Crossing continents … only to find familiar ground

Barry R Ashpole, Communications Consultant and Educator, Ontario, Canada

Barry Ashpole

My recent visit to Singapore was at the invitation of the Centre for Biomedical Ethics (CBmE), at the National University of Singapore, and the Lien Centre for Palliative Care (Duke-NUS).  The experience reinforced the view that, cultural differences aside and also taking into account the differences from one country to another in the provision and delivery of health and social services, there remains much common ground in the global effort to improve the quality of care for those living with a terminal illness – both patient and family.

During my three weeks in Singapore, I observed what I would term ‘the spirit’ that so distinguishes hospice and palliative care from many other aspects of social and health services. For example, I had the opportunity to observe end of life care first hand during visits to a free-standing hospice and to a hospital-based palliative care service. One afternoon, I accompanied two community nurses on home visits. Even though all of the conversations between nurses and family and patient were in one or more dialects of Chinese, the concerns and emotions of the illness experience were clearly evident and all too familiar. One thing that left a lasting impression was the reverence afforded elders, in their daily lives and, most notably, during times of illness or incapacity.

In my lectures at Khoo Teck Phuat Hospital, the National University Hospital and Singapore General Hospital, I addressed audiences of ethicists, physicians, nurses, social workers, allied health professionals, and representatives of government on a fairly broad range of subjects: care planning; engaging the patient and family in the decision making process; supporting the family caregiver through the illness experience; the withdrawal or withholding of life-sustaining treatment; and, coping with the sense of loss and separation following the death of a loved one. Conversation and discussion, particularly during the workshops that were linked to three of the lectures, ventured well beyond these subjects and into exploring many related issues and topics. A common thread throughout, however, was the critical importance of communication and the direct correlation that can be drawn between the quality of communication and the quality of care. I emphasised that communications is, and of itself, a therapeutic intervention.

Kong Meng San Ohor Kark See Buddhist Monastery, Singapore – Barry is in front of the statue of Guanyin, revered by Buddhists as the Goddess of Mercy

Discussions explored patient autonomy and the family involvement in decision-making. Noticeably, in a multicultural society generational differences are often pronounced. The older generation struggles to hold on to traditional beliefs and values; the younger generation is likely exposed to many other ‘ideas’ and sometimes conflicting points of view. As a consequence, in a single family, there may evolve widespread opinions about such societal issues as abortion, adoption, ageing, bankruptcy, divorce, homosexuality, racially-mixed marriages …and, the appropriate care and medical treatment for a family member or loved one living with a terminal illness. Family optimism can often impede decision-making.

In closing…
In comparison to many countries, hospice and palliative care is a relatively new concept in Singapore. What I observed was reminiscent of the early years of the hospice and palliative care movement in Canada …and, of the ‘pioneering’ spirit that prevailed. At the time, a handful of physicians and nurses often had to work against the current of government policy (or lack of policy) and of mainstream medicine in order to break new ground. Creativity, enterprise and tenacity were prerequisites.

Find out more…
The July 2012 issue of the newsletter for the Clinical Ethics Network for Training, Research & Support (CENTRES) includes articles based on each of the three lectures I gave in Singapore.¹ Each was recorded and annotated versions of the videos are also posted on the CENTRE’s website.^2,3,4

1. CENTRES e-newsletter
2. Advance Care Planning
3. The Family Conference
4. Withdrawing or Withholding Life-Sustaining Treatment

Barry Ashpole publishes Media Watch, an annotated listing of current articles and reports that may be of interest to those working in hospice, and palliative and end of life care. International in scope and intended as an advocacy and research tool, the weekly report is posted on the website of the International Palliative Care Resource Centre.