Should I fight to the bitter end?

How do healthcare providers help patients decide? To what extent do they, or should they, limit options?
by Alicia Wong


SINGAPORE - His sister died two years ago of advanced liver cancer. Till today, Alexandra Hospital chief executive Liak Teng Lit and his family believe the "best care" she received was the three-hour talk with the surgeon on her options, and the subsequent decision not to operate.

"She had a really good death. She spent the last two months doing family things ... and when she finally died, we had a celebration," said Mr Liak.

Contrast this with oncologist Ang Peng Tiam's patient, who battled a "stormy post-operative course" which included many days in intensive care and temporary dialysis, after her family decided to fight to save her life when the stage four colon cancer sufferer developed a perforation in her intestines and went into shock.

But the reward came when she was "well enough to watch her daughter get married in February", said Dr Ang, the founding head of the Department of Medical Oncology in Singapore General Hospital and the Medical Director of Parkway Cancer Centre.

And herein lies the tricky situation in deciding just when enough is enough, in medical treatments.

As Dr Ang puts it: "The problem with patient care, is that one can never be certain how things will eventually turn out."

Or, as Mr Liak sees it, when people think there is hope they become "irrational".

This was an issue Health Minister Khaw Boon Wan addressed at a health conference in March, when he spoke about medical advances as a major source of healthcare cost escalation.

High-tech, high-cost medical interventions which are also futile during end-of-life care have presented particularly difficult ethical choices, Mr Khaw said.

While noting advances eventually help provide cures, Mr Khaw stated that the key to sustainable healthcare is sticking to the basics, which includes accepting the limits of medical science and one's mortality.

So, how do healthcare providers help patients make choices, and to what extent do they, or should they, limit the options, say, by only providing cost-effective solutions?

The current policy is that if the drug is essential to one's treatment, one is not denied access even if the drug is not subsidised, said MOH.



UNREALISTIC EXPECTATIONS - AND THE ONUS ON HEALTHCARE WORKERS

Group procurement of common drugs lowers their cost, and where applicable, patients can get help under Medifund or the Medication Assistance Fund, it noted.

But as Changi General Hospital's chief executive T K Udairam puts it, it is only natural to search for a cure, or prolong a loved one's life through any means possible. Advances in medical science has sometimes created "unrealistic expectation", he said.

So, healthcare workers have the responsibility to assess a treatment's benefits, or lack of, and advise families, said visiting professor to the Centre for Biomedical Ethics at the Yong Loo Lin School of Medicine, Professor Paul Macneill.

He said families do need assurance that "they are still good and moral" when they say "no" to a treatment that offers little or no benefit.

But to do this, hospitals and doctors have to be rigorous in their assessments.

Dr Ang noted that in private healthcare, patients are told about their condition and presented the options and recommendations. But in the public sector, "considerations of cost and equity come in".



NEEDED: GUIDELINES FOR DOCS

Doctors, who often end up the "gate-keeper on what level of care to offer", are not best-suited to "bear the burden" of the non-medical decision of allocating limited resources, he believes.

Mr Liak believes it is the hospital chief executives' "job to sieve through the literature and try to understand new technology, and ask ourselves the tough questions. Is it better? And, if it's better, is it worth the money?"

But with so many new products and options available, doctors do need the discretion to decide for their patients, says health policy and management Associate Professor Phua Kai Hong.

So, this is where guidelines and data - provided by the Government or hospital - are essential.

Doctors sometimes do not keep up with the latest developments, or only know about the latest drug, said Assoc Prof Phua, from the Lee Kuan Yew School of Public Policy.

As such, they tend to only want to prescribe the latest drugs, he added.

Doctors must be provided with data on prices and cost effectiveness, or "they will just depend on advertisements and drug companies promoting products in subtle ways", he said, citing advertisements, medical journals and in the course of continuing medical education.

New drugs should also be subjected to "rigorous economic analysis", which accounts for quality of life improvements too, added Assoc Prof Phua.

"The dilemma is all these bells and whistles being added to drugs (to reduce side effects, and improve quality of life), and how much are you willing to pay for those," he noted.

Prof Macneill suggested that institutions narrow down usage of very high cost medicines only to circumstances where they offer "irresistible benefits", and decide on the amount to subsidise.

Or, he added, noting the difficulty of developing a criteria-based system, the best option may be to just have medical and finance experts discuss each treatment case by case, he added.

Currently, some patented drugs do qualify for subsidy. In such cases, the decisions are made based on cost effectiveness and the number of patients that it would benefit, according to MOH.



Patients to decide

Ultimately patients themselves should decide on the care while they are still rational, said Mr Liak.

He said: "If I'm 76 and stricken with cancer, do I sell my HDB flat and spend $300,000 to try to save my life, or do I want to pass on the flat to my children?"

The question to ask is at what stage will one feel that enough is enough, he added.