Dr Patrick Kee

I REFER to the discussion in the press on the Advance Medical Directive (AMD) and euthanasia over the past two weeks. When legislation on the Living Will was first proposed in 1997, much concern was expressed that it will lead to euthanasia. Representations were made by religious and other groups. Consequently, the legislation was modified and passed as the Advance Medical Directive. To avoid any possibility that this might lead to euthanasia, the restrictions actually made the AMD ineffective as it is applicable only in situations when the patient is certified to be dying by three doctors.

It is alarming that there are now calls for the legislation to be amended so euthanasia will in effect become legal. We have 'medicalised' the process of dying and dehumanised the dying. Our focus on medical and legal aspects of death have blinded us to its emotional and spiritual dimensions. Dying is more than a medical event - it is a psychosocialspiritual experience.

Recently, an elderly man was dying from renal failure and chronic lung disease. His family members insisted the truth be kept from him. However, as he grew weaker, he realised he was about to die. One day, he told his doctor and his daughter-in-law that, when we are well, it is easy to say we do not have to fear death. However, when death stared him in the face, he was afraid to die. He also experienced the emotional pain of having to lose all his loved ones.

Another elderly woman was found to have advanced cancer. She did not want any further investigation or treatment. Her concern was not fear of death but prolonging the process of dying and being a burden to her family. With supportive care, she was encouraged to come to terms with her illness and disability. As she accepted the reality of death, she was encouraged to make full use of each day to create precious memories for her family members. She subsequently died peacefully at home and her family were able to get over their grief quickly.

The physical suffering of the dying can be relieved by medication and by stopping futile medical treatment which causes more suffering than good. There is a need to understand that stopping futile treatment is not passive euthanasia. Stopping futile treatment in the dying should not need to be legislated but should be achieved by discussion and communication between the patient, family and medical team.

With medical advances, it is becoming more difficult for doctors and family members to face the reality that their patient is at the end of his life. Doctors and families feel guilty about giving up too soon. When it is clear the patient is at the end of his life, the question of euthanasia does not arise as it is simply a matter of allowing nature to take its course.

It is in situations when the patient is not at the end of life but is incapacitated and comatose that the issue of euthanasia arises. At such times, family members may still hope he will recover. The AMD will also not be applicable in such cases as doctors cannot certify that the patient is dying. The issue in such cases is often the use of parenteral or tube feeding. Many feel that failure to feed in such cases is tantamount to euthanasia.

There is a need for open and sensitive communication about death and dying. Another better alternative to the AMD is the Durable Power of Attorney given to a loved one to execute one's decision with regard to medical matters if one is not able to do so.

For the aged sick and for those who are suffering, many are tired of living but at the same time scared of dying. The challenge is to help them find hope and meaning in suffering. This can be done only in a compassionate community.

It is time we talked about death and dying more openly in our families. We also need to learn from those who are dying, for they have much to teach us about how not to take our lives for granted and live our lives well when we are still healthy and fit.

This article was first published in The Straits Times on November 04, 2008.