Sumytra Menon

Patient and family involvement in decision making for management of cancer patients at a centre in Singapore

Background The practice of patient autonomy within the prevailing bioethical framework in the West appears increasingly at odds with the prominent influence of the family in medical decision making in the Asian culture. The actual extent of involvement of patient versus the family in the decision making process for cancer management in clinical practice is largely unknown in Asia. Aims (1) To describe patient and family involvement in healthcare decision making in actual practice, and to determine whether those practices are consistent with Singapore law; and (2) to act as a pilot for a larger prospective study examining the preferences of cancer patients on the decision making process, and the reasons for excluding patients from that process. Methods A retrospective review of patients who died in an oncology ward in Singapore General Hospital from February to April 2011. Patient and family involvement in discussions on (1) disclosure of diagnosis, (2) initial treatment decisions and (3) initiation of a ‘maximum ward management’ order was evaluated by reviewing case notes completed by healthcare professionals. Results Data were collected for 55 patients. Involvement of patients and families at first disclosure of diagnosis was noted in 61% and 64% of cases, respectively. In 12% of cases, the family requested withholding of the diagnosis from the patient. 86% of patients were involved in the initial treatment decisions, and their family was involved in 65% of cases. Only 9% of the 32 alert patients were consulted in end of life decisions. Factors associated with lower patient involvement were advanced age and inability to speak English. Conclusions While most cancer patients are involved in the healthcare decision making process during the early phase, familial involvement gains prominence as the disease progresses.

Advance Care Planning in a Multicultural Family Centric Community: A Qualitative Study of Health Care Professionals', Patients', and Caregivers' Perspectives

CONTEXT Advance care planning (ACP) has been shown to improve end-of-life care, but it was developed in the U.S., and most research has been conducted in western communities. OBJECTIVES We aimed to study the attitudes and perceptions of patients with life-limiting illnesses, informal caregivers, doctors, nurses, and medical social workers regarding ACP in a multicultural family centric community. METHODS We conducted an explorative qualitative study, using focus groups and individual in-depth interviews. We used purposive sampling techniques to recruit 61 adults (15 doctors, 13 nurses, 5 medical social workers, 15 patients, and 13 caregivers) from multiple health care settings across the country. RESULTS The participants are genuinely anxious about the implementation of ACP. They had positive and negative expectations of ACP. Many were confused about the legal framework for health care decision-making and expected ACP to be of limited value because family members, rather than the patient, were usually the key decision makers. CONCLUSION A nuanced approach to ACP that considers the family network is required in multicultural family centric communities. Policies should be reconciled to create a more consistent message that respects patients, the family, and is legally coherent. Further research could focus on adaptations of ACP to promote its acceptance in such communities.

Singapore Modifies the U.K. Montgomery Test and Changes the Standard of Care Doctors Owe to Patients on Medical Advice

The Singapore Court of Appeal issued a landmark judgment on the legal test for negligence in medical advice in Hii Chii Kok v Ooi Peng Jin London Lucien and Another [2017] SGCA 38 (HCK). The previous precedent of Khoo James and another v Gunapathy d/o Muniandy and another appeal [2002] 1 SLR(R) 1024 held that the standard of care, including the provision of advice to the patient, was to be judged by Bolam v Friern Hospital Management Committee [1957] 1WLR 583 and subjected to the addendum in Bolitho v City and Hackney Health Authority [1988] AC 232. A doctor will satisfy the Bolam-Bolitho standard of care if her conduct is supported by a responsible body of medical opinion, which is logically defensible. In HCK, the court held that a blanket application of Bolam-Bolitho to all aspects of medical care is incompatible with the Bseismic shift^ in medical ethics and in societal attitudes, which now places a premium on a more patient-centric model of care that is less paternalistic and which respects patient autonomy (¶120). As such, it set out a modified version of the test adopted by the U.K. Supreme Court in Montgomery v Lanarkshire Health Board [2015] UKSC 11. The modified Montgomery test inHCK departed from Bolam-Bolitho for negligence with respect to medical advice but retained it for diagnosis and treatment. In what follows, we will briefly describe the facts and reasons underpinning the HCK decision, highlight key differences between the Montgomery and modifiedMontgomery test in HCK, and examine some implications of the modified test for medical practice.

Understanding the Practice of Collusion on End of Life Care in Singapore

The practice of collusion is commonplace within Asian healthcare settings. Here we study a typical case of collusion within the Singapore setting to highlight the rationale and the predisposing factors behind this practice. Through such understanding, it is believed that a better means of practice is possible- ostensibly through the use of a multidisciplinary team approach to ensure that the best interests and goals of the patient are protected.

Applying the Welfare Model to At-own-risk discharges

“At-own-risk discharges” or “self-discharges” evidences an irretrievable breakdown in the patient–clinician relationship when patients leave care facilities before completion of medical treatment and against medical advice. Dissolution of the therapeutic relationship terminates the physician’s duty of care and professional liability with respect to care of the patient. Acquiescence of an at-own-risk discharge by the clinician is seen as respecting patient autonomy. The validity of such requests pivot on the assumptions that the patient is fully informed and competent to invoke an at-own-risk discharge and that care up to the point of the at-own-risk discharge meets prevailing clinical standards. Palliative care’s use of a multidisciplinary team approach challenges both these assumptions. First by establishing multiple independent therapeutic relations between professionals in the multidisciplinary team and the patient who persists despite an at-own-risk discharge. These enduring therapeutic relationships negate the suggestion that no duty of care is owed the patient. Second, the continued employ of collusion, familial determinations, and the circumnavigation of direct patient involvement in family-centric societies compromises the patient’s decision-making capacity and raises questions as to the patient’s decision-making capacity and their ability to assume responsibility for the repercussions of invoking an at-own-risk discharge. With the validity of at-own-risk discharge request in question and the welfare and patient interest at stake, an alternative approach to assessing at-own-risk discharge requests are called for. The welfare model circumnavigates these concerns and preserves the patient’s welfare through the employ of a multidisciplinary team guided holistic appraisal of the patient’s specific situation that is informed by clinical and institutional standards and evidenced-based practice. The welfare model provides a robust decision-making framework for assessing the validity of at-own-risk discharge requests on a case-by-case basis.

Perceptions of Quality-of-life Advocates in a SoutheastAsian Society

In family-centric societies, maintenance of hope amongst ill family members is a pivotal duty of the family. Meeting this duty often takes the form of continuing treatment even when such options may be futile. This makes efforts to maximize quality-of-life options challenging. We explore Singaporean perceptions surrounding quality-of-life advocates who advice quality-of-life measures over potentially life-prolonging treatment in terminal illness using a novel video vignette based semi-structured interviews. Findings suggest that quality-oflife advocates are viewed as failing in their filial obligations and perceived as ‘selfish’, ‘money-minded’ and ‘immoral’. These findings highlight the need to educate patients and caregivers about quality-of-life approaches.

Studying Cost as a Factor in the Choice between Quality and Quantity of Life amongst Patients with Cancer and their Caregivers at a Cancer Centre in Singapore

Background: Treatment costs and sociocultural concerns play a significant role in decisions regarding Quantity of Life (QuoL) options that seek to prolong life, such as chemotherapy, or a Quality of Life (QoL) approach where the patient refuses available treatments such as chemotherapy in favour of maximizing comfort and quality of life at the end of life in Singapore. Deciphering the reasons behind such care decisions is often difficult because of local social taboos regarding discussions about death and dying. Objectives: To scrutinize the rationale behind QuoL and QoL within the Singapore context and delineate the impact of cost upon such decisions. Methods: To overcome local sociocultural taboos about discussing death and dying with patients, participants watched a video vignette of a family discussing treatment options for their mother (Mrs Tan) who was recently diagnosed with terminal cancer. Participants were asked what advice they would offer Mrs Tan regarding her treatment plans in the face of a poor prognosis, incurable cancer and costly treatment. Participants were then asked what their advice would be when the costs of treatment was covered by the patient’s insurance policy. Their responses were evaluated using Grounded Theory analysis. Setting/Subjects: 132 oncology patients and their caregivers were recruited from an ambulatory treatment unit at a tertiary oncology centre. Results: 63 (47.7%) of 132 participants advised Mrs Tan to opt for the QoL approach but when treatment costs were covered by insurance, only 5 (3.8%) of 132 participants chose QoL, whilst 108 (81.8%) participants chose QuoL options. Conclusion: Whilst cost is a significant factor in end of life decision making, strong sociocultural influences that perceive QoL approaches as ‘giving up’ ultimately determines the course of care.

IS THERE AN IDEAL LEGAL FRAMEWORK FOR END OF LIFE DECISION-MAKING?

Background The law should help and not hinder patients, their loved ones and healthcare professionals in making advance care plans and end of life decisions. Aim This paper will review the relevant laws of England and Singapore, and compare their frameworks for end of life decision-making. Methods The advantages and disadvantages of each regime will be analysed in the context of three groups of patients and their loved ones facing an end of life scenario. The first group is patients who have capacity to make their own treatment decisions and have expressed their wishes. The second is patients who have lost capacity and did not make their wishes known, and the final group is patients who made their preferences known before they lost capacity. Results There are some similarities between the English and Singapore frameworks but also some striking differences, especially relating to the powers of donees on healthcare decision-making and advance refusals of treatment. Discussion Given initiatives in advance care planning in England and Singapore, this paper will make recommendations on the elements of an ideal legal framework. England and Singapore do not have legislation pertaining to Physician Orders for Life Sustaining Treatment (POLST) or default surrogates. Are these aspects essential in an ideal legal framework for end of life decision-making? Conclusion The ideal legal framework is one that empowers patients and their loved ones to plan for their future health care and enables health care professionals to honour those wishes at the appropriate time.

Legal Commentary on Incompetent Patient with Myotonic Dystrophy

This patient has not made an advance care plan or appointed a substitute decision-maker (donee) for healthcare under the Mental Capacity Act (Cap 177A, 2010 Rev Ed Sing.) (MCA). It is irrelevant whether she made an advance medical directive pursuant to the Advance Medical Directive Act because she is not suffering from a terminal illness and at imminent death (Cap 4A, 1997 Rev Ed Sing.). Making future healthcare decisions on the patient’s behalf will now become more difficult because no one knows what her care or treatment preferences are, and the doctor has indicated she is unlikely to regain capacity. The MCA provides a framework, using the best interests test, for making decisions on behalf of persons who lack mental capacity (section 6 MCA). The question is whether the tracheotomy, which is medically indicated, is a treatment that is in the patient’s best interests. The final decision-maker is the doctor because the tracheotomy is life-sustaining treatment, or treatment to prevent a serious deterioration in the patient’s health. The MCA does not specifically say that the doctor is the final decision-maker in these circumstances, rather it states that the donee appointed as a healthcare proxy cannot make those types of healthcare decisions (section 13(8) MCA). The best interests test requires a holistic appraisal of the person, taking into account relevant medical and non-medical factors such as the person’s past or present wishes, her belief and culture, and the views of family members. A medically indicated treatment is not by default a treatment in the patient’s best interests. Based on the information in the case study, the doctor will have to weigh up the benefits and burdens of treatment, in the light of these various factors, in coming to a decision.