Greying nation must talk about death

Wannapha Kunakornvong

We may not know when death will strike, but we can certainly choose to have a good death. However, if you don’t know how to do it, you are not alone.

The right to have a good death is the right to pass away naturally and peacefully without having to go through painful and expensive life-prolonging medical interventions.

It’s the right to die with dignity. Refusing life-sustaining medical technology during one’s terminal illness is now the right of every Thai under the law. Yet most people still don’t know about this. Nor do they know about palliative care services which help terminal patients die “naturally” and comfortably instead of being kept alive artificially.

According to recent research on “Public Awareness and Attitudes toward Palliative Care in Thailand” by the Thailand Development Research Institute (TDRI), more than 75% of Thai people do not know that palliative care is available for terminal patients. Moreover, 79% have not heard of a “living will”, a written directive prepared in advance to refuse life-prolonging medical technology.

Why do the majority of Thais refuse to prepare themselves for a good death? The reason is simple. It’s still a huge taboo to talk about death in Thai society. Bringing it up is considered a bad omen, a curse even.

Even when one is not afraid of death for oneself, suggesting preparations for the imminent death of a family member who has a chronic or severe illness is blasphemy, making that person blatantly rude in the eyes of others.

Such taboo makes the patient and family unprepared when the critical time arrives. Without a living will, the use of life-prolonging machines against the patient’s wishes may actually inflict more physical pain.

The stubborn use of expensive medical interventions is considered a gesture of love and gratefulness by family members. More often than not, it ends up plunging the family into bankruptcy.

As Thailand rapidly becomes an ageing society, it’s more urgent than ever to embrace palliative care and allow natural death for terminal patients to take its course. This is not only a kinder option for the patient, it’s also less costly for both the family and the national healthcare system.

The law is supportive. According to Section 12 of the National Health Act 2007, “a person has the right to make a directive in writing to refuse medical interventions which can only prolong one’s terminal stage of life, or to refuse medical services in order to cease one’s severe suffering from the illness”.

This is known as the right to a natural death, or good death.

A rude awakening awaits those who refuse to plan for their end-of-life care in advance. The medical expenses during this period are catastrophic due to the sky-high costs of modern medical technologies to prolong life.

This is a global phenomenon. When Nobel Prize winner Leon Lederman died last year, he was not remembered only for his contribution to experimental physics, but also for selling his Nobel Prize to pay his medical bills.

Society’s refusal to accept a good death also affects people afflicted with severe pain from chronic illness, as in the case of Vis Arshanakh who decided to seek euthanasia in Switzerland. His Facebook post about his decision went viral and helped Thai society to discuss death with a physician’s assistance. Euthanasia is still illegal in Thailand.

Many people mistake natural death without medical intervention for euthanasia. It is not. It is returning to society’s traditional way of dying; a peaceful, natural death, preferably surrounded by loved ones. Having this gooddeath option is legal in Thailand.

Despite being legal, the living will of the patient may not prevail when it faces strong resistance from family members and physicians – especially when the patient is no longer in the condition to insist on his or her right.

Therefore, as important as a living will is the mutual understanding between the patient and family, objective information about medical options and consequences, and respect for the patient’s wishes.

Since fear of lawsuits prevents many doctors from opting for palliative care for terminal patients, giving legal protection to the doctors who respect patients’ wishes goes a long way to strengthening the right to die with dignity and end-of-life care services in Thailand.

Preparing a living will and mentally preparing family to accept it is increasingly important in a greying society like ours. It helps terminal patients to have a comfortable transition before their last breaths. It prevents families from financial bankruptcy. It also helps soften the pangs of grief knowing one has done one’s best to fulfil patients’ wishes. One of the biggest wishes is to die at home.

Providing end-of-life care at home is also less costly for the national health system. Studies from the universal healthcare system show medical treatment for cancer inpatients during their last month of lives costs about 45,000 baht. For outpatients receiving palliative care at home, it is about 27,000 baht.

Interestingly, even those who know about palliative care think of it as only the medical services for terminal patients at hospitals or hospices. This thinking is too narrow.

End-of-life and palliative care is not just about concerns about aggressive medical technology and money. It’s about helping loved ones with terminal illnesses to live their last stages of life as comfortably and with as little physical pain as possible.

Apart from medication to reduce pain, family members play a key role in providing psychological support for terminal patients so they can pass away without worry, guilt, or regret. Only then it can be considered a good death.

Wannapha Kunakornvong is researcher at Thailand Development Research Institute. Policy analyses from the TDRI appear in the Bangkok Post on alternate Wednesdays.

First Published on Bangkok Post