By Salma Khalik, Health Correspondent

IN THE past 11 years, out of a population of over four million, only 10,000 people have signed Advance Medical Directives (AMD), a document that in essence indicates that you don't want doctors to prolong your life unnaturally should you be seriously ill.

Why so few?

It could be because Singaporeans do not agree with what the AMD represents. If that's the case, then the Government should respect their wishes.

Health Minister Khaw Boon Wan, however, is confident that that is not the case. Based on feedback he has received, and from the personal experience of his wife, who agrees with the philosophy behind the AMD but hasn't yet signed one, he concluded that there are other factors holding people back.

It could be sheer lethargy - people can't be bothered to go through the trouble of addressing an issue that is not pressing.

It could be the hassle of getting a doctor who is willing to act as a witness. Surprisingly, quite a number of doctors have said they are not comfortable lending their signatures. A reader wrote to say she was turned down by a polyclinic doctor when she approached him to be a witness for her AMD.

A chat with doctors revealed that some were not even sure what an AMD involves. Some who know do not want to spend the time explaining it to patients - a duty the doctor witness has to bear. Although doctors are entitled to charge a fee for this service, most feel awkward doing so. In their minds, they would have performed no 'real' medical service.

Thus, the Health Minister has suggested amending the AMD so that a doctor witness is no longer needed.

This makes sense. Explaining the ramifications of an AMD can be done by non-doctors. Even better, there could be more extensive mass education to explain what signing an AMD means.

Such explanations are necessary, as most people aren't really sure what they are getting themselves into when they sign an AMD.

Some equate it with euthanasia or medically-assisted death for the terminally ill. This, however, is way off the mark. An AMD is not about helping terminally ill patients die. That is against the law.

The AMD states clearly that 'nothing in the Act shall authorise an act that causes or accelerates death as distinct from an act that permits the dying process to take its natural course'.

There are also people who think signing an AMD means telling doctors not to work so hard to keep them alive should they be seriously ill. Some fear that doctors might be less willing to save an elderly, highly subsidised C class patient who has signed an AMD - when they would do so for an A class private patient.

Again, totally off the mark.

Doctors have no way of knowing who has signed such a directive. Only at the point when they have exhausted all hope of saving the patient, does the hospital check on what the patient wants done in such a situation.

If the patient has signed an AMD, his wishes will be followed. If he hasn't, the doctors will need to ask his family what they want to do. Three doctors have to unanimously agree that nothing can save a patient, before the AMD kicks in.

Even if you have signed an AMD and are dying, you will still be given medicine, especially if it is to ease pain, as this is part of 'normal' medical treatment accorded to all.

What the AMD means is merely that doctors will not attempt 'extraordinary life-sustaining treatments', such as putting a patient with multiple organ failure on a respirator to help him breathe, a dialysis machine to clear toxins from his kidney, and repeatedly shocking a heart into beating every time it stops.

But all this will be done - whether an AMD has been signed or not - if doctors feel that there is a chance that doing so could lead to recovery.

These treatments will be stopped only if three doctors - and the AMD requires all three, two of whom must be specialists, to be unanimous in their opinion - are sure that such treatment would only prolong the process of dying.

Given the stringent conditions before an AMD kicks in, you may well ask if such a document is even necessary. If doctors decide that nothing more can be done to save a patient, isn't that final?

Associate Professor Chin Jing Jih, a senior consultant in geriatric medicine at Tan Tock Seng Hospital, says most families will go with the doctors' advice in such cases - whether a patient has an AMD or not.

Dr Robert Lim, a cancer specialist at the National University Hospital, says there is usually time to discuss the issue with terminally-ill cancer patients and their families, and most will opt for not going to extremes when the end is near.

But there are rare cases when the family will not accept that the patient is near death, and insist on doing everything possible, at all cost. In spite of going all out to save the person, the end is often as the panel of doctors predict. The result is that the patient suffers for a few more hours or days, and the hospital bill soars.

If these people were the patient, chances are they will say: 'Let me go.'

Not all, of course, as there will always be people who fear death too much to be willing to embrace it.

Why is it so difficult to make the same decision for someone else, that we are willing to make for ourselves?

Sometimes, it is fear of being accused of being ungrateful, of 'wanting' Mum or Dad to die. In moments of emotional stress - and few things are more stressful than the impending death of a loved one - accusations may be made which, no matter how unfair or untrue, can be extremely hurtful.

It is times like this that an AMD from the patient could save a lot of uncertainty and ill will that could tear a family apart.

Perhaps the AMD is more to assuage the guilt of the living than to accede to the wishes of the dying. If so, it does play a useful role.

salma@sph.com.sg

This story was first published in The Straits Times on Oct 29, 2008.

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