Today’s topic is a lot heavier. This question is less common than “#1 When can I recover” but remains the top because everyone of us would ask this at some point of our lives. Maybe because I tend to see geriatric cases, I get this question more often since they are in last stage of life. While some wanted an estimation on how much time they are left with, most of the cases that I encountered said this as an expression of their hopelessness in life.
You see, the elderly they have achieved much in their life. They worked hard, married, had children and now even grandchildren. When they finally have the time to enjoy, they are down with multiple sickness or chronic illnesses that makes their schedule filled with appointments with doctors and checkups in clinics or hospitals. Naturally they are discouraged. Some feel life is meaningless or hopeless because the longer they live, the longer they suffer. Some feel like a burden to their children because of the time and money they have to spend for their health problems.
Again, this is not a question that we can give a definite answer. For terminally ill patients, doctors may give an estimation based on clinical conclusions. Though some passed on within the time estimated by doctors, there are many who managed to outlive by months or years.
Despite not being able to answer this question, I do think we would need to address this and not brush them off by telling them not to think too much. Love and encouragement is important in helping someone to shift their focus from worrying about death to living purposefully each day. Here are some ways on how you can support a elderly member or someone facing death:
1. Be a listening ear
Be patient with their sharing when they express their fear or anxiety about death.
Listen carefully and make appropriate responses to acknowledge what they said or how they feel. Keeping silent completely may make them feel unheard and unloved but it is ok to be silent when they are crying or in emotional state to let them process their emotions.
2. Help them see meaning in their lives
Most elderly say they are useless because they are old and sick. I often remind them that there are different seasons in life and at the golden age, it is time for them to rest and take on lighter work than they used to do in younger days. It is also natural for our body to fail as we age and they should not blame themselves for being old and sick but be thankful
3. Keep them active and shift their focus to living purposefully
Most children try to pamper their elderly parents or loved ones facing death by telling them not to do any work at all. Of course, given their age or condition, they should be enjoying or resting instead of busying with chores. However, removing their work completely could make they feel completely useless. It is better to keep them active with some light work they can manage given their condition.
4. Spend time with them
This is especially important for those who are immobile or bed bound. Set aside time to keep them accompanied. Chatting, reading or singing with them work well because there is interaction to keep them stimulated and feel love from others.
5. Joke with them (at right time!)
Laughter is the best medicine! Be sure it is in the right mood to joke with them in an appropriate way.
I am often involved in management of home-bound patients or terminally ill patients as a Chinese Medicine practitioner and see the value of TCM in their care. No doubt Western medicine may offer immediate relief or results for certain conditions or symptoms e.g. constipation, bloated stomach, fever, infections, blood pressure, heart rate or delirium, there is nothing much they can do for degenerating conditions. Geriatric or terminally ill patients are often complex because they have a mix of ’Deficient’ (虚 xū) and ‘Full’ (实 shī) syndromes which we termed it as ‘虚实夹杂’ in TCM. Deficient can mean deficiency of vital substances or weak internal organs that cause them to feel weak or fatigue all the time. ‘Full’ syndromes are due to pathogenic factors that caused their illness or build-up of by-products such as phlgem, oedma or stools due to ‘Deficient’ syndrome. As such, we often use a combination of tonifying (补 bû) and discharging (泻 xìe) herbs to bring up their energy and at the same time, remove pathogenic factors or by-products that cause their discomfort.
What TCM can do for end-of-life care:
1. Chinese herbal medication
Apart from traditional decoctions, it can come in the form of concentrated medication powder which most TCM clinic now uses since it is convenient to take. There are also capsules, pills or grounded powders that can be prescribed depending on condition.
We often advise patients to take western and chinese medication apart with 2 hours interval to avoid potential adverse-drug interaction or side effects.
2. Diet Therapy
TCM diet therapy is different from western dietetics in a few ways. While we have common grounds in maintaining healthy, nutritious and balanced meals, TCM diet therapy has an emphasis on consuming food with appropriate thermal nature and functions based on body constitution. For example, if one tends to feel cold or deficient in Yang, we would encourage taking food that are neutral or warm in nature e.g. pumpkin, carrots, ginger, sweet potato and minimise intake or avoid cold foods such as banana or watermelon. Often, diet therapy may also involve addition of small dosages of Chinese herbs to help enhance nourishment of the body. Some herbs commonly used include Codnopsis (党参 dâng shèn), Astragalus (黄芪 huáng qí), Angelica root (当归 dāng guī), Atractylodes (白术 bāi zhú), Poria (茯苓 fū líng), Reishi (灵芝 líng zhī), Solomon’s seal (yù zhú), red dates (hóng zâo).
3. Acupuncture needling or acupoint massage
Acupuncture involves needling of acupoints to stimulate or restore balance to the body. Especially for patients who are already on a lot of western medication and hard for us to find a time for them to take chinese medication or for end-stage patients who are unable to ingest medication. Acupoint massage can be done for patients afraid of needles or can’t take needling for other reasons. Often, this is something caregivers can do daily for the patient as it is easy to perform and can help to relieve minor symptoms or discomforts. Acupuncture or acupoint massage is also suitable for pain management or relief for late stage cancer patients.
4. Tuina massage
This helps to stimulate circulation and prevent muscle wasting. It can be done daily by caregivers or helpers with guidance from physicians or Tuina therapists.
There are other ways or methods I did not cover here e.g. external applications, moxibustion, foot bath that can also help to support end-of-life or palliative patients.
In Singapore, palliative and end-of-life care is rather well developed in our healthcare institutes. Western doctors, nurses and therapists are often involved in a care team in acute and community hospitals, hospices and day care centres but TCM physicians are often not part of it. House call visits for TCM practitioners are starting to develop in Singapore as more seek alternative treatments for end-of-life or palliative care. I hope to see more communication or collaboration between western healthcare professionals and TCM practitioners to provide holistic care for such patients.
We cannot avoid death but we can choose to prepare ourselves for death in a meaningful way. Here are some practical suggestions to prepare one for end-of-life care:
1. Plan care preferences ahead with Advanced Care Planning (ACP)
ACP is the process of planning for future health and care preferences. You can look up Agency for Integrated Care (AIC) for more details. Do this early when one still have mental capacity because should one lose conscious or mental ability, the care team and family members can act according to the care preferences when one can no longer communicate in difficult medical conditions.
ACP can be done even when you are relatively healthy and the care goals can be reviewed according to your condition.
2. Engage palliative care services to support end-of-life care management
Palliative care is an approach to care for people with serious illnesses at any age or stage of the illness to enhance their quality of life. It involves multi-disciplinary team of healthcare professionals who would provide care and support with aims to prevent or relieve symptoms associated with the illness. You can get more details from My Legacy @ LifeSG: https://mylegacy.life.gov.sg/end-of-life-planning/what-is-palliative-care/
3. Appoint someone you trust through and Lasting Power of Attorney (LPA)
LPA is a legal document that appoints someone you trust to make decisions on your behalf for personal welfare (healthcare preferences) and property affairs (banks, CPF, insurance payout, property etc) should you lose mental capacity one day. This is usually the same person you appoint in ACP as nominated healthcare spokesperson so it is easier for that person to make decisions on your behalf when you lose mental ability. It can be done online but you would have to visit the Certificate Issuer to witness the signing of LPA. You can get more details from MSF: https://www.msf.gov.sg/what-we-do/opg/lasting-power-of-attorney/how-to-make-a-lasting-power-of-attorney
There are other difficult questions and emotions involved when facing death. Often, one would ask if they could die peacefully or where would they go after death with fear and anxiety. We may not always be able to answer them but giving our love and support is something we can do as they face death.