Forum: Advance medical directives may need fine-tuning to tackle end-of-life issues

Forum: Advance medical directives may need fine-tuning to  tackle end-of-life issues

https://www.straitstimes.com/opinion/forum/forum-advance-medical-directives-may-need-fine-tuning-to-tackle-end-of-life-issues

2023-11-01

As I read Dr Sandeep Jauhar’s thought-provoking article “My father didn’t want to live if he had dementia. But then he had it” (Oct 26), on siblings torn between honouring their father’s advance medical directive (AMD) wishes and those of the weakened man he had become, my mind went back to a patient I encountered a year ago.

He was a man with moderate-stage dementia who had undergone emergency surgery to remove blood clots in his brain after injuring his head in a fall. After the surgery, he was apathetic, unmotivated and largely refused to eat or drink anything, including medications.

Feeding through the nose was attempted, but he repeatedly removed the tube. As he had not made any AMD indicating a desire to limit life-saving interventions, his family and I could discuss and decide what to do in his best interest.

A feeding tube was inserted into his stomach to give him medication and nutrition to help him recover, and he did.

Today, he no longer feeds through the tube and is back to his ambulant and cheerful self. While he requires some help with daily activities, he appears to be enjoying a reasonable quality of life with his loved ones and savouring the food he likes.

If, like Dr Jauhar’s father, he had indicated in an AMD to refuse life-saving interventions such as surgery or tube feeding under life-threatening circumstances, he would almost certainly not be alive today.

Given the purported value of AMDs to achieve the goal of aligning care to the patient’s preferences, how might we navigate the conundrum whereby an AMD stands in the way of potentially life-saving interventions?

First, instead of making AMDs immutable decisions, advance care conversations can help to elicit one’s goals, values and preferences in preparation for future in-the-moment decisions. Second, one can indicate how much leeway to allow in the AMD so that families and healthcare professionals can have the latitude to make decisions that are responsive to changing circumstances while trying to uphold the person’s wishes.

In this way, AMDs can continue to uphold personhood and dignity by respecting a person’s values and preferences without the risk of following a self-imposed bondage that closes the door on possibilities.

Philip Yap (Dr)

Chairman

Dementia Singapore