Incognisant of life, why ponder death?

Preface 

        Three years ago, a friend entrusted me with accompanying a liver cancer patient through the final stretch of his life. It was my first time. When the patient told me that his body truly felt unbearable, I was as helpless as he was. I could only stare at him; hadn’t I just given him his medication? What more could I do? He said to me, “I could collapse at any moment.” I understood what he meant, yet I chose to avoid it.

        I said to him, “Don’t be afraid! I’m right here. If you fall, just don’t hit your head—I’ll support you.”
       Later, my friend suggested that I call the nurses from HCA Hospice Care for help. That was my first encounter with a hospice organization. The nurse asked me to find the morphine. I almost cried out, “What? Drugs?”

        I was unable to lift my friend. He passed away.

        After his death, he left me with many questions and regrets. I had failed his trust and his request. I hadn’t done my job of accompanying him well.

        For a long time afterward, I continued to avoid — avoiding hospital visits, funerals, even conversations about death.

        Three years later, my father faced his final days; also liver cancer. I muttered to myself: What kind of joke is Heaven playing?
       But I knew there was nowhere left to run. So I forced myself to read, to prepare, to face the subject.

        Three months ago, my father passed away peacefully in a hospice bed. So peaceful; like falling asleep. There was little struggle, little pain. At the moment when the hospice doctor removed the infusion device clipped to his chest, I suddenly understood: how merciful, compassionate and generous Heaven had been to me. It had long been preparing me; giving me advance lessons for this very moment.

Hospice Care: A Humane Way of Facing Life

— An Interview with Dr. Grace Pang Su Yin,  Resident Physician at Assisi Hospice 

1   How did hospice care develop?

        In 1967, Dame Cicely Saunders founded St Christopher’s Hospice in London. From there, hospice care gradually developed worldwide.

        From the Middle Ages through the 19th century in Europe, critically ill patients often travelled to churches to pray for recovery. Many never made it. Some died along the way; others worsened and were forced to remain near the church. Christian organizations thus set up simple shelters for those unable to return home, providing basic food and spiritual comfort until death. This was the earliest form of hospice care.

        St Christopher’s is regarded as the pioneer of modern hospice care because Dame Cicely Saunders herself had experience as a nurse, social worker and physician. This enabled her to develop medical approaches to pain control.

        Today, hospice care is no longer limited to terminal patients. Any patient facing a life-threatening illness, at any stage of disease, may receive hospice care upon referral by their primary physician.

2   What is the difference between hospitals and hospice care?

        In Singapore, hospice facilities generally do not perform complex scans or emergency resuscitation for terminally ill patients. These interventions can be carried out in hospitals, but whether they truly benefit dying patients and with what likelihood of success, are questions worth reflecting upon.

        Hospice care focuses on controlling symptoms such as pain and vomiting, and pays special attention to patients who lack adequate family support.

        The patient-to-staff ratio in hospice care is higher than in hospitals, allowing better physical, emotional, and psychological care.

        Hospice care is grounded in the belief that patients are not merely illnesses. Care is provided by a responsible team: doctors, nurses, social workers, physiotherapists, cleaners. No physician can do this alone.

3   Could you elaborate on the philosophy of hospice care?

        All hospice professionals would agree: every person is a unique individual. A “patient” is not simply “a person with a disease.” When life is nearing its end, comprehensive care is essential; medical, nursing, psychological, and spiritual.

        Birth, aging, illness, and death are natural. Hospice care respects individual wishes, whether death is imminent or not. It is like a marriage vow: regardless of storms or sunshine, we stay together until death parts us.

        Major hospice organizations in Singapore include Assisi Hospice, Dover Park Hospice, Hospice Care Association, Kwang Ming Hospital, Methodist Welfare Services, Ci Guang Senior Day Rehabilitation Centre, Singapore Cancer Society, and St Joseph’s Home.

        Services vary but generally include day care, home care, and inpatient care. Hospice outpatient services are also available at major hospitals.

        Home care is free; patients pay only for medication. Inpatient fees are means-tested. Hospice services are supported by government funding and public donations.

4   When should patients seek hospice care?

        There is no single correct answer.

        Many people mistakenly believe hospice care means “treatment failure,” a last resort. This is untrue. Hospitals and hospice care can, and should, work together.

        In hospitals, doctors are pressed for time. Listening, diagnosing, explaining, and building rapport all require time. Because of this, many patients’ pain is inadequately managed before they reach hospice care, leading to despair or even suicide. By then, it may be too late.

        If pain cannot be controlled, patients should ask their doctors for a hospice referral. Hospice care does not replace existing doctors; it respects all medical efforts.

5   How should we care for terminally ill patients?

          Facing death is a profound lesson.

        Understanding one’s illness is less important than understanding one’s approaching death. Knowing death is near allows time for estate planning, final wishes, reconciliation and decisions about care preferences. This brings peace to patients, families and the soul itself.

Even if patients do not accept death, they can still make preparations while continuing to seek treatment.

        Hospice care offers choices and respects them. Patients may choose stronger or gentler medication. Even if we disagree, informed decisions are honoured. Care must be accepted by the patient.

6   What role can family members play in critical moments?

        Blood ties matter. Family members can help change diapers or simply sit silently by the bedside. We encourage holding hands, massaging, gently patting patients to sleep. Physical contact conveys closeness and reassurance.

        Regarding traditional medicine or alternative therapies: we neither oppose nor encourage. Patients may choose, but should inform doctors, as herbs can have side effects or interact with medication.

        We encourage healthy habits, balanced diets (unless restricted) and appropriate exercise.

7   As a hospice doctor, how do you remain calm emotionally?

        I believe: To be able to give is a blessing from God. Separation is temporary; we will meet again.

        Religion sustains me, but so do patients and families. From them, I witness courage, love and generosity.

        Death is part of life. It is not failure. Modern medicine has made us reluctant to accept incurable illness. We hear about successes, but do we acknowledge failures?

        How we treat the dying reflects our societal values. Hospice care is not about death; it is about how to live.

Postscript

        My friend has gone. My father has gone too. This time, though, there is sorrow but little regret. I have stepped out of the shadows of the past.

        Life has changed. At night, I check whether the door is locked; just as my father used to. In the morning, I now read stock prices. After bathing, I place the soap at a 30-degree angle to dry; my father’s habit. I feel he has not left; he lives with me in another form.

        Confucius said: Incognisant of life, why ponder death?

       If life and death are beyond our control, at least we can choose how we face life.

        Let us cherish every minute.