Ae* was a healthy 80-year-old woman who played tennis two or three times a week, but when a physical examination showed a lump in her lung, she refused further medical examinations. Instead, she met Dr Nuttapon Kanprugse, the head of the Palliative Care Team at Camillian Hospital in Bangkok. Dr Nuttapon, who is also a family physician, told her that if the results of further tests showed the lump to be cancerous, she could possibly be cured because the tumour was small. However, Ae said as she was already 80, she preferred to live the rest of her life naturally rather than undergo surgery, radiation therapy or chemotherapy.
Two years later, Ae began to develop pleural effusion, but still refused treatment because she did not want to be hospitalised. Dr Nuttapon respected her decision and informed her of both the positive and negative effects of her choice. While Ae was at home, she was monitored by Dr Nuttapon and his team through online communication. Ae's daughter picked up medications when necessary but she eventually passed away peacefully at home without going to the hospital during the last two months of her life.
Ae required palliative care, but this is a concept Thais are not familiar with. However, people should learn about it since Thailand has become an aged society and more elderly will need palliative care. According to the Department of Mental Health, there are 11.8 million elderly in the country, making up 17.9% of Thailand's total population of 66 million.
Dr Nuttapon explained that palliative care increases the quality of life of patients with chronic and serious illnesses such as cancer, heart disease and lung disease as well as their family members.
"Palliative care helps patients and their family members and/or caregivers deal with suffering, pain and stress related to illness. The palliative care team evaluates the physical, mental and spiritual needs of patients and family members. The team aims to provide as much comfort as possible to patients. Palliative care neither hastens nor postpones death. There is no life-sustaining treatment that forces patients to give up their normal life," explained Dr Nuttapon. Since Thais are not familiar with palliative care, many misunderstand it. Dr Nuttapon added that healthcare workers also misunderstand palliative care.
"Healthcare workers misunderstand palliative care and think it deals with patients in the final stages of life. Some physicians treat patients until treatments no longer work and it is only then they consult the palliative care team. The fact is that patients can start palliative care right after diagnosis of a chronic or serious illness," explained Dr Nuttapon.
"Palliative care is an integration that accompanies other treatments, but its role depends on how severe the symptoms are. Take for example a patient with cancer. The primary treatment initially focuses on symptom control, which may include surgery, radiation and/or chemotherapy. If the patient experiences pain and exhaustion, the palliative care team will take care of these symptoms, but when the disease cannot be controlled and treatment does not work, the palliative care team's involvement increases. When the patient is able to communicate, the team discusses what they want and what can help to reduce their discomfort," Dr Nuttapon added.
Moreover, many healthcare professionals and people misunderstand the role of morphine in palliative care. Dr Nuttapon explained that every physician knows how to prescribe morphine to treat pain for a few days, but palliative care patients require morphine for months or years.
"Many physicians mistakenly think that use of too much morphine is dangerous, but palliative care doctors consider morphine as necessary medication. Some patients also worry that morphine may lead to addiction and that when they recover and stop its use, it may worsen their symptoms. However, we tell them that under the supervision of the palliative care team, there will be no problem," he said.
"Many people assume that if the patient is prescribed morphine, it means they are close to death. This assumption happens because patients come to a palliative care doctor when treatments no longer work. Patients are already in a bad shape and close to death. They can no longer take oral medication and need morphine injections. At this stage, patients usually do not survive. As a result, people associate morphine with patients near death. However, morphine is not only a painkiller. It also helps reduce other symptoms such as coughs and exhaustion. Many of my patients use morphine for years and can go about their daily activities as normal. A significant side effect of morphine use is constipation, so I prescribe a laxative drug with it," said Dr Nuttapon.
In Thailand, some people consider palliative care as giving up on medical treatment. Dr Nuttapon explained that palliative care is not about giving up, but how people accept the reality of letting their loved ones go naturally.
For family members, it is difficult to decide to withdraw a feeding tube or other medical equipment used to maintain life. The head of the Palliative Care Team said equipment helps extend life, but there is no quality to that life.
"Medical doctors consider prolonging life as useless when patients have no quality left. For example, a feeding tube is uncomfortable and sometimes painful. Therefore, patients' hands are tied to prevent them from pulling the tube. The patient must suffer, but if the patient can be cured, it is necessary to do that. If the patient cannot be cured, doctors will inform the patient and family members about the situation, so they can make a decision about withdrawing life-supporting equipment. We also tell them how we can help them stay as comfortable as possible," Dr Nuttapon said.
It is important for a terminally ill patient to inform their family members or caregivers about their decision because when the time comes, the family may not know of the patient's wishes and do the opposite.
In Thailand, palliative care is available nationwide in almost every hospital. Patients and family members can ask for palliative care from the doctor in charge of their case. With palliative care, patients can choose to stay at home or at hospitals in the end-of-life stage.
"Most people in Bangkok prefer to stay in a hospital because they do not have a caregiver at home. Also, people who live in an apartment do not want a patient to die in their building, but if a patient has a place and a caregiver, the palliative care team will evaluate the patient to see what kind of medication they need. Even if the patient remains at home, the team can update on their condition through online communication. In the countryside, there are palliative care networks in provinces, districts and even sub-districts. Medical officials in the Sub-district Health Promotion Hospitals [SHPH] can visit a patient in their area and the patient's caregiver can pick up more medication at the SHPH when needed," Dr Nuttapon explained.
As a palliative care doctor, Dr Nuttapon is concerned about patients' dignity and he hopes people will choose to leave the world in a peaceful manner.
"We cannot choose how we are born, but we can choose how we die. We can choose to die alone in ICU with technology where we are breathing but there is no quality of life or we can choose to die peacefully with dignity surrounded with people we love in our home or a hospital," concluded Dr Nuttapon.
*Not her real name.