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GROWING OLD - CAN WE COPE?
There is no more surprise to Singaporeans to learn that our population is ageing rapidly and that our procreation pattern is lopsided. Time is not on our side and to rectify these problems and face the challenges, changes must be made to our society and ourselves fast.
The sun sets on every life – no doubt about that, the timing of that event is beyond human control unless it is suicide or euthanasia. The sunset may be beautiful or it may be not. Sometimes, a cloud covers the sun that never rises in one’s experience. “The cord of life may snap for young and old. By illness or some mishap, oft fall the strong and bold”.
Thus not every human being will savour the chance and experience of growing old. Some may prefer not to, seeing the infirmities and suffering of those around, preferring rather to be taken away while still healthy, suddenly and quickly. Not many envisage a lingering death for themselves; they prefer a fading life without too much sorrow and regrets. Mortality statistics reveal cancer, and heart disease to be the prime killers in Singapore. Recently there was an appeal to help cancer patients die with dignity through the services of a hospice movement.
THE
PATIENT
We can grow old gracefully without becoming a patient. In the good old
days, a man just died in his sleep after living to ripe old age. He was
happy, contented and satisfied - he was accepted by his family and society.
He went to bed and never opened his eyes again. There was no illness to
record on his death certificate. He died of senility.
For many of us today, that may be wishful thinking. We are told that the life we live determines to a large extent the death we die. The diseases prevalent in our society have much to do with our habits and ways of living. Modification of behaviour is necessary. Moderation in activity and diet is advised. Yet not all can escape the onset of age related diseases, many of which we do not know the cause of, much less therefore, ways of their prevention.
We may therefore, become unwilling patients in our old age subject to medication and restriction in diet and lifestyle. Worse, we may become handicapped and disabled and lose our independence. Who then will care for us?
There are many health education activities and campaigns in Singapore exhorting us to self-help in caring for our bodies and maintaining our health. Are they effective? Do we believe them enough to apply them to ourselves? Even if we have chronic illness, should we resign ourselves to dying young? Is there a vigour and enthusiasm to love life, to value it and to struggle and keep life going in a meaningful way?
Different patients react to life’s circumstances differently. Upbringing and religion have much to do with our perceptions and perspectives of different situations. In the end, it must boil down to a personal choice what to do with ourselves.
I have seen patients with the will to live, fighting every battle and winning them. The spirit never gives up. Mind over matter, they say, is a powerful means to life and there appears to be scientific evidence to say, “As a man thinketh so is he.” There are endorphins from the brain that give pain relief. And the immune system is said to be influenced to a considerable extent, by thought processes. It seems as though if you will yourself to live, the body’s army (immune system) will be on red alert but should you will yourself to die, giving up the will to live, it may be possible that the body’s resistance will be lowered enough to allow the multitude of microbes living in us to gain the upper hand and finish us off.
Doctors are patients’ advisors on health matters. It should not be misunderstood that doctors are little or big gods ordering and commanding patients around. Today’s patients are knowledgeable enough to question their doctors on the decisions taken which affect their bodies and their health. And rightly so.
Much of medicine is no more straightforward. The risk of harm may outweigh the benefits of certain treatment plans. Who is to check that doctors use high technology correctly and to the patient’s advantage? It has to be the patient himself. As consumers of health care, they ought to know what they are paying for and obtain value for their money.
There is the expectation, that life should last three score years and ten. It is a biblical quotation. Belief in such leads to certain reactions in dying people. Should they die younger than this, relatives and friends feel much sympathy and cry that their life was not lived to the full. Should they die past this age, feelings are different; well, they have lived a full, long enough life. Another way of viewing this is whether the cause of death is expected or unexpected (sudden). If someone had been suffering a great deal, the feeling may be – it is better that he/she has departed; it is a release, a welcome experience.
Twelve
Years On
In the November/December issue of the SMA Newsletter of 1987, I had written
about “Vision 1999”. The New Year is soon to be upon us and I have re-read
my article.
One suggestion still not implemented is the concept of a peaceful death at home. With today’s social structure of small and non extended families, it appears more difficult for this to occur. Worse, it appears that once dead, the body is not welcome home. Many obituaries state that the body is somewhere else, that the wake is somewhere else, far from home. Many elderly therefore, still die in our acute hospitals and this is not cost effective. Many who live out their last years in nursing homes or homes for the aged somehow still land up in our hospital beds for their death certificates. The undue pressure this creates on hospital beds means that our management of the dying process is still not optimal, neither cost effective.
THE
DOCTORS
My second point in the article covered the divide between the private
and public sector doctors. Would it not be fair to say that today, there
are more private specialists and more private general practitioners than
ever before and more significantly, the majority of specialists and general
practitioners do not practise in the public sector. And as they age, as
also their colleagues do in the public sector, it is important that their
practice remains relevant to society’s needs. What are we to do about
ageing doctors? How do we ensure they are updated, skilled and competent?
At what age is it considered unsafe for a doctor to practise or is there
no such thing? In the public sector, it is well to retire doctors off
at certain ages but in the private sector there is no retirement?
The third point I mentioned 12 years ago was the Specialist Register. This has come to pass. The entry criteria are clearly spelt out and if the training and experience are adequate, doctors easily qualify to be on the Register. The problem confronting the profession now is what happens in the long term? How is the public assured that the specialist on the register is keeping up with the time and doing a good job for his patients?
In the USA and for some specialties in the UK and Australia, revalidation or re-certification is necessary. In Singapore, what should we do? The other thing well recognised today is the short half-life of much medical knowledge and an even shorter half-life for certain skills. It may not be possible not to go for re-training. Would the skills development fund pay for this?
The last point I would like to reexamine is the role of the family doctor. The Minister for Health recently stated that there is the need to shift the centre of gravity of the whole health service more towards primary care and away from specialist care. He announced plans for verticle integration so that hospitals and national centres would see fewer patients and refer more back to primary care. This is a laudable move not helped by patients misperceptions that the primary care doctor is not adequately trained to handle their care.
Well, the Master of Medicine (Family Medicine) has since been born and with the additional diplomas in various skills like Geriatric Medicine, Dermatology etc, hopefully the care given by our front-line doctors would improve the trust the public has in their abilities and capabilities to handle more than coughs and colds. More importantly, the fast ageing population of Singapore will exact an unduly heavy burden on hospital specialists, if the primary care component of health is not effectively doing its job of preventing and managing the chronic sickness, many of which begin long before old age. In fact, some such diseases start in the womb.
CONCLUSION
My concluding paragraph here paraphrases the last four of my 1987 article.
The family doctor properly trained and equipped for primary care has become
reality in sufficient numbers to make a significant impact on the health
of the nation. Let it do so unhindered.
The family unit must survive; in health and in sickness, it has a vital role to play. Unfortunately the hospital bed is still seen as a cheap subsidised hotel bed, a home away from home and sometimes as a hospice bed. This is because such facilities in the community are still woefully inadequate, and those in the private sector are rather costly. If there is a home and not just a house, home care as proposed by Parkway Holdings is a worthwhile service to develop not only for the rich, but also for the less well-to-do.
The challenge I laid out 12 years ago remains as relevant today. We have not achieved but Minister has announced recently the new health policies about health care delivery. It is good we have made a start.
A/PROF CHEE YAM CHENG