Decision-Making at the End of Life: A Singaporean Perspective

Case Study

Andrew was a 69-year-old Singaporean businessman of mixed parentage who grew up adhering to a mix of his paternal Chinese and maternal Indian cultural beliefs. He maintained these conservative beliefs throughout his education in England and even chose to conform to his family’s custom of an arranged marriage upon the completion of his studies.

Lynette passed away in her late 40s, leaving Andrew to support their three children who were by then in their 20s. Following the marriage of his youngest daughter, Andrew remarried and had a son who turned nine when Andrew was diagnosed with lung cancer. It was an aggressive cancer that progressed unchecked to involve his brain, bone and liver despite multiple lines of chemoradiotherapy, resulting in Andrew being pronounced incurable. Anticipating this, Andrew did not waste time setting goals to maximise his quality of life. He voiced the wish to remain alert for as long as possible and to be nursed in his own home in the bosom of his family.

Yet as his disease progressed, Andrew became increasingly distressed with his breathlessness and confusion, and his doting family struggled to deal with this worsening condition at home. They resolved to try a hospital admission in hopes that his symptoms could be ameliorated. However, it became increasingly apparent within this short admission that morphine was the only palliative intervention available. Whilst being effective at ameliorating his symptoms, it became more obvious that morphine induced sedation, a side effect, which went against Andrew’s previously stated wish. Despite this, his family rather hesitantly accepted this effect in face of the news that he had exhausted all other treatment options and medical interventions. They then decided to take him home to be cared for as he would have wished.

Not long after arriving home, Andrew’s condition worsened and he began to react violently to his visual hallucinations that seemed to compound his increasing shortness of breath and agitation. Various interventions by his palliative home care team failed to provide any respite to these symptoms and a second opinion was sought. The second palliative care specialist concurred with Andrew’s home care team in concluding that terminal sedation was the only viable treatment option remaining and presented this option to the family.

This development threw up a number of ethical considerations. The first was that Andrew’s wish to remain lucid for as long as possible was in direct conflict with the implementation of terminal sedation. Indeed, such an option would effectively put Andrew into a deep sleep to prevent him from being cognisant of his worsening symptoms. It however left him with little chance of regaining consciousness. This procedure is discussed later. The second ethical dilemma was the extent to which a physician should be obliged to attempt to gain consent for such a procedure particularly in face of such distressing symptoms (Krishna 2010). The third consideration was determining to what extent the family’s wishes should be considered given that they were struggling to come to terms with the rapidly deteriorating situation and their increasing difficulty at managing his spiralling distress. Indeed, an increasing number of family members were becoming more distressed and were clearly not coping with the rigours and emotional and physical demands in the caring of Andrew.

At this juncture, it would be apt that definitions and implications of terminal sedation and the Best Interest Principle be elucidated.

Terminal Sedation

The term “terminal sedation” here is defined by Charter (1998) as “the intention of deliberately inducing and maintaining deep sleep but not deliberately causing death in very specific circumstances such as for provision of relief of one or more intractable symptoms when all other possible interventions have failed OR for the relief of profound anguish that is not amenable to spiritual, psychological or other interventions and the patient is perceived to have a prognosis of less than 2 weeks”. Charter further explicates the terms “refractory or intractable symptoms” as “symptoms that cannot adequately be controlled despite aggressive efforts to identify a tolerable therapy that does not compromise consciousness”. Such a...