Ignorance stymies palliative care
Palliative care -- a holistic approach to treatment and support for people approaching the end of life -- is not new to Thailand. But although the service has been delivered in this country for a long time, the average Thai knows little about it.
This type of terminal care aims to neither hold back nor accelerate the patient's approaching death, but to ensure that the patient lives pain-free and in comfort for their remaining days up until a natural death. A number of hospitals currently provide palliative care services to patients as well as assisting them when they need support at home. Only some Thai universities have integrated the concept of palliative care into their medical curriculum.
According to the World Health Organisation, palliative care is an approach that improves the quality of life of patients and their families that face problems associated with life-threatening illness, through prevention and relief of physical, psychological and spiritual sufferings. In addition, some other organisations extend its definition to include physical, psychological and spiritual care for both patients and their families, focusing on appropriate treatment for patients' pain without hastening or postponing death.
The approach covers all stages of care throughout the patients' terminal period. For incurable patients, the use of life-sustaining equipment such as Respiratory Assist Devices is important in prolonging their life, but it might also cause them discomfort or annoyance. Thus, it is pain relief and pain control that are central to palliative care. Patients should be additionally supported to fulfill their dreams and needs before the end of their life. This might include a warm stay with their family at home that helps patients to be prepared to die dignified and peaceful. It also lets patients' relatives stay with their loved ones during the patients' final days.
The legal aspects of palliative care are among the most important issues that need deeper understanding. Many countries have enacted laws concerning the concept. Among them, the Netherlands is the only country legalising euthanasia or mercy killing with a patient's consent. Some countries also recognise "the right to refuse medical treatment" in laws such as the United States of America's Patient Self-Determination Act (1990) and Uniform Health-Care Decisions Act (1993), Australia's Northern Territory National Death Act (1988), South Australia's Consent to Medical Treatment and Palliative Care Act (1995), Australian Capital Territory's Medical Treatment Act (1995), and England's Mental Capacity Act (2005).
In Thailand, the related law is the National Health Act B.E. 2550 (2007). Its Section 12 stipulates that a person has the right to make a living will in writing to refuse the medical treatment or other health related services which is provided merely to prolong his/her terminal stage of life, or to make a living will to refuse the service to cease the severe suffering from illness. The living will shall be carried out in accordance with the rules and procedures prescribed in the ministerial regulation. An act done by public health personnel in compliance with the living shall not be held as an offence and shall not be liable for any responsibility.
Although the Act has been in force since 2007, and the ministerial regulation has been implemented since May 2011, making a living will is still unpopular in Thailand. This might be due to many Thai people's superstitious beliefs, which see such action as a bad omen. Some also misunderstand that with a living will, a doctor might refuse to cure them when they are ill. Indeed, a refusal of medical treatment is a patient's decision, not a doctor's. Moreover, a living will can be easily revoked.
Readiness of the service system and personnel is vital to pushing forward palliative care. Regarding the system, the government-funded health insurance in Thailand is not so comprehensive, since patients and their families have to assume the expenses if they decide to spend their final days at home. The government covers the cost only when they stay in the hospital. This is similar to the health insurance provided by the private sector that only covers patients' expenses in hospital. This system does not motivate any patients or their families to embrace palliative care, especially home-based care.
As to the readiness of the personnel, there is a huge gap between nurses and doctors. Nurses, whose job generally requires frequent, close interaction with patients, are good at understanding society and patients' families. Palliative care with support from nurses therefore often leads to positive results. However, doctors are less ready for terminal care because of the limitations of the medical curriculum. Doctors' analgesic prescriptions are also restricted for various reasons.
But the main obstacle to palliative care in Thailand is the negative attitude towards the idea, which sees it as euthanasia or the intentional ending of life. This attitude has grown based on a denial of death or fears of making mistakes. Therefore, if people understand the concept correctly, the fear will diminish.
In fact, access to palliative care services requires systematic assessment, and only incurable patients will be offered the choice to receive the service. In other words, obtaining the service is an alternative, not a necessity. Once patients choose to receive terminal care, it means they don't deny their demise. Death is just like birth in that it needs preparedness. When we are about to be born, we have mothers preparing for the process. When we are about to pass away, we all should have the right to prepare ourselves for that transition as well.
Worawan Chandoevwit, PhD, is an adviser of the Thailand Development and Research Institute. Yos Vajragupta is a TDRI researcher. Policy analyses from the TDRI appear in the Bangkok Post on alternate Wednesdays.