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     A healthy life and a good, dignified and discreet death

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Source: www.moh.gov.sg

Official opening of the Children Hospice International's 18th Congress

07 Sep 2007
By Mr Khaw Boon Wan
Venue: Pan Pacific Hotel

"Live Long, Live Well, With Peace of Mind"

Live Long

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. 

Okinawa has 740 centenarians, making it the highest ranking prefecture in Japan for longevity.  In comparison, Singapore has over 500 centenarians but out of a much larger population of 4.5 million.  What is particularly impressive about Okinawa and Ogimi is that 80% of their elderly live independently, requiring no hospital or nursing home care.  They manage quite nicely on their own, with support from family and community and in close communication with those around them.

Secret of Longevity

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.  I visited Toshiko Taira who runs a cottage industry of about 20 workers, weaving banana fibres into art pieces, textile materials and expensive kimono threads.  She is 87, with excellent hearing and dexterity.  She tried to teach me how to tie the fibres into a continuous thread, without revealing any knot.  While I am proud of my eyesight, it was no match compared to hers and I failed in my task.  She has the status of a Living National Treasure in “kijoka bashofu” (banana fibre weaving) and is well respected among Japanese.  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.  I had several longevity meals and I also joined the villagers in their activities, of which there were many: folk dancing, singing, socialising or simply helping one another.   The elderly are fiercely independent and are proud of their independence.  The oldest woman is 106 and lives with her daughter who is 80.  Although recently wheel-chair bound, that does not stop her from coming to the community centre to observe the village dancing and simply to socialise.

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.  We met many grand parents in their 80’s but still fit, looking after the bed-ridden great-grand parents.  The parents who form the third generation are however missing, having to work in the cities.  The children who could form the fourth generation are few in number, if any, as Japan is facing a rapidly declining birth rate.  As a result, village schools are progressively being closed and existing schools are struggling with very low enrolment and tiny class size.

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.

But there have been cases of the terminally ill living out their final phase of life at home.  Let me mention one.  Mr Samsudin bin Mohammad Ismail was terminally ill with kidney cancer.  He decided that he would want to die at home.  His family members prepared themselves by going through care-giver training.  Supported by palliative home care provided by Dover Park Hospice, his loved ones were able to render quality care to him at home.  Mr Samsudin lived out his final months in dignity and with fortitude.  He passed away peacefully two months ago, surrounded by familiar surroundings and warmed by familiar faces.

Home hospice care was critical in meeting Mr Samsudin’s final aspiration. However, for many elderly Singaporeans, hospices still carry a stigma.  Perhaps, this is a legacy of the “death houses” at Sago Lane which in the 1950s were where the destitute and the sick went to die.  It was a pitiful way to go – alone, in fear, and more often than not, in squalor.

Rendering Peace of Mind

Our hospice movement has come a long way since.  It affirms life and regards dying as a normal process.  It neither hastens nor postpones death.  It provides personalised services so that patients and families can attain the necessary preparation for a death that is satisfactory to them.  We have much to thank the pioneers for their untiring efforts.  Let me single out two outstanding individuals: Dr Seet Ai Mee and Prof Cynthia Goh.  They were and remain passionate about the cause and have inspired many to join the movement.  Many are in the audience today.  Thank you for your dedication and hard work in service of this worthy cause.  My Ministry will work with you to make hospice and home palliative care an important part of our healthcare delivery system.

First, we will support and grow palliative medicine as an attractive and effective medical sub-specialty. 

Second, we will extend palliative care and its benefits beyond oncology to other terminal-stage chronic conditions, such as chronic obstructive lung disease (COLD) and heart failure.

Third, we will ramp up other manpower to support the growing demand.  This is a labour and skill-intensive service.  We need to train many more nurses, counsellors, medical social workers and therapists.  We need to support them with long term career paths and meaningful salary schemes to attract and retain them.

Fourth, we will do more to educate the public on hospice and end-of-life care. Death remains a taboo subject and most people avoid talking about it.  There was a time when death was an integral part of family life.  People died at home, surrounded by their loved ones.  Family members experienced death together, mourned together and comforted one another.  My grandmother died of old age at home.  She had never been hospitalised and hospital was the last place she would want to be to draw her last breath.  My mother died of ovarian cancer at home; we were all with her to bid our final farewell.  She had been in and out of hospital for her surgery and chemotherapy and when the end was near, we knew that she would want to die at home.  In a way, modern healthcare has made dying a lonelier process as more people die in hospitals.  Their loved ones have less opportunity to be with them and often miss their last moments of life.
 
Let’s Talk About Death

While death is a difficult subject to discuss among adults, it is even more difficult to broach with youngsters.  Unfortunately, some children do not get to live long.  In such case, all the more we hope that they can live well for the time that they live and that they can die free of pain, discomfort and in peace.  If we are to help them deal with death, we must let them know that it is alright to talk about it.  Talk does not solve all problems but without talk, we are even more limited in our ability to help them cope.  In any case, not talking about it does not mean we are not communicating.  Children are great observers; they read our facial expression and our body language. 

Helping the young terminally ill therefore requires special skills and sensitivity.  Often the patient’s condition deteriorates over several years, placing enormous strain on the family.  While family members willingly invest their love, energy and devotion into the care of the child, they can and do become exhausted.  Meanwhile, the healthy siblings can feel left out.  With proper training and support, we can help the patients cope with their final phase of life.

Let me share with you the brave story of Adam Kamaruddin, a 7-year old leukaemia patient.  After multiple rounds of chemotherapy and having exhausted the limits of medical science, Adam’s last wish was to die at home.  The KK Paediatric Palliative Care team cared for Adam at his home, while supporting and guiding his family through the difficult period.  Last year, Adam passed away peacefully at home.  His last wish was fulfilled.

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.

“Live long, live well and with peace of mind”.  This is my Ministry’s motto.  Working together, we can help most Singaporeans realise this goal.  I wish you a fruitful congress.  Thank you.
 

Source: www.moh.gov.sg News 7 Sep 2007