Approaching death
The number of Singaporeans aged 65 and above is expected to double to 900,000 by 2030. With our rapidly ageing population, GPs who see patients literally from the womb to the tomb will have to be prepared for end-of-life issues faced by patients.
Physician-assisted suicide and euthanasia
To many elderly and terminally ill patients, suffering from prolonged sickness, having a poor quality of life or being a burden to their children may make them wish for a quick end to their suffering.
Many make the mistake of thinking that ending their life is a quick, easy and painless process. The reality is that when faced with mortality, how many will actually embrace it fearlessly? Many will balk, grasp at straws and hope for a miracle.
The issue of physician-assisted suicide (PAS) came up recently during the World Medical Association (WMA) conference and there were polarised views among the member countries of the WMA. In particular, the Asian and South American countries, where there are big, closely knit and supportive families, reject the idea of PAS, while the opposite holds true for countries that do not have such clan support structures.
In Singapore, the Advance Medical Directive (AMD) Act allows citizens to register in advance their wish to reject extraordinary life-sustaining measures when terminally ill. However, the AMD Act does not condone, authorise or approve euthanasia, mercy killing or PAS.
PAS, however, is legal in Switzerland, Belgium, the Netherlands, Luxembourg, Mexico and three states in the US. In Singapore, anyone who assists in the suicide of an adult can be jailed up to ten years and fined. As the population ages and we have more who are terminally ill, this issue will rear its head time and again in the years to come.
Jaga me and dying at home
Most Singaporeans, including many of my patients, express their preference to die at home. However, according to a 2017 report by the Registry of Births and Deaths, many do not end up doing so and 63% of Singaporeans die in the hospitals. In 2014, the Lien Foundation conducted a survey of 1,000 people and found that 76% of respondents who wish to die at home would still choose to do so even if there is insufficient support from family, friends or medical professionals.
It is believed that dying at home will preserve dignity without a sense of abandonment, while granting closure to the patient and family.
Advance Care Planning
Advance Care Planning (ACP) involves planning for future health and personal care towards the end of life, especially for patients with a poor prognosis of a few weeks to months (eg, advanced cancers), and those with incurable illnesses that may last several years (eg, dementia and motor neuron diseases).
ACP helps patients to share personal values and beliefs that may affect healthcare preferences in various medical situations, and allows them to nominate someone to be their voice after they lose their ability to make decisions independently. ACP also helps patients and family members to understand complex medical decisions during their journey of terminal illness, palliative care and death, and prepare for various scenarios and outcomes.
Some issues discussed include life-sustaining treatments, Do-Not-Resuscitate orders, artificial ventilation, tube feeding, use of antibiotics in terminal illness and even one's preferred place of care and death.
Studies done in 2015 and 2018 have shown that less than half of the 158 patients engaged were willing to continue conversations on ACP. This could be due to various reasons, such as a preference to delegate decisions to family members, refusal to entertain and engage in such conversations, and quiet acceptance of "come what may".
Some have wondered if the AMD may actually limit one's freedom in some contingencies (eg, the use of antibiotics or tube feeding). For example, a patient with advanced cancer, who suffers from acute pneumonia, could be treated with antibiotics and temporary artificial ventilation. Another patient who has advanced dementia, but is eating well, could require temporary tube feeding if he/she comes down with a viral illness.
Hence, with ACP, the best course of action comes from active listening, respectful dialogue and mutual trust and understanding between healthcare professionals and surrogate decision makers who have the patient's best interest at heart.
However, although the patient ultimately makes his/her own choices and decisions, tension may arise among them and their family members, friends and society. Especially in an Asian society, where group decision-making has sociocultural roots, the choices and decisions that one makes also has an impact on those around them. The freedom to make choices for ourselves does not negate the need to take those around us into consideration.
Deskilling of GPs
One of today's trends is the deskilling of GPs and the underlying fear that the days of solo practitioners may be numbered. Throughout the years, many aspects of GP work have changed.
As previously mentioned, GPs often look after patients from the womb to the tomb. Antenatal care is one area in which GPs have been made less relevant. Patients obtain pregnancy test kits directly from the pharmacies and make appointments directly with obstetricians (often ones recommended by their friends or found on the Internet).
Although shared care is still practised, individuals may prefer to consult their obstetrician for regular checks and expect an ultrasound during every visit. Most GPs do not use ultrasound for their antenatal follow-ups.
Moreover, all Singaporean babies are currently entitled to free vaccinations at the polyclinics. This has affected the GPs and paediatricians adversely in terms of income and their coming into contact with new patients. Many GPs also no longer perform growth and developmental assessments for children, and could become deskilled in identifying developmental delays.
Employers of foreign domestics helpers now have the option of having their domestic helpers do their six- monthly blood test at home instead of at a GP clinic. This means that domestic workers will no longer have the opportunity of getting their general well-being assessed by a GP every six months.
There are still many other examples of deskilling of GPs. So how should GPs face these challenges?
Upskilling
When one door closes, another one opens. One needs to have an open mind to see the opportunities guided by the Singapore Medical Council Ethical Code and Ethical Guidelines, and send a message to our fellow colleagues that they need to help themselves. Change is inevitable and information technology is a huge hurdle for senior GPs. I understand that a fair number of senior GPs called it a day when they heard that the implementation of the National Electronic Health Record would be mandated by the law.
Solo GPs can choose to join a Primary Care Network (PCN) to upskill themselves. The network can empower their clinics with nurses, allied health support and upgrading programmes. Many programmes from the Ministry of Health (MOH) will be channelled into the PCN, including the right-siting of patients.
GPs need to upskill and be resilient in taking up various challenges relevant to this day and age. It is necessary to be flexible and adapt to new roles while giving up other roles that have been made redundant. With frequent lunchtime academic conferences, weekend workshops and highly subsidised graduate diplomas made available by the MOH, there are many avenues to upgrade oneself.
Ethically speaking, the right thing should be done – keep the moral high ground and charge reasonably. Practitioners must also not short-change themselves; the undercutting of fees could adversely affect our profession, patients and the public at large. Primary care is very important to society; transforming and staying relevant will surely help us survive.
PS. Coming up next: the future of medical practice.