Remember the Terry Schiavo case in the United States which made headlines worldwide about two years ago?
Terry Schiavo was a lady who was in a persistent vegetative state (PVS) after suffering a heart attack in 1990. PVS is also known as cortical death, which means that there is permanent loss of the part of the brain that controls judgement and reason. Though a person is still alive, for all other purposes there is no longer any meaningful life. Such a person cannot recognise even his dearest and nearest loved ones.
Terri was kept alive in a hospital and force-fed through a feeding tube. This is an artificial life support employed when a brain-damaged person like her could no longer swallow on her own.
For a long while, there was a legal battle in the United States courts over whether the feeding tube could or should be removed. Terri’s husband said that she would have wanted the feeding tube removed so that she could die with dignity. Her parents, however, said that Terri was conscious and would have wanted to live.
Finally, after 12 years of complicated legal battles that involved even Congress, the local court in Florida agreed on 18 Mar 2005 that the feeding tube could be removed. She died eight days later.
Even after her death, the controversy continued unabated for a while until public interest finally died down. What happened to her was that while she was still in control of her faculties, she did not have what is known as an Advanced Medical Directive.
An Advanced Medical Directive (AMD) is a medical guideline which pertains to treatment preferences, including the designation of a surrogate decision-maker in the event that a patient should become unable to make medical decisions on their own behalf.
There are actually three types of AMDs but for most purposes, people will equate the AMD with the Living Will. This is a written document that states the types of medical treatment that a person desires if he is no longer able to communicate effectively with his relatives or doctor to make known his desires.
For example, if the illness or disease or condition is incurable, irreversible or terminal, it can be stated in the Living Will his direction to follow certain life-sustaining measures or even to withhold or discontinue them.
A Health Care Proxy is also an AMD and in it, a person designates another person to make health care decisions if he or she is rendered incapable of making their wishes known. The Health Care Proxy confers the same rights to the proxy holder as the person would have if he is capable of making and communicating his own decisions.
AMDs have been allowed in Singapore since 1997, unlike Malaysia where it is not recognised by the government. In the first half of this year, 1,429 people in their 40s to 60s signed the AMD in Singapore compared with 3,486 in the past two years and 2,512 in an eight-year period since 1997.
What this suggests is that more Singaporeans are now accepting that their doctor should pull the plug on their lives if they become unconscious while terminally ill. They would prefer not to continue being a burden to their families.
According to the Health Ministry, Singapore, making the AMD is voluntary and is not euthanasia (a deliberate ending the life of a person suffering from an incurable and painful disease by unnatural means, such as the administration of lethal chemicals).
“An AMD acts as advanced instruction for your doctor not to prolong your life with extraordinary life-sustaining treatment, and to let the dying process take its natural course when you become terminally ill and unconscious,” said the ministry on its website.
Singaporeans aged 21 and above can make an AMD by filling up a form, sign it in the presence of two witnesses, one of them a doctor, and send it to the registrar of AMDs. The AMD form is free but a person may have to pay the doctor whom he or she needs to consult before signing the AMD.
In Malaysia, a doctor was relating to me that recently, he attended the wake of a 51-year-old lady who had suffered a massive brain haemorrhage. She was warded in the ICU. Not only was she connected to the respirator, there were also tubes sticking out of her trachea, skull, central veins, artery and urethra.
Ten days and RM110,000 later, she died. This doctor said that she had mentioned before that if anything were to happen to her, she would prefer not to be on life support. She wanted to die peacefully and not have her agony prolonged through artificial means.
“Unfortunately, nothing was given in black and white and her wishes could not be carried out. We felt so sorry for her. Even if her request has been translated into a so-called AMD, I don’t know whether any hospital or doctors in Malaysia would dare to put this into practice. Such directives would certainly make our jobs in ICU easier. More importantly, we can allow unsalvageably critically ill patients to die with dignity,” the doctor said.
But while this example points to the usefulness for an AMD to be introduced and recognised in Malaysia, there will bound to be resistance to its use. Even in Singapore, there is resistance after the AMD was passed into law 10 years ago.
Mainly, the objections are on religious grounds. Many people still hope for miracles to happen. “Let God decide,” seems to be a favourite answer to end all discussions. However, they tend to forget that in letting God decide, should we interfere with His decision by artificially prolonging the life of the unconscious person? Should we not leave the decision totally in God’s hands?
I don’t wish to delve further into the religious aspect of this discussion but ultimately, people will need to remember the fallacy that because you don’t want to talk about it, the problem will go away. It just doesn’t work this way.
By the time patients are dying or not able to express themselves, the burden is left to family members. Not many families can debate over such an issue objectively and come up with a consensus. If the AMD is recognised in your country, write one and you can spare your family the pain by deciding for them while you are still coherent and in control of yourself.