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     FrontPage Edition: Tue 11 September 2007

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A healthy life and a good, dignified and discreet death


Official opening of the Children Hospice International's 18th Congress 07 Sep 2007 By Mr Khaw Boon Wan Venue: Pan Pacific Hotel
An Excerpt
Last week, I spent some time in the Japanese island of Okinawa. It has a population of 1.4 million, largely concentrated in the capital city of Naha. But it also has a significant rural sector population spread over 40 small towns and villages.
I visited one such village called Ogimi (“大宜味村”). It has 3,500 villagers. Accompanied by the village Mayor, I participated in the village life and absorbed the villagers’ attitude towards life and death. They have much to teach us.
The Ogimi village has a reputation as “the village of long life”. It has the highest number of centenarians, adjusted for population, in Japan and most probably, in the world. Out of a village of 3,500, 1,050 are above 65 and 100 above 90. Among them, 16 are above 100: 1 man and 15 women. I have not spoken to so many centenarians on the same day...
I visited Ogimi not to seek the secret of longevity. But a local University academic who has studied this subject and observed the villagers for years briefed me on his research findings. I suppose there is no harm in sharing his conclusions. As genetic factors are beyond our control, his briefing focussed on non-genetic factors, of which there are many. But he singled out three important factors which help explain the villagers’ longevity.
First, their traditional diet: they eat more pork, more tofu (bean curd), more dark green vegetables and more seaweed than other Japanese. And their salt (sodium) intake is low, about half of Japan’s national average and many times lower than the Western countries.
Second, they are physically active. They exercise a lot and keep active all their lives. They work for as long as there is work available.
It is common to see some of the villagers continue to work into their 70s and 80s, even in laborious work such as farming and weaving...Even when work is not available, they are committed to an active social life, in senior citizens’ clubs, village events and volunteer activities. They meet friends often and very few isolate themselves at home.
Third, their active daily life in turn benefits their sleep at night. They sleep easily and while they do not sleep long, they sleep soundly with little interruptions.
Live Well
So this is the Ogimi secret to longevity: a healthy diet, an active life and good quality sleep...
Given their diet and regular activity, the prevalence of diabetes and cardiovascular diseases is way below their national average. Osteoporosis is also less of a problem, with the incidence of hip fractures at half of the US rate.
Unlike most elderly villagers in other parts of the world, the old folks in Ogimi walk with straight backs. I did not meet any hunch-backed residents. This is not the result of medications or health supplements, but sheer simple and healthy diet with plenty of vegetables and physical activities...
We talked about the younger generation. They lamented the erosion of traditional village lifestyles and worried a lot about the bad influence of fast food.
They prefer their “slow food” tradition - prepared from fresh ingredients and cooked slowly to carefully remove the animal fat. They also practise “hara hachi bu”: eating moderately and only to 80% full. The other 20%, they believe, will only go to enrich the doctors. We did not meet any who were obese...
Ogimi is, of course, not entirely a bed of roses. Among the 16 centenarians, 3 are bed-ridden, including the oldest man who, at 108, also suffers from dementia. I visited several nursing homes where the bed-ridden elderly were being served. Just like in some of our nursing homes here, many of the elderly seemed unaware of what was going on around them. The difference is that their residents are one generation older...
Good Death
Okinawa reflects the extreme end of a society dealing with advanced ageing. But the rest of Japan is heading in that direction.
In Tokyo, I had a substantial discussion with the Health Ministry on a range of ageing issues, including the morbid topic of where people died. They noted that soon after WWII, 85% of Japanese died at home, with the remaining 15% in hospitals. They lamented that the reverse is now true. This is despite regular surveys pointing to the elderly patients’ preference to die at home.
The Japanese are not unique. Last month, NHS London released its review report on "Healthcare for London: A Framework for Action". It devoted a section to end-of-life care and lamented the lack of discussion in society about “what constitutes a "good death".
It observed that "most people are dying in hospital when they would rather die at home". It added that repeated surveys of the general public have shown that the first preference for most people would be to die at home. In practice, only 20% of deaths in London occurred at home, with 66% occurring in hospitals.
We have not done such a survey in Singapore, but I will be surprised if Singaporeans are any different from the Japanese or the Londoners. After a full and meaningful life, I certainly wish to die at home, among my loved ones, in familiar and peaceful surroundings.
We have done a study of where Singaporeans died, mostly (55%) in acute hospitals. 28% died at home but I suspect many more would prefer that too.
Meeting Preference
Why is the modern healthcare system failing in meeting the preference of the dying? I think this is a subject worthy of a study. I believe we should try to facilitate dying at home for the terminally ill if this is their preference.
The London report recommends creating a register to elicit and record patients’ preferences on where to die. Perhaps we should study this aspect too.
While dying in hospitals is natural for fatalities due to accidents, heart attacks and other unforeseen events, the terminally ill have time to prepare for their final moments and express their preferences.
The families and the healthcare workers should strive to meet their final wishes. My Ministry will study this subject in greater detail and identify the obstacles and gaps. If need be, we shall change the rules and processes that currently hinder dying at home...
Let's Talk About Death
End-of-life issues are deeply emotional. But at the Ogimi village, I did not find the villagers squeamish when talking about it. They laughed and joked about it.
They realise that treating death as taboo does a disservice to both the dying and the living, adding to loneliness, anxiety and stress for all. They are grateful for a healthy life and pray for a good, dignified and discreet death, a “pokkuri” moment.
It takes humility to acknowledge that medical science, however advanced, has its limits. For the most vulnerable group of patients at the close of their lives, for whom curable treatment is no longer an option -- their last moments matter.
We must use the art and science of medicine to help them and their families find comfort and meaning in the last phase of their lives...

Full Text of Speech

Source: News 7 Sep 2007

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