'Your mother only has three months left to live." Despite his professional training, Somsak Anupong, a registered nurse at a private hospital in suburban Bangkok, was aghast hearing this heartbreaking news from the doctor.
"It felt like being slapped in the face. I have bachelor's and master's degrees in nursing but no one taught me how to deal with this kind of situation. All my life, I have been trained to try the best to get patients better and heal them. Preparing them for death was never in my book," Mr Somsak explained.
After he pulled himself together, Mr Somsak changed his whole perspective on how to prolong the life of his mother to make the last moments of her life the most precious so she could do the things that she wanted to do before the departure day.
He turned his broken heart to professionals dealing with patients with terminal illnesses. His mother received palliative care instead of intensive care. Even though saying the last farewell to his mother wasn't be easy, at least she had a choice to stay at home during the last hours of her life. She got to be surrounded by people she loved. It was a good example of a "good death".
A GOOD DEATH
A good death is one free from avoidable distress and suffering, for patients, families and caregivers; in general accord with the patients' and families' wishes; and reasonably consistent with clinical, cultural and ethical standards. The term reflects an individual preference for how a person wants to die. For many people, factors that constitute a good death include dying at home, among family and friends and without stressful physical symptoms.
Assoc Prof Pagorn Singsuriya, head of the humanities department at Mahidol University's faculty of social sciences and humanities, explained to Spectrum that a good death or a successful death is one with dignity. The term dignity can be divided to two types: inherent dignity and contingent dignity.
"Inherent dignity is the dignity inside everyone, such as dignity as a human being or personal dignity. Contingent dignity is usually linked to position, rank, status, excellence or the virtue of that person," he explained.
"Death with dignity can be divided into two categories: death without mortifying the dignity, and death that is worth the dignity. Death without mortifying the dignity is entirely up to the medical personnel to take care of the patients during their last moments. Meanwhile, death that is worth the dignity is entirely up to the patients themselves."
A good death is something that medical personnel or relatives of the patients can provide by making sure that their dignity is not mortified. The medical personnel should not ignore the patients' pain.
They should help the patients face the illness and suffering courageously.
"If the patients prefer not to have tubes in their body or rely on a life support machine, that wish should be granted since that is what they want in order to maintain their dignity," Assoc Prof Pagorn said.
HONOUR THE DYING
The National Health Act of 2007 is the first law that recognises the living will, allowing patients' wishes to be honoured. But the delay put Thailand in the 3A category for palliative care, which means that while we have the law, the system has yet to be implemented. The result is that only some major hospitals in Thailand recognise and honour this law.
Patients with terminal illnesses are turned away from hospitals simply because the doctors can't heal them. The limited number of beds and high medical fees are other key factors that force such patients to resort to home care with no professional training or lack of knowledge in healthcare.
The National Cancer Control Programme for 2013 to 2017 specifically mentions preparation for death, the living will and a good death.
However, its main focus is on patients with cancer, although the number one cause of death among Thais is heart-related problems, which account for 39 percent of the total, while cancer represents 36 percent.
The programme mainly focuses on cancer patients because doctors perceive that patients with other diseases still have a fighting chance -- unlike cancer, especially when it is discovered at the final stage. Even though the law refers to preparation for death, current legislation still focuses on palliative care throughout the final stage of life for patients with terminal illnesses.
"No one really talks about a good death, which covers the issue of medical and non-medical treatment. I proposed three strategies focusing on developing the knowledge and attitude towards a good death, developing the healthcare system and developing a support system and the National Health Assembly has approved them," said Dr Ugrid Milintangkul, former deputy secretary of the National Health Commission. "Now we have to ensure that we can really apply such principles in real situations."
"People have to understand that death is a fact of life and nature. No one can avoid it. We have to learn how to handle it."
DEATH AND BELIEF
While the definitions of a good death and a living will have yet to be defined and interpreted to make them unambiguous to medical personnel, a group of academics who represent each religion are discussing what constitutes a good death. They are seeking to interpret the term in a way that will not conflict with the tenets of their faith.
Prof Anas Amatayakul, a lecturer at Mahidol University's faculty of social sciences and humanities and an Islamic studies expert, explained the view of death among Muslims. They are taught that Allah created souls at the same time but not everyone is sent to live in human form at the same time. Souls are created equally with no form, no colour and no figure. They are all pure until the day they come to walk the Earth as humans.
"Souls are immortal. Just because that person died, that doesn't mean their life has ended. They will continue to live in different forms. Death means the end of time to do good things, bad things or communicate with other people. But the soul will live forever," Prof Anas explained.
Even though the concept of taking lives is not acceptable in any religion, preparing for a good death has always been a part of every religion.
"Before a person dies, they will be told to think of Allah and try to relax. They should think about how Allah will be compassionate to them. On the death bed, the closest relative will remind the expiring person about God and all the good deeds. Then they can die peacefully. That is how we define a good death," Prof Anas said.
For Christians, death doesn't mean the end. Just like Muslims, Christians believe that life after death will be pleasant since they can depart their body to be with God in Heaven.
"This is why we are not scared of death," Prof Pratheep Chatsuphang, a lecturer at Mahidol University's faculty of social sciences and humanities, explained. "Death for us means the end of human life and the beginning of eternal happiness with God in Heaven. But to be able to be with God, that person must have a good relationship with God, for example, by believing in Him, by being a good person and by doing good deeds."
Christianity usually encourages people who are sick to accept the illness because it is God's will, God's will always chooses the best for everyone, and illness is the law of nature. Christians usually get spiritual support from a priest or vicar. Some clergymen visit ill people and if they are patients with a terminal illness, they will prepare the person for death by praying or reading the Bible to them.
FREEDOM OF DEATH
Unlike Islam and Christianity, Buddhism advocates reincarnation. The death of one person presents life leading to a new journey while waiting to be reborn in a different form. The Lord Buddha taught that death is one of the dharmic truths along with age and illness that no one can avoid, yet humans still fear it and are unable to accept it.
When a person is going to die or suffering enough that they think they are going to die, they might feel sad and still feel attachment to all their possessions. That is why it is difficult to set their minds free. But when an individual can let go of everything and come to their senses, they will find a peaceful death or the freedom from death, freedom from physical form and freedom from thoughts.
"We believe that to have is not peaceful. If they can let go of what they have, they will finally find the peace they are searching for," Assoc Prof Wutthinant Kantatian, a lecturer in Buddhism studies at Mahidol University, explained.
"Humans can't take anything with them when they die except their last breath. Death is a fact of life. If you are afraid of death, you shouldn't have life since we are all end up at the same destination."
Assoc Prof Wutthinant explained that talking about death is taboo in many Thai families. They believe it is not a suitable topic to talk about and some people even believe talking about death will bring bad luck as if they are inviting death to their families.
"The best way for Buddhists to prepare for a good death is to collect the consciousness and the intellectual power that will lead to true peacefulness. When their mind is peaceful, they will have a good death," he explained.
FROM WOMB TO TOMB
Even though the national healthcare policy is now focusing on the living will and holistic palliative care, it will still only use the national budget to develop people from birth until they get old; no one is really talking about preparation for death among the terminally ill.
Dr Ugrid thinks that the best policy we should have is one that takes care of people from womb to tomb. He said just because a person is dying, doesn't mean we should stop spending money on them and let them have a poor quality of life before their departure.
"I'm happy that all hospitals in Thailand now recognise the living will of patients. Such a will was drafted when the patient was fully conscious and the doctor can use it to make the final decision whether they want to try their best to help or to let the patient go. I've seen many patients write their own living will and use them," said Dr Ugrid.
"What I would really like to see is a policy that focuses on terminally ill patients. They should have equal rights as human beings even though they may not have much time to live," he added.
Dr Ugrid encourages everyone to study the living will and how it will help make decisions for medical personnel and relatives. A good death is also something to consider as an alternative for those with terminal illnesses.
"Instead of running to the hospital and taking a chance that patients may or may not make it, the relatives of such patients should respect the patients' rights. I know many cases in which they wish to die at home surrounded by their loved ones, but only 20% of them have their wishes honoured. The rest of them died in the emergency room or intensive care unit surrounded by nurses and doctors," said Dr Ugrid.
"People in the past had a better understanding of death and were more prepared than people today. Now, with all the medical technology, people believe they can prolong their lives as long as possible. That's why a good death is something they don't want to think about. I think it's harder living with the guilt when they let a loved one die, but death is part of nature. Since we can't avoid it, I think it is better to be prepared and get ready for it wisely."
Pagorn: A good death has dignity. PHOTO: CHAIYOT YONGCHAROENCHAI
Anas: The soul will live forever. PHOTO: CHAIYOT YONGCHAROENCHAI
Ugrid: Prepare for death wisely. PHOTO: CHAIYOT YONGCHAROENCHAI
Pratheep: Illness is God's will. PHOTO: CHAIYOT YONGCHAROENCHAI
Wutthinant: Death is a fact of life. PHOTO: CHAIYOT YONGCHAROENCHAI
TOUCHY SUBJECT: The national healthcare policy only covers people from birth until old age; no one is talking about preparing for death among the terminally ill. PHOTO: © 2017 THE NEW YORK TIMES
FINAL FAREWELL: Factors that constitute a good death include dying at home among family and friends and without stressful physical symptoms. PHOTO: REUTERS