“Dying Well” in Singapore: Reflecting on Terminal Cancer Management

Case Study

Mr YF was a 65-year-old single Chinese male who worked as a security guard. As the eldest son, he inherited his parents’ three-bedroom Housing and Development Board (HDB) flat. To earn extra income, he rented out one of the rooms in the flat. He had no other close family members, except for a younger brother whom he was seldom in contact with.

About nine months ago, Mr YF was found to have primary lung cancer with metastases to the brain. Despite the diagnosis of Stage IV carcinoma, he maintained a positive attitude, declaring that he would fight the disease till the end. He subsequently underwent surgical excision of both lung and brain tumours, followed by adjuvant chemotherapy and radiotherapy. Following this, he was discharged. By then, he was unable to continue working. However, the rent collected from his flat tenant was still sufficient to maintain a modest lifestyle. During this period, Mr YF was not spoken to in regard to any form of advance care planning or palliative care.

Less than six months later, the cancer recurred and became more widespread. Mr YF was re-admitted to hospital for cancer-related shortness of breath, chest and abdominal pain. The medical team prognosticated a limited survival owing to the extent of disease. In view of this, the hospital social worker contacted his estranged brother and sister-in-law to inform them of the patient’s condition. In addition, she intended to seek their assistance in managing the patient’s finances and affairs. Although clearly not in the best of health, Mr YF remained relatively conscious throughout his inpatient stay. His brother and sister-in-law demonstrated concern for the patient, citing that they would help him in whatever way they could. At the social worker’s urging, Mr YF gave power of attorney for his brother to manage his flat. The latter promised to renovate the flat to be more accessible for the patient, as Mr YF expressed a strong wish of dying at home once discharged.

The remainder of Mr YF’s stay was eventful. He had bouts of severe infection that required repeated courses of intravenous antibiotics. The palliative care team was consulted on the management of his cancer-related symptoms. Many medically-initiated discussions were held with him, in regard to non-escalation of aggressive therapy. Despite acknowledging his disease was terminal, the patient always requested for “just enough” treatment to allow him to be better so that he can go home. After a few weeks, Mr YF was eventually declared stable enough to be discharged home with home hospice services, and assistance as initially promised by his brother. At this stage, although the patient had no more acute infective issues, he had become mentally incapacitated owing to the extent of his cancer. However, it was discovered by the social worker that his flat was now rented out to a new tenant, and no renovations had been made, and Mr YF had been unaware of his brother’s actions. There was nothing the hospital could do to intervene as the patient had already signed over his power of attorney to his brother.

Eventually, Mr YF was placed in an inpatient hospice, with appropriate comfort care measures. He passed away not long after from his primary disease. At the time of death, he was alone.*

Introduction

Mr YF’s case is a depiction of how end-of-life care for a terminally ill person can have a less than ideal outcome. In this respect, the following article will reflect on the issues faced by a dying patient in a Singaporean context.

I. End-of-Life Planning: The General Consensus

“End-of-life” generally refers to a period of time during which a person’s condition is actively deteriorating and when death is expected. The general consensus now is that the aim of successful end-of-life care is to help those with advanced progressive, incurable conditions to live as well as possible until they die.²⁹ These patients are a unique subset of people — they are...