is crucial.

The Catholic Church in its fortnightly newsletter had an article on euthanasia written by one of its priests. In the Catholic News, the priest said it is important to offer palliative care.

The Methodist and the Anglican churches, as well as the National Council of Churches, could not be reached for comment yesterday.

While several countries make it relatively easy for the terminally-ill to decline treatment, few have actually taken the step of allowing doctors to end the lives of patients. Only the Netherlands and the state of Oregon in the United States allow the controversial practice.

Archbishop Chia told The Straits Times in an interview yesterday: 'This is a matter of life and death. It is not up to you or me to decide.'

http://www.straitstimes.com/Breaking%2BNews/Singapore/Story/STIStory_297852.html

via : http://forums.vr-zone.com/showthread.php?t=347747

[tags] Euthanasia

[Vorsprung durch Technik]

just wonder, any old folks step up and voice out if this is what they wants.. not that i anti-gahmen, all those policies seems to me are deem on evading the responsibility of taking care the old ages till they deemed incurable. this makes me think what's intangible or what's not.

[zuoom]

Should we help people to die?
MPs, doctors and churches are among those who have come up to state their opposition to the suggestion that Singapore might have to consider legalising active euthanasia for presumably the terminally ill. -ST
 
SINGAPORE'S Health Minister Khaw Boon Wan suggested last month that the authorities might have to consider legalising active euthanasia - or assisted dying - for presumably the terminally ill who are mentally competent.

A euthanasia debate was triggered by a letter published in Lianhe Zaobao on Sept 20 from a 72-year-old woman, who said she and her husband lived in fear of falling ill and becoming dependent on others. For weeks after that, readers of the Chinese daily wrote in, calling for euthanasia to be legalised in Singapore.

While several MPs and doctors interviewed by The Sunday Times welcomed the discussion, they all said they were personally against euthanasia, calling instead for palliative care, which involves the management of suffering for terminally ill patients.

Yesterday, the National Council of Churches of Singapore, the umbrella body for some 200 Christian churches and organisations, issued a statement denouncing the act of euthanasia.

'(Euthanasia) is societal killing; it will have grave implications on the way we think about ourselves and about matters of life, and open the door to serious abuses that would threaten the rights and dignity of persons and society,' stated the council. It maintains that palliative care is the answer for the terminally ill, as patients with inadequate symptom and pain control would request for euthanasia.

On Sunday, the Catholic Church's Archbishop Nicholas Chia became the first religious head in Singapore to openly express opposition to euthanasia since Mr Khaw's speech, saying the act was equivalent to committing suicide.

The debate comes at a time when the Government is trying to promote Advance Medical Directives, which instruct doctors not to take extraordinary measures to prolong life if a person is terminally ill or unconscious.

Euthanasia is legal in Switzerland, the Netherlands, Belgium, Australia and Oregon in the United States.

Source: http://www.asiaone.com/Health/News/Story/A1Story20081110-99473.html

via : http://forums.vr-zone.com/showthread.php?t=350236

[Cobra]

They claim, AMD is different from Euthanasia.

The govenrment directive (AMD) is to allow a person a legal form of indicating if he/she wants Assisted Dying in the event he/she suffers from some terminal illess but mentally competent.

Euthanasia, is the practice of terminating a persons life in the event that he/she suffers from some terminal illness but mentally competent, painlessly. In otherwords, Assisted Suicide. (I'm assuming we are talking about ethanasia by consent).

Errrr ... so what's the difference apart from the way they are worded or described ?

How would you define and be 100% sure that the person at that point is mentally competent ?

How can we ensure, the Directive is not misused by some members of the public who does not want to prolong their responsibility and efforts in supporting a dying person ?

How can we ensure that the person is not actually seeking suicide when he/she is diagnose to have terminal illness, which is illegal in Singapore ?

How do we ensure that the Country Gives the Best Care for its People when they are diagnose with terminal illness and not take the easy way out ?

Should we make all the thousands of Aids Suffers and Cancer Patients sign this and 'kill' them before their natural last day ?

Everyone deserve the Right and Hope to Live ... the Passion of a Doctor is to Assist and Prolong that Right to the Best of their Means.  The same with the Fundamental Principles of Medicine.

Are we denying ourselves a chance of Hope and Miracle which in many times proves our technology wrong ?

In religion some would say our Life belongs to God and only him has he right to take it back.

SHOULD WE HUMAN PLAY GOD ? ..... 

[zuoom]

Euthansia is different from the "Advanced Directive". in AD, you must specifically lay instructions to your loved ones not to save you should you become mentally incompetent.

But if you are mentally incompetent but lives, it is not right for anyone to take away your life. Yes it is a burden but this borders on murder for the convenience of the living.

via : http://forums.vr-zone.com/showthread.php?t=350236

Cobra, the AMD is more on cases when the patient is dying and he ask for not to be resuscitated. something like DNR?

not clear about AMD allowing assisted dying. 

maybe the docs here can advise better?

[Cobra]

I used the term Assisted Dying as in the report you posted abve.

In any case, removing  a life support system for example from a dying person is assisted dying.

[zuoom]

SINGAPORE'S Health Minister Khaw Boon Wan suggested last month that the authorities might have to consider legalising active euthanasia - or assisted dying - for presumably the terminally ill who are mentally competent.

*strange, i remember posting an article on AMD - advance medical directive.
can't find it anyway.

i would have thought the AMD is more towards DNR.

[Cobra]

SINGAPORE'S Health Minister Khaw Boon Wan suggested last month that the authorities might have to consider legalising active euthanasia - or assisted dying - for presumably the terminally ill who are mentally competent.

*strange, i remember posting an article on AMD - advance medical directive.
can't find it anyway.

i would have thought the AMD is more towards DNR.

You are right that DNR is part of AMD.

It instructs medical personnel not to perform life-saving cardiopulmonary resuscitation (CPR) or other procedures to restart the heart or breathing once they have ceased.

(1) Imagine if your love one suffers a heart attack and have signed the AMD, the doctors and yourselve will just stand there and watch him/her stop breathing.

(2) Imagine if your love one suffers a heart attack but did not signed the AMD, and the doctors try their best to resusitate him/her, but at the end he/she could not be revived.

You may prefer scenerio (1), but a law like this implicate millions in this country that may prefer (2). Psychologically, they have done their best in supporting their dying love ones and have peace.

[Cobra]

Buiding a Palliative Care Business can be rewarding.

Palliative Care Organization near us includes the following but more are needed :

(1) Asia Pacific Hospice Palliative Care Network   http://www.aphn.org/

(2) Palliative Care Nurses Chapter, Singapore Nurses Association  http://www.sna.org.sg/site/palliative-care/palliative-care.html

(3) Section of Palliative Medicine, College of Physicians,

(4) Academy of Medicine Singapore     

(5) Singapore Association of Social Workers   

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Presenting the Business Plan

A business plan is a new program proposal with operational and budget information. Think of it as a story that tells the “who, what, why, when and how” of a palliative care program. It explains how palliative care will improve the hospital’s performance and what is needed to achieve that end.

The business plan should have the following elements:

Executive Summary -

This should be a simple, easy-to-present section that can be discussed with key audiences in ten minutes or less. This section synthesizes the contents of the overall plan into a concise, persuasive summary of:

(1) Context for the proposal
(2) Key program features
(3) Need or problem addressed
(4) Funding requirements
(5) How the palliative program will meet the need
(6) Expected impact and measures


Financial/Budget Summary

The financial summary is the program’s budget. It identifies the program costs (both at start-up and during operations) and potential sources of revenue or cost avoidance that the planning team identifies in earlier stages. Cost avoidance is especially important in making the financial case, because palliative care is not a significant source of revenue.
 
Operational Plan for Implementation

The operational summary specifies:

(1) Organizational model and structure
(2) Space needs
(3) Staffing requirements and roles
(4) Basic policies and procedures
(5) Patient volume and program capacity projections
(6) Degree of integration with other programs in the hospital and community

The operational plan must describe how funds will be spent to implement project elements, hire staff, and care for patients and their families. It should explain how the program will coordinate with related services such as geriatrics, hospice or pain management, and how it will differentiate itself.

See Defining Palliative Care for a comparison of these services.

Defining Palliative Care

(1) Palliative care aims to relieve suffering and improve quality of life for patients with advanced illness and their families.
(2) Palliative care is provided by an interdisciplinary team and offered in conjunction with all other appropriate forms of medical treatment.
(3) Palliative care programs structure a variety of hospital resources to effectively deliver the highest quality of care to patients with advanced illness.
(4) The resources and team include: medical and nursing specialists, social workers, clergy, and others.
(5) Vigorous pain and symptom control is integrated into all stages of treatment.
(6) The palliative care approach decreases length of hospital and ICU stays and eases patient transitions between care settings. This results in increased patient and family satisfaction and compliance with hospital care quality standards.
(7) Successful palliative care programs have used an array of delivery systems from consultative services to inpatient units.

 
Institutional and Market Analysis

This section summarizes information developed during a Needs Assessment. Describe how the program is an improvement over the process currently used to care for seriously ill patients, from clinical and financial perspectives. Openly acknowledge the program’s potential downsides, including financial, political or clinical disadvantages and explain how they will be addressed and tracked.
 
Marketing Plan

Describe how the program will get the services to its audiences and position, promote, and communicate about them effectively over time.

See Effectively Marketing a Palliative Care Program for more information.

Effectively Marketing a Palliative Care Program

The marketing plan describes how the palliative care program will promote services to the proper audiences and position, promote, and communicate effectively over time.

To market a palliative care program, advocates need to:

(1) Develop the Marketing Plan
(2) Create Promotional Materials
(3) Leverage Hospital Channels to Get the Word Out
(4) Launch the Program
(5) Measure and Monitor the Marketing Activities

 
Develop the Marketing Plan

The following are components of an effective marketing plan:

Target Audiences: Defines the various audiences for palliative care, including hospital leaders, nursing and social work leaders, case management leaders, clinicians, potential referring physicians, community agencies, and patients and families.

Marketing Objective: Describes, by audience, the action or result that will be achieved if successful.

The Services Offered: Details what benefits the services offer to each audience.

Cost Exchange: Defines the costs to each audience and considers how to make a program seem worth the price.

Communications Plan: Outlines for the message strategy for reaching each key audience. Defines the types of communications activities to be employed (e.g., including personal relationships, presentations, mailings, newsletter articles, advertisements, public relations, etc.) and associated budget.

Create Promotional Materials

Execute the marketing plan by creating promotional materials such as brochures or fliers. Not only does each audience require different messages (and therefore unique materials), but also the method of translating into physical materials will need to differ.

Decide who the brochure is for.
Start from the patient’s vantage point rather than beginning with a definition of palliative care or launching into a description of the program.

Emphasize the immediate benefits that palliative care can offer such as what patients and families seek in the face of serious or life-threatening illness.

Talk about the specific elements of a palliative care program in concrete, everyday language – avoid jargon.

Provide a clear action the audience can take to get palliative care -- a phone call to the program, a drop-in location, a request for a referral to their primary physician, etc.

Leverage Hospital Channels to Get the Word Out

In addition to brochures or printed matter, there are many other ways to reach the palliative care program audiences. Consider these other communications outlets:

- Grand rounds
- Hospital brown-bag lunches
- Department meetings
- Continuing education programs
- Board meetings
- Board orientation materials
- Hospital newsletters, both internal and for the community
- Hospital-sponsored community events
- Health care system and partners community events and materials

Launch the Program

The marketing plan will specify the timing of activities, so the palliative care program can ensure that marketing supports each critical step in program development. Distribute communication materials and use hospital communication channels ahead of the program launch, through the launch, and as the program continues.


Measure and Monitor the Marketing Activities

The marketing plan and marketing efforts need to be reviewed and renewed over time so as to reflect the evolving clinical and fiscal context of the palliative care program. The reasons why various audiences will support or need a palliative care program are likely to change, as will the demand for services.

 

[zuoom]

docs, need some help here.

not familiar with the medical world.

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i see DNR n Euthanasia as two very different subject.

the first action to be executed when the person is unable to talk/action.
the 2nd action is executed when the person is alive, able to talk/think.

your scenario number 1 would be a tragic event no doubt. but what's the underlying clause behind the person who had done the AMD for his/her DNR? (we probably should spend sometime ponder over that.)

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do you know that each human lives are given a certain amount of value in the airline industry?
ie: if the cost of implementing a safety fix cost more than that figure, then the industry will not go ahead n do it.
basic economics at play. they figure it would be cheaper to pay the families off rather than pay the money to make it safer.

likewise, in the medical world. it's a money venture as much as it's about saving lives.

if it cost that much to save a life, and that person will not be able to pay back. would the director of the hospital go ahead n sign the "yes" form?

i can answer for him/her. "NO."

it does not make economic sense, and the manpower saved there n then will be better deployed in other patient with more chances of survival, better returns etc.

simply put, if this patient hogs on to the breathing machine, he/she is depriving of someone else who might need it more.

resources are limited, must make use of it (to the max.)

(so far these points are for the cases of AMD, DNR, Euthanasia etc. will do cases against in the future.)

[Cobra]

Actually you should ask a Lawyer rather than a Doctor ..... kekeke

All these stuff has more legal implication than medical ... Doctors just want to save Lifes and go Tracking and leave
the Legal decisions to Lawyers and Politcians.

Thats why these things are more often debated in Parliament (not only s'pore) and not in Medical Associations.

The fear of passing such a law is also exactly how modern socialty equate ones life with economic values and costs, which is an unfair process in itself. E.g the value of yours and mine is different from say MM, even if all signed AMD.

Affordability is another equation but has nothing to do with AMD. Thats where creative people invented insurance. For example, with stage 4 cancer, SGH will tell you you got only few months to live, but if you can afford to go to the best cancer specialist here, your live may be prolong for 2-5 years with the most advanced and most expensive medicine that SGH do not have.

I'm sure many have other views ... come guys share your thoughts ....

[Vorsprung durch Technik]

waah.. suddenly the discussion get hot.

when it comes to legal, everyone (perhaps maybe those high-level ranks) just want to have their 'backside' covered.

[zuoom]

why does the medical association discuss this indepth?

why dun they take a stand?

one camp yes. one camp no.

======================

something about Euthanasia and AMD (or DNR as we put it here.)

Experts call for clearer difference between euthanasia and AMD
http://sg.news.yahoo.com/cna/20081110/tap-893-experts-say-singapore-society-re-231650b.html

Channel NewsAsia - Tuesday, November 11
SINGAPORE : Doctors, caregivers and religious groups in Singapore have said there is a distinct difference between euthanasia and the Advanced Medical Directive (AMD) which the Health Ministry wants to simplify.

While the AMD extends a person’s autonomy on how he would like to die, euthanasia is seen as an act of killing.

As Singapore’s population ages, the country is in the midst of a debate on how one can die with dignity. At the centre of it is the Advanced Medical Directive.

The Health Ministry is studying how to make it easier for people to sign up for the AMD — a document, where you can explicitly state how you want your final days to be, if you are terminally ill.

The issue now is a confusion between what is AMD and what is euthanasia.

Singapore’s Health Ministry has stressed there has been no proposal to legalise euthanasia.

Experts said it is all in the definition. They said signing the AMD to say you would rather have the plug pulled — than be kept alive by machines if you are terminally ill — is not euthanasia.

Dr Chin Jing Jih, Executive Director, Centre for Medical Ethics and Professionalism, Singapore Medical Association, explained: "A lot of times, people think that when doctors switch off these life support systems, it is as if it is that act of stopping that kills the patient.

"But in actual fact, it is not. It is the underlying disease that has killed the patient. We are merely removing an intervention that is no longer effective on the patient. Emotionally, it looks as if that act has ended the patient’s life but it is actually the underlying illness.

"We know that if we do not remove the life support, the patient will perish too in a matter of days. That is not euthanasia because if we remove these cumbersome machines and the patient is still alive, we accept that and we palliate the patient.

"But if it is euthanasia, I remove the machine and the patient is still alive, then I would say... what else do I have to do to make sure the patient dies. So the intent is very clear. When doctors remove these machines, death is foreseeable, but it is not intended, so we make that ethical decision and intent is central to euthanasia."

Experts believe the AMD is not a slippery slope towards euthanasia. Doctors said a key issue is in ensuring optimal palliative care to ease the pain of patients.

Dr Cynthia Goh, head, Palliative Medicine Department, National Cancer Centre Singapore, said: "Palliative care includes care that takes care of physical symptoms and physical pain, but we also do a lot of psycho—social support, which is to support the person emotionally and to sustain hope.

"Much of it is about treating that person as a person... showing that person that he is worth something, and he will also be worth something provided that he is alive.

"And showing respect and showing that we are there for them and we won’t abandon them — I think these are common things that people are afraid of, and they say, ’I would rather be dead before I am abandoned or before the pain becomes unbearable or before my suffering becomes unbearable’.

"But if we can encourage them and say we would do our best to ensure that it does not become unbearable and we will stand by you, very often people will feel encouraged and they generate a little hope for themselves to say that things can get a little bit better."

Another point medical professionals agree on is that if euthanasia is allowed, then doctors should not be the ones administering death because it affects the integrity of the profession. Instead, euthanasia should be done by trained personnel.

Major religious groups in Singapore are also strongly against euthanasia, saying it is tantamount to killing.

The National Council of Churches of Singapore has condemned the act as "diminishing the value of human life", while both the Singapore Buddhist Federation and the Islamic Religious Council of Singapore see euthanasia as tantamount to the act of killing.

However, it is a grey area for Hindus. Channel NewsAsia understands that the terminally ill can choose to fast till death or refuse medical treatment, but subject to certain conditions. These include getting the blessing of the family and so long as the dying process is unaided.

Meanwhile, all four religious groups support AMD. The Buddhist Federation said that in AMD, "the patient is dying in a natural way as no device is used just to prolong his/her life". — CNA/ms

the more i read about it the more confuse i'm getting.. 0_o"