Palliative care dept at TTSH (ST Nov 28, 2008)

It is first public hospital to do so; move follows growing need to improve lives of the terminally ill By Salma Khalik

WHEN her father and grandfather died two weeks apart after losing their battles with cancer, Ms Angeline Chew was devastated.

Fortunately, she was able to draw strength and comfort from palliative care doctors and nurses at Tan Tock Seng Hospital (TTSH). They helped the family members come to terms with their imminent loss, while also seeing the patients through their painful last days.

The need for such support has grown over the years. Once offered exclusively to terminally ill cancer patients, palliative care has since been extended to other terminal illnesses such as organ failure. Last year, palliative care doctors at TTSH helped more than 1,400 dying patients and their families, up from 1,100 in 2005.

To cope with the larger numbers, the hospital has decided to set up a department devoted solely to palliative care - the first public hospital to do so. If it works out well, a Ministry of Health spokesman said others would follow suit.

With the change, the current team of four doctors will be able to grow the service with more nurses and registrars, as well as train more doctors in this field, said Dr Wu Huei Yaw, a consultant in palliative medicine at TTSH.

Only about 60 per cent of people who need palliative care are getting it, Health Minister Khaw Boon Wan said recently.

Palliative care doctors treat not only physical symptoms such as pain and breathlessness, but also the emotional and spiritual needs of the patient. They spend a longer time with each patient, with a new case taking anything from 30 to 60 minutes for the first consultation.

The question they most often have to deal with is 'Why me?', said Dr Wu. Patients, especially those in their 30s or 40s, often protest that they are not ready to die.

Older patients, on the other hand, are usually less afraid of death, but they do fear pain and suffering, he added. This can be helped by palliative care doctors explaining what they can do to alleviate suffering.

If the pain gets really bad, they will get anaesthetists to administer an injection into the spinal cord - like epidurals given to women in labour to help them cope with the pain. In extreme cases, a patient can be kept sedated till he dies.

Ms Chew's father suffered from intense pain in his last days. But 'his eyes would light up when Dr Wu or the nurses came by', she recalled.

He knew they were doing their best for him, and was grateful. Dr Wu once returned to the hospital at 10pm when he heard that Mr Chew was in great pain.

Mr Chew was given a 'terminal discharge' after the doctors told his family that there was not much more healing they could give him. Instead, he would die at home, while his pain treatment continued through a home hospice care service.

Dr Wu said an increasing number of patients and their families are opting for terminal discharge.

Last year, more than 50 patients chose to go home. This year, more than 80 have already done so.

Another new department, called Community and Continuing Care, is working with nearby nursing homes to provide their patients with palliative care, so there is no need for them to be admitted.

This is better for both the patient - who does not have to be shuttled to and fro - and the hospital, which faces a perennial shortage of beds.

When first approached some months before her father's death, Ms Chew, who is in her 30s, was upset and rejected their help. Her father was only 57 years old, and the diagnosis of late-stage colon cancer came as a shock.

'I thought the doctors had given up on my father and were sentencing him to death,' the mother of two young children said. 'I couldn't have been more wrong.'

(source: www.straitstimes.com/Breaking%2BNews/Singapore/Story/STIStory_307844.html )

My comments:
I recalled the recent demise of my mother-in-law. She was discharged from SGH around June 2008 and hospice care was given because she was deemed to be terminally ill. Since then, a nurse and occasionally a doctor from Hospice Care Association would visit her weekly, talking to her, ensuring her health condition was still "fine".

Lately, when my mother-in-law was unable to move around, a wheel-chair and a toilet pan were loan. Morphine solution was given to relieve pain and suffering. Just a few days before she passed on, the nurse said that my mother-in-law might be at the last stage of her life and advised her family members to spend more time with her. True enough, my mother-in-law left this world within a week.

Special thanks goes to Debbie, who is so patient, thoughtful and sensitive to our needs.

Boy Jumped over CCA

A 15-YEAR-OLD jumped from the 11th-floor bedroom window of his home - in front of his mother - after a disagreement with his parents over his intention to switch his co-curricular activity (CCA) in school.

http://www.straitstimes.com/Breaking%2BNews/Singapore/Story/STIStory_307353.html

My comments:
My heart goes out to the mother of this teen. How can the son do such a cruel thing to his mum? Seeing your loved one ended his life yet can't do anything at all is simply the most cruel thing in this world.

I don't think time will heal this wound. A significant part of this mum was gone forever.

Time to do something extra for Forgery Cases

On the same day (25 Nov 2008), I read two articles from Straits Times Online on forgery cases; "Borders staff jailed 4 years " and "Woman jailed for forgery, CBT".

In both cases, both forged signatures on the cheques to direct banks to transfer money into their own bank accounts for personal usages. In the first place, forging signatures is already a serious crime. Secondly, they are taking money which does not belong to them openly. Thirdly, much resources have been employed to prove forgery and to prosecute them in the courts.

Have we forgotten one crucial point that the banks involved which allowed such cheques to clear need to bear some responsibilities? How can such cheques be allowed to clear in the very first place?

The relevant authorities should look into the loopholes in this process before more forgery cases emerged in this difficult times. In addition, I urge severe punishment imposed to act as a deterrent.

Up to 19% pay cut for top civil servants; lower year—end bonus

SINGAPORE: Ministers and top civil servants will get a pay cut of up to 19 per cent next year. The Civil Service is also reducing the year—end bonus payment for this year.

Top civil servants and ministers were supposed to get a pay rise in January next year to bring their salaries in line with private sector pay.

It was to be the third adjustment to bring public sector pay to 88 per cent of the private sector benchmark, a move announced in April 2007.

The benchmark is set at two—thirds of the median pay of the top eight earners in each of the six sectors: multinational corporations, lawyers, bankers, accountants, local manufacturers and engineers.

In April 2007 and January this year, the salaries of top civil servants and ministers were revised to keep pace with soaring private sector salaries. But the Public Service Division said the 2009 salary revision for this group has now been deferred, in view of the clouded economic outlook.

In fact, the annual salary for top civil servants and ministers will fall next year to levels below April 2007, because close to 25 per cent of their annual salary comprises variable payments linked to the GDP growth of Singapore and their salary will fall as long as the economy remains weak.

In 2009, the Prime Minister and President will see their annual salaries cut by 19 per cent. Ministers and Senior Permanent Secretaries will see an 18 per cent fall. The allowance for Members of Parliament will be cut by 16 per cent.

Commenting on the pay cut, Mr Teo Chee Hean, Minister in charge of the Civil Service, said: "Public sector salaries follow the market up and down. The mechanism we introduced last year to link a significant proportion of the salary of senior civil servants to the performance of the economy is working as intended. This mechanism allows salaries to respond more rapidly to market conditions."

The Public Service Division also said the Prime Minister has and will continue to donate all increases in his own salary after the April 2007 revisions, to good causes for five years.

Next year, the Prime Minister will actually see his salary fall to pre—revision levels.

As for civil servants such as teachers and police officers, they are getting a total of two months’ bonus payment this year, plus S$100 to S$300 paid out in July. This comprises the 13th month payment or Annual Wage Supplement and a one—month Annual Variable Component or AVC.

The year—end AVC has been reduced to 0.5 month.

Last year, the total bonus payment was three months plus S$220, including a half—month Growth Bonus which was paid for the exceptional economic performance in 2007.

Public Service Division news release on civil servants’ annual pay

(source: sg.news.yahoo.com/cna/20081124/tap-904-civil-lower-year-end-payment-ser-231650b.html )

My Comments:
I am glad that I am still holding onto a job which means I am still getting my monthly salary until further notice. The year-end bonus is an extra amount of money meant to pay tax and bills or saved for rainy days.

Christmas - a month away

Today is 24 Nov. Exactly a month later, it will be christmas eve and many will be celebrating christmas.

Christmas is not only a day for party, drinks and food. It is also a day to remember our loved ones and spend some quality time with them.

Since the demise of my mother-in-law, I have been quite depressed. I can only keep myself busy with work so that I don't think of her often.

We will only treasure when we lost it.

Friends,
Treasure your parents and loved ones now. Drop your work now and spend some quality time with them. You will never know what is going to happen the next day, week or even month.

My mother-in-law's final moments (part 3)

Around 0255hr of 15 Nov 2008, my mother-in-law finally gave up her last breath. She left this world while two family members were at her bedside.

She was cremated today (17 Nov 2008 9am) in Mandai Crematorium. Collection of ash was done at 3pm.

What gave me a deep impression was when the casket was being wheeled automatically away from us in the Viewing Hall, it gave me a feeling that my mother-in-law was on her way to another world alone. I finally understand the meaning of the final journey.

My mother-in-law (part 2)

Since Wednesday, I have not been sleeping much at night, for fear of receiving a call to break the news.

My mother-in-law's conditions are deteriorating. She could no longer control her bowel. She could not drink or swallow. What left behind are just a set of skeletons and a breath.

The HCA doctor and nurse visited her yesterday. They did nothing except to console the family members. Anybody without any medical knowledge would know that D day is coming.

It is really painful and heart-breaking to see a loved one to be in such a state, so thin, helpless, lifeless.

This is how a person appears at the last stage of its life.

Not Giving Up

WHEN the doctor asked 'Mr Charity' Gerard Ee to sit down, he knew the news about his colon check was not good.

'I told the doctor I'd watched enough movies to know that when the doc says take a seat, it's bad news,' recalled Mr Ee yesterday. 'I told him: 'Don't waste my time, tell me what the outcome is.''

The doctor replied: Stage 3 colon cancer, with a tumour almost as big as a tennis ball.

Patients at this stage of colon cancer are said to have a 40 per cent survival rate on average. 'If the cancer was Stage 4, I'd be a goner,' said Mr Ee.

For the veteran volunteer and charity personality, this marked the beginning of a period of contemplating the possibility of death and what it would mean for those around him, especially his wife and teenage children.

Almost a year since that day in the doctor's clinic, the 59-year-old came out in public yesterday to share the story of his fight against the dreaded Big C.

He did so to show his support for a campaign by the Lien Foundation to get people talking more openly about death and dying.

The campaign coincides with the Government's move to promote the Advance Medical Directive, a legal document to instruct doctors not to take extraordinary measures to prolong life if one is terminally ill or unconscious. The Lien Foundation's chairman, Mrs Margaret Lien, said of the campaign: 'A lot of unnecessary burden and pain can be avoided if we can talk about end-of-life matters openly.'

For Mr Ee, a retired accountant who is currently chairman of the National Kidney Foundation (NKF) and Public Transport Council, the past year has meant undergoing surgery to remove the tumour and 12 sessions of chemotherapy.

The good news is that he is now 'in the clear' since finishing his last round of chemotherapy in June.

Looking back, he said what helped him through the year was his faith in God, a sense of humour and the fact that he had put his finances in order. The devout Catholic said: 'People were surprised I was so calm throughout the whole thing. I think if I didn't have a strong faith in God, I would have been in a panic.'

His calmness helped his wife, 15-year-old son and 13-year-old daughter to accept the diagnosis as well.

'I tried to avoid using dramatic words like 'tumour' when I broke the news to my family,' he said. 'I said: 'I have a growth that needs to be operated on.' I knew that if I was hysterical about it, it would have had a chain effect on others.'

Mr Ee was hard-pressed to answer when asked what proved most difficult for him in facing up to cancer. But he confessed to being worried before the surgery to remove his tumour.

'There are only two outcomes: you wake up, or you don't,' he said. 'If you don't wake up, that's the end of the story and my will and life insurance would take care of what happens after that.

'But if you wake up, you have to figure out what to do after that.'

He woke up. And what he did after that was work to keep his spirits up.

He had a rule for his family: No one was allowed to treat him like an invalid.
So he drove himself to chemotherapy sessions and, within two weeks of the operation, was back to performing a host of volunteer commitments.

The surgery involved removing a part of his small intestine, over half a metre of large intestine and his appendix as well. Over the whole process, he also lost 25kg.

'Having a sense of humour is important. I told my friends I had a free liposuction with the operation,' he said.

After keeping his illness private for a year, the Lien Foundation campaign gave Mr Ee a chance to share what he had gone through.

He thinks it is important to get people to prepare for death. Among other things, their families may suffer if they fail to settle their finances before they go.

He said: 'The only thing in life you can guarantee, and nowadays people talk about guarantees, is death.

'If you treat death as taboo and don't prepare for it, you are leaving behind a legacy in which your family will suffer because you ignore it and pretend it won't happen to you.'

(source: www.straitstimes.com/Breaking%2BNews/Singapore/Story/STIStory_301700.html )

My mother-in-law

I have been thinking for a long time if I should pen this personal issue in my blog.

The days of my mother in law are really numbered. After battling so many years with cancer, she finally lost. She has been sleeping most of her days. Her sleeping hours are certainly much more than the hours when she remains alert and conscious. She has not been eating much too.

Her body systems are shutting down. She does not need much food since she does not have much energy left.

Her eyes are closed most of the time even when she is awaken. She is aware of the surroundings. I told her that she did not have to worry much. Isa has done well in her studies and I will take good care of her.

She can't move by herself. She is very weak. Her limbs feel cold and pale. She breathes heavily. All these are signs of death is very near.

Although I have read about death quite some time ago, when it is near, I feel fear and anxiety. I feel so helpless and weak. I can't do anything except to watch by her bedside.

"Mother, we will take good care of ourselves."

From A Face in the Crowd to One the Crowd Faces

If you travel along Bukit Timah Road, you may have noticed a very prominent banner outside Singapore Chinese Girls' School (SCGS). It said "From a face in the crowd to one the crowd faces".

This phrase strikes me hard.

A crowd refers to a group of people. This crowd can be small or large. So a face in a crowd often goes unnoticed.

The last part of the phrase "to one the crowd faces" means the crowd faces a face of a person. So this particular face becomes prominent and the whole crowd faces him or her.

This phrase literally means from a little unknown person in a crowd and then become a person whom the crowd looks upon.

Next time if you travel along Bukit Timah Road, please take a look at this banner outside SCGS.

Global Ozone Map

Have you wonder what is the amount of ozone overhead? We know that the ozone layer in the atmosphere protects us from the harmful ultra-violet radiation emitted from the hot sun.

It is the presence of this ozone layer that there are living things on Earth. Ozone layer is thinning, especially at the southern pole during a particular season in the year.

If you like outdoor activities, do not forget to bring your sunblock cream. This waterproof cream helps to protect our skin, which is our largest sense of organ.

(source:
ftp://toms.gsfc.nasa.gov/pub/omi/images/global/FULLDAY_GLOB.PNG)

Euthanasia

Euthanasia (literally "good death" in Ancient Greek) refers to the practice of ending a life in a painless manner. As of 2008, some forms of euthanasia are legal in Belgium,[1] Luxembourg,[2] The Netherlands,[1] Switzerland,[1] the U.S. states of Oregon[3] and Washington[4] the Autonomous Community of Andalusia (Spain),[5][6] and Thailand.[7]

(source: en.wikipedia.org/wiki/Euthanasia)

My comments:
This topic is extremely sensitive. It deals with death. Much debate is going on whether euthanasia should be legalised. If so, would there be an abuse of this killing? Ending a life in a painless manner is still killing a life which can easily becomes murdering.

I support euthanasia.

What is the purpose of prolonging a life which isn't really a life anymore? Usually the patient involved would be in coma or terminally ill, which means death is already very near. Some doctors are required to certify the necessary conditions of the patient before euthanasia can be considered. The problems are : who can decide that euthanasia can be applied to the patient? Who (the doctor) is going to administer that lethal injection which will bring an end to a life? What are the psychological effects on the people involved?

I asked Isa who is only 9 years old. She does not support euthanasia. Her reasons being : now no cure for the illness does not mean cure is not available tomorrow or the future. She also said that she could not allow her loved one to die.

I am touched by her comments. She certainly has real and valid points.

Maybe this issue of euthanasia has to be relooked again seriously.

Very Close Competition

Exam results were out and the report book should be ready for parent's signature.

When I was young, I hate this moment because I always got lousy grades. Crying and canning became inevitable. This situation stopped when I reached the secondary school where canning was deemed unsuitable.

Isa has done pretty well this round. Competition was very stiff and pressures were very high.

After a year's of hard work, it is time to taste the fruit of success.

You reap what you sow.

Well done Isa and keep it UP.

Helping the Dying with Living

Instead of discussing euthanasia, the focus should be on helping terminally ill live with less pain, says expert By Radha Basu, Senior Correspondent

Dr Shaw with Ms Joyce Neo Soh Hoon, 54, at St Joseph's Home and Hospice. Communicating with the dying can be taught and learnt, Dr Shaw believes. Often, what doctors need to do is simply to listen.

Dr Rosalie Shaw, 70, is executive director of the Asia Pacific Hospice Palliative Care Network, which helps develop services for the terminally ill in Asia. She is also a consultant at the National Cancer Centre and a visiting consultant at the KK Women's and Children's Hospital.

EUTHANASIA is the wrong conversation to have in a nation concerned with dying with dignity.

Often, those who have the hardest time accepting death are successful men in their 50s and 60s 'who seem surprised that wealth cannot buy health'.

The focus instead should be on care - how to help the terminally ill live with less pain, says Dr Rosalie Shaw, a palliative care specialist who has helped hundreds here live out their last days over the past 16 years.

'Euthanasia is not about allowing the terminally ill to die with dignity and without distress,' asserts the Australian, who moved to Singapore from Perth in 1992 to help set up hospice care here. 'That is what palliative care does. Instead, it is an act with the intention to kill.'

As a consultant at the National Cancer Centre and visiting consultant at KK Women's and Children's Hospital, she tends to the terminally ill. As executive director of the Asia Pacific Hospice Palliative Care Network, she helps train doctors and nurses in end-of-life care all over Asia.

Weighing in on the euthanasia debate, which was sparked off here when Health Minister Khaw Boon Wan raised the issue last month in response to letters on euthanasia in the Chinese press, she says most terminally ill people do not really want to die.

Yet, once every few months, a patient asks her for help to end it all. 'When people ask to die, what they really mean is, 'Do you know how difficult this is?',' she says.

The plea is usually a cry for help. 'As their bodies break down, they hope that they will not linger long, but they don't expect doctors to do anything but listen.'

Her zeal in opposing euthanasia resonates with that of Catholic Archbishop Nicholas Chia who last weekend called on his flock, including Catholic doctors, to reject euthanasia.

Dr Shaw declines to discuss her religion, saying it is a 'private matter'. The grounds on which she opposes euthanasia are both professional and personal, she says. As a doctor taught to heal or cure, the 'intent to kill' is anathema.

Listening to hundreds of terminally ill people has taught her that the wish to die is not always due to physical pain. Very often, distress is made more acute by mental turmoil - caused by social isolation, depression, anxiety or sorrow.

Dr Shaw has distilled 16 years' worth of experience caring for the dying here into a book, Soft Sift In An Hourglass, now available in book stores.

It offers haunting portraits of how different people face the inevitable.

There is the unmarried violin player dying of bowel cancer, still in love with the married man she spent one weekend with 30 years earlier.

There is the frail housewife with two young children, angry at leaving the world before her time.
'The book is not meant to be didactic,' she says. 'It merely opens windows into issues we must all confront some day.'

While no two people face death exactly the same way, she has noticed broad similarities.
Such as how the dying often lose their appetite as their organs shut down, yet their families continue to force-feed them in the hope that they will recover.

And how some embrace religion before death, hoping for a miraculous recovery, but feel let down by God as death closes in on them anyway.

Often, those who have the hardest time accepting death are successful men in their 50s and 60s 'who seem surprised that wealth cannot buy health'.

In general, she has found that most people cling to life, rather than want to end it.

Studies bear this out. One by Melbourne University's palliative care professor David Kissane examined cases of seven cancer patients who had sought euthanasia when the practice was made legal for eight months between 1996 and 1997 in Australia's Northern Territory.
'It showed that some people asked for euthanasia not because death was imminent, but because they found life intolerable,' she says.

Singapore, she says, should not be taking a short cut and legalising this form of killing. 'A society that allows euthanasia devalues life,' she maintains.

Sanctioning it could pressure the elderly and terminally ill to want to end their lives. They may feel compelled to 'shuffle off' so they do not become burdens to society.

It could lead society down a slippery slope to involuntary euthanasia, where others make such choices for patients no longer able to decide for themselves. The Netherlands, where euthanasia has been legal since 1984, has reported many cases of involuntary euthanasia.

Dr Shaw warns that doctors may also be inclined to take the easy way out when they are unable to control difficult symptoms. And families may make decisions on behalf of patients who are unconscious or have dementia.

What Singapore should work on instead, she feels, is improving end-of-life care.

Currently, home hospice services reach nearly three in four cancer patients here. But for non-cancer patients, such care is limited. Only about one in four patients who died last year had subsidised hospice care.

The network of home care services for the elderly is also limited. Both need to be broadened.
Back home in Victoria, Dr Shaw's father had heart disease, diabetes, arthritis and prostate cancer. Yet he lived alone. His meals were brought to him and his home was cleaned by state-subsidised home care professionals.

'He loved the people who came. We need more of that here,' she says.

Keeping the elderly out of hospitals and nursing homes would not only make them happier, but could be cheaper too.

At the same time, doctors need to be better trained both in how to control symptoms such as pain, and how to help the gravely ill face death.

Often, young doctors are reluctant to discuss openly with patients how little time they have left.
'They interpret death from their own perspective,' she says. 'Because they are not ready, they feel their patients may not be.'

During a training course she conducted, a young doctor asked how he could avoid lying to his patients.

Dr Shaw's reply: 'Often, what is required is not for doctors to talk but to listen.'

Communicating with the dying is an art which can be taught and learnt, she believes.
Some doctors ramp up treatments during their patients' last days, even though it is futile, because they do not know any other way to help. 'They don't have the heart to explain how ineffective the treatment is likely to be.'

But explaining that, and stopping the treatment, may prove liberating.

Just last week, one of her patients was told by a cancer specialist that she had reached a stage where neither chemotherapy nor radiation was likely to work.

'It was like a cloud of confusion had lifted. Now she knew what to do - go home, eat just what she wanted and enjoy life,' said Dr Shaw.

Not all patients, however, like to discuss death or say their last goodbyes. Dr Shaw's own mother, who died of heart disease in 1991, was reticent till the end.

'When I asked her how she was feeling, she said she did not want to talk about it. But she was prepared and had sorted out all her drawers. We have to be sensitive to what patients want.'
Either way, listening is key.

When a patient in great pain asked for help to end her life some years ago, Dr Shaw asked why.
The woman revealed that she had never told her husband - or anyone else - that their child was actually fathered by another man.

'All I did was listen. All she did was cry,' Dr Shaw recalls. 'And the pain just melted away.'

The woman died three days later, unburdened and at peace.

(source: www.straitstimes.com/Breaking%2BNews/Singapore/Story/STIStory_298600.html )

MiMi

Mimi is sitting on a self-made litter tray.

Mimi arrives

Thanks to barbs who found an abandoned rabbit at her flat and willing to let go this lovely mammal, Mimi started to live with us.

Before Mimi's arrival, Isa and I have borrowed some books on rabbits from the library. We have cleared a corner in the living room to be her new home.

After picking Mimi up, we headed straight to a petshop in the neighbourhood to buy the hay, dried food and other accessories. Dad helped to set up the folded metal cage. In no time, Mimi's home is ready.

Mimi is an adult rabbit whose fur is almost black with white patches. She has a pair of big and round eyes. She is short-fur and has a pair of pointing ears.

She settles well into her new home.

I am becoming a Mum soon!

I am going to be a mum soon! And yet not pregnant! How can this be possible?

Ok, let me reveal more. My family will be going to keep a pet soon. This time, Isa has been very determined to keep a small pet. I tried the cooling off period. After this period, the decision is still the same - "Yes, I want a pet and I promised I will look after it well."

All along I resisted the idea of keeping a pet because I am fully aware of the responsibilities of looking after a life. From the moment the little animal enters my family, I will have to look after it till "death do us part". Everybody is so busy with his or her own work. Who will have the spare time to look after this pet?

After some considerations, I think I should not be so stubborn and deprieve a learning opportunity for Isa.

Yes, we will be looking around for a small pet soon! We will shelter it with lots of love!