The Catholic Medical Guild offers some advice on the issue
By Dr Colin Ong and Dr Irwin Chung
Advance care planning is essential today, as technological advances in medicine have enabled people to live longer even when a cure is no longer possible.
However, the use of advance directives or “living wills” may be morally problematic if they contain language that is too simplistic or vague, and suggest that all choices at the end of life are morally the same, for example, “If my doctors decide that I have severe brain damage and I am not likely to get better and life-support only delays death, I (want/
do not want) life support treatment”.
Such questions are prone to the “slippery slope” towards euthanasia especially when patients’ conditions are poor and erroneously considered “not worth living”.
In truth, not all end-of-life choices are morally the same. Catholic teaching affirms that “ordinary” or “proportionate” treatments, i.e. those that would likely benefit the patient’s life and health without undue burden to oneself or one’s family, are morally required. It also affirms that all human life, even in less-than-ideal states, has intrinsic dignity and is worth caring for.
Furthermore, advance directives are made without knowing the actual circumstances during the time of severe illness and may not reflect the real wishes of the patient at that moment.
Perhaps during the experience of being severely short of breath, one may want the life-sustaining treatment that was previously decided against; or one’s decision may have changed because of an important family commitment or a new religious worldview.
As such, advance directives are often not robust enough to ensure that the patient’s preference is upheld at the end of life.
The only legal advance directive in Singapore, the Advance Medical Directive (AMD), contains the problems mentioned above.
AMD states that you do not want to receive extraordinary life-sustaining treatment to prolong your life if you become terminally ill, unconscious, and where death is imminent.
While the parameters are narrow and well defined, it is still prone to different interpretations of what one means by “imminent death” or “extraordinary treatment” as well as lacks ability to definitively know the actual wishes of the patient at the moment when treatment is needed.
Better than an advance directive, or at least something that should be made in conjunction with one, is the appointment of a surrogate decision maker for one’s end-of-life care. There are two complementary instruments to do so:
1. LPA – appointing a surrogate for when one no longer has the mental capacity to make decisions
Lasting Power of Attorney (LPA) is a legal document that you sign to appoint a donee to make financial or personal welfare decisions on your behalf when you no longer have the mental capacity to do so (e.g. dealings with
banks, CPF matters, where to live etc).
While the donee may not make any decision with respect to the carrying out or continuation of life-sustaining treatment, he/she can inform the medical team about your care preferences and execute your LPA in accordance with those wishes (e.g. unlocking funds to finance care in your preferred care setting) if you have appointed him/her as your nominated healthcare spokesperson as well (see ACP below).
2. ACP – planning for one’s future care with loved ones
Advance Care Planning (ACP) begins by having an open discussion about your end-of-life wishes with loved ones, preferably written down for future reference. Consider who among your loved ones (a nominated healthcare spokesperson) can be your advocate if an unexpected event should happen and you can no longer speak for yourself.
This person(s) should know and honour your personal values, beliefs and healthcare preferences especially in difficult medical situations such as the use of CPR (cardiopulmonary resuscitation), ventilator support and so on. You may even want to share your wishes with your doctor.
Here is a brief suggestion of how to do ACP:
• Setting the stage: Think of a suitable place or time of day in which you and your loved ones feel comfortable to begin this conversation.
• Start with a familiar topic: Talking about care at the end of life may be difficult. Some conversation starters include:
- Death of a family member, friend or colleague
- Hospitalisation or serious illness in the past
- Newspaper articles and TV news stories, shows
- Books and magazines
- Religious teachings
• Go slow and keep an open mind: Discussing healthcare matters can bring up concerns and uncomfortable feelings. Your loved ones may not even agree with your decisions. That’s okay. Be patient and give it time.
For persons with more complex conditions, ACP discussions may need to be facilitated by a trained healthcare professional. These facilitators are available in most public and community hospitals. For more information please refer to www.livingmatters.sg.
Let’s not put it off any longer. Planning for our end of life is not only responsible, but also the loving thing we can do for those who love us both “now and in the hour of our death”.
Guild’s bioethics centre
The Catholic Medical Guild of Singapore (CMG) provides a resource for those who are seeking help in answering real-life ethical dilemmas on issues ranging from contraception and abortion counselling to that of end-of-life care in a manner that is both professional and faithful to the teachings of the Catholic Church.