{"id":15725,"date":"2019-12-16T21:00:45","date_gmt":"2019-12-16T13:00:45","guid":{"rendered":"http:\/\/varsity.com.cuhk.edu.hk\/?p=15725"},"modified":"2021-06-23T17:16:26","modified_gmt":"2021-06-23T09:16:26","slug":"when-life-comes-to-an-end","status":"publish","type":"post","link":"https:\/\/varsity.com.cuhk.edu.hk\/index.php\/2019\/12\/when-life-comes-to-an-end\/","title":{"rendered":"When Life comes to an End"},"content":{"rendered":"\n

Patients in their last stage of life can choose the end-of-life treatment they receive by signing an advance directive, but medical workers, paramedics and their family members have little knowledge about the directive.<\/strong><\/p>\n\n\n\n

By Howard Li <\/strong><\/p>\n\n\n\n

Wan Sin-man is an 81-year-old volunteer of Sham Shui Po District Elderly Community Centre. She is diagnosed with Angina pectoris which means she suffers from chest pain due to coronary heart disease. She has been admitted to hospital many times and undergone five surgeries for the same illness so far. But Wan is not afraid of talking about death, as without the advanced medical facilities, she thinks she would have died already. <\/p>\n\n\n\n

Wan learns about advance directive from news and supports the signing of it. Her doctors have never mentioned anything about it during\nfollow-up consultations. Wan already has her last\nwill prepared, though she still has not signed the advance directive. \u201cIt was tough for both patients and family\nmembers to see windpipes being inserted into a patient’s throat,\u201d says Wan. <\/p>\n\n\n\n

\"\"
The current Advance Directive form provided by Hospital Authority.<\/figcaption><\/figure><\/div>\n\n\n\n

Advance directive is a written document which a mentally-competent\nperson aged 18 or above indicates what healthcare treatment he or she refuses to have, such as tube feeding and\ncardiopulmonary resuscitation, when he or she\nenters a persistent vegetative state, goes into an irreversible coma or suffers\nother end-of-life illnesses. It must be signed under the supervision of two\nwitnesses, one of them must be a registered doctor and neither of them is a\nbeneficiary of the patients\u2019 inheritance.  \n<\/p>\n\n\n\n

The government has launched a three-month public\nconsultation over the legislation of advance directives in early September 2019. It is part of the advance care planning process in which patients express preferences over end-of-life care\nafter discussing with family members and healthcare workers.<\/p>\n\n\n\n

Medical not Equipped Well Enough<\/strong><\/p>\n\n\n\n

Advance directive was promoted when the Law Reform\nCommission of Hong Kong introduced the concept back in 2006. It can uphold the right\nto self-determination and enhance the quality of life of a patient. But the\nfeasibility of legislation has raised concerns.\n<\/p>\n\n\n\n

\u201cThe responsibility of medical professionals is to\nfacilitate decision-making process of patients and their family members by\nmaking sure they are well informed of the decision,\u201d says Joseph Lee Kok-long,\nthe chairperson of Hong Kong Association of Nursing Staff. But not all healthcare providers know the\nbasics of advance directive as it depends on their specialties. To become palliative care professionals, medical\nworkers are required to have further training including understanding the\nend-of-life context and improving the patient\u2019s quality of life during\nend-of-life care.<\/p>\n\n\n\n

Though the government proposes that treatment providers will not incur liabilities for withdrawing treatment from patients in the presence of an advance directive, family members might be reluctant to let their loved ones go. These all come down to the cultural and ethical issues that cannot be regulated and measured. <\/p>\n\n\n\n

\u201cMedical professionals won\u2019t mechanically follow what the\ndirective states. They will keep checking on patients and take appropriate\nactions at the request of family members,\u201d says Lee. He also stresses that communication with clients is important for medical personnel to\nresolve any misunderstandings about the advance directive. <\/p>\n\n\n\n

In view of the overloaded medical system, each\nconsultation only lasts for a\nfew minutes. \u201cHealthcare\npersonnel is unable to map out details of advance directive even when patients\nand their families want to learn more about it,\u201d says Yuen Siu-lam, the chairperson of the Self-Help\nGroup for the Brain Damaged.<\/p>\n\n\n\n

Legislation Lacks Legal Power <\/strong><\/p>\n\n\n\n

The government proposes\nthat the original copy of advance directive, which may be revoked\nat any time\nby the patient, should be presented to paramedics as proof of its\nvalidity. Otherwise, they will continue to\nprovide clinically indicated emergency life-sustaining treatment. The\nrequirement causes inconvenience to elderlies who live alone. <\/p>\n\n\n\n

\u201cOnce\nthey fall\ninto a coma or become unconscious, they are unable to show valid documents to\nparamedics,\u201d says Yuen. He points out that revocation of the directive\nadds trouble to the elderly.\nHe suggests replacing\na valid advance\ndirective with a QR code on a wristband or a\nnecklace that stops the paramedics from doing Cardiopulmonary Resuscitation (CPR).<\/p>\n\n\n\n

Paramedics from the Fire and Service Department\n(FSD) carry out CPR and other relevant treatment procedures to\nresuscitate patients in need of immediate medical attention before arriving at hospitals. Then, they convey patients to hospitals for appropriate treatment. <\/p>\n\n\n\n

In the current protocol, doctors also sign the Do-Not-Attempt Cardiopulmonary Resuscitation (DNACPR) if the patient stated their preferences in their advance directives. But the paramedics may revoke the advance directive if they deem the patient falls outside the directive. In other words, the paramedics do not have to follow the guidelines of DNACPR. This leads to conflict between patients\u2019 wishes expressed in advance directive and paramedics\u2019 duty to aid the patient. <\/p>\n\n\n\n

\u201cThe problem can be resolved by either removing \u2018resuscitate\u2019 from the ordinance or establishing a new law to reinterpret \u2018resuscitate\u2019 so that the ordinance won\u2019t override the advance directive,\u201d says Roger Chung Yat-nork, associate professor of the Jockey Club School of Public Health and Primary Care. The Mental Health Ordinance, the only law dealing with mental health matters in Hong Kong, defines mental incapacity as \u201cmental disorder\u201d or \u201cmental handicap\u201d. <\/p>\n\n\n\n

Chung explains, \u201ca person with mental illness\ndoesn\u2019t necessarily mean he or she cannot make decision on medical treatments. We\nshould resolve the uncertainties with definitions to make the advance directive\nvalid and applicable.\u201d He takes the Mental Capacity Act from the UK as an\nexample, \u201cUnder the Act, the advance directive has legal backing when the\nperson signing it is losing his mental capacity. Otherwise, it is pointless to sign\nin advance.\u201d  <\/p>\n\n\n\n

Changes Starting from Education<\/strong><\/p>\n\n\n\n

Public awareness about end-of-life issues is also low\nin the socio-cultural context. Statistics from the Hospital Authority show a slight\nincrease in the number of patients signing advance directives from 937 in\n2016 to 1,557 in 2018. Another population-based cross-sectional telephone\nsurvey of 1,067 adults in 2017 by the Chinese University of Hong Kong indicates a total of 85.7% had not heard of advance\ndirective. But after explanation, 60.9% said they would make their own advance directive if it is\nlegislated. <\/p>\n\n\n\n

Chung agrees that the public mindset about death can\nbe changed through education. \u201cTake Taiwan\nas an example, end-of-life education is covered starting from kindergarten, so they are\nmore mentally prepared for discussing death,\u201d says Chung. <\/p>\n\n\n\n

The Taiwanese government includes\nlife and death topics into the education system to break down cultural taboos\nagainst discussion about death.\nThe concept of palliative care is also introduced through mainstream and social media to increase\npublic awareness. In the 2015 Quality of Death Index conducted by The\nEconomist, Taiwan ranked sixth among other 80 countries with a score of 83 over\n100. While Hong Kong only ranked 22 with a score of 67. <\/p>\n\n\n\n

\"\"

A program about End-of-Life care and planning launched by the CUHK Jockey Club Institute of Ageing. <\/figcaption><\/figure><\/div>\n\n\n\n

The power of education is echoed by Dr. Paul Shea Tat-ming, Co-Chairman of the Hong Kong Medical Association of End of Life Care, and a Specialist in Geriatric Medicine. He believes people with higher education comprehend life planning easier. \u201cTo promote a measure, you should start from citizen\u2019s education instead of legislation,\u201d says Shea.<\/p>\n\n\n\n

Developing a culture of respect\nbetween members of the public is crucial in promoting advance directive. \u201cDoctors will bring\nout the topic to patients when a bleak future is foreseeable\u2026 family members\nwho have taken care of patients around the clock are more likely to respect patients\u2019\ndecisions,\u201d says Shea. And he thinks that the public, especially secondary school\nstudents should be more exposed to life and death topics, so that they have a clearer concept of\nadvance directive and higher acceptance of it. \u201cIt should be done by the Education\nBureau because Hospital Authority is\nonly a medical department,\u201d says Shea. <\/p>\n\n\n\n

Edited by Civi Yap<\/em><\/p>\n","protected":false},"excerpt":{"rendered":"

Patients in their last stage of life can choose the end-of-life treatment they receive by signing an advance directive, but medical workers, paramedics and their family members have little knowledge about the directive.\ufeff<\/p>\n","protected":false},"author":2,"featured_media":15729,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[1802,8],"tags":[1368,1367,1365],"class_list":["post-15725","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-issue-154","category-our-community","tag-advance-directive","tag-end-of-life","tag-medical"],"_links":{"self":[{"href":"https:\/\/varsity.com.cuhk.edu.hk\/index.php\/wp-json\/wp\/v2\/posts\/15725","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/varsity.com.cuhk.edu.hk\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/varsity.com.cuhk.edu.hk\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/varsity.com.cuhk.edu.hk\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/varsity.com.cuhk.edu.hk\/index.php\/wp-json\/wp\/v2\/comments?post=15725"}],"version-history":[{"count":8,"href":"https:\/\/varsity.com.cuhk.edu.hk\/index.php\/wp-json\/wp\/v2\/posts\/15725\/revisions"}],"predecessor-version":[{"id":15771,"href":"https:\/\/varsity.com.cuhk.edu.hk\/index.php\/wp-json\/wp\/v2\/posts\/15725\/revisions\/15771"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/varsity.com.cuhk.edu.hk\/index.php\/wp-json\/wp\/v2\/media\/15729"}],"wp:attachment":[{"href":"https:\/\/varsity.com.cuhk.edu.hk\/index.php\/wp-json\/wp\/v2\/media?parent=15725"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/varsity.com.cuhk.edu.hk\/index.php\/wp-json\/wp\/v2\/categories?post=15725"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/varsity.com.cuhk.edu.hk\/index.php\/wp-json\/wp\/v2\/tags?post=15725"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}