End of life care in hong kong

Introduction

Death can be a difficult issue for the elderly, some of them may not want to discuss it because of the traditional culture. However, there are thanatologists who study death and dying issues, they have shown that death can be classified into two types as functional death and brain death. The functional death refers to a stopped heartbeat and no breathing, the brain death refers to a diagnosis of cessation of all sign of the brain activity, it can be measured by the electrical brain waves. Dying is different from death, it is a process which may include the five stages of grief as denial, anger, bargaining, depression and acceptance. The patient will first be denying the truth that he or she will die soon, they may think that is not happening, when they pass this stage they will start to feel anger for the reason that why they needed to die. After that, the patient will come to the stage of bargaining which they will begin to believe they are dying but struggling with it. When the bargaining stage has passed, they will be depressed that they are going to die, and they would accept it finally with positive thinking such as they embraced the truth of dying that is part of life and try to live at the present.

Situation in Hong Kong

The aging population is one of the major issues that Hong Kong facing which strongly related to chronic disease. Therefore, apart from the healthcare service, there is a need to bolster the palliative care service in Hong Kong. The Hospital Authority (HA) is the main resource of the palliative care service, the service providers such as the doctors, nurses, social workers, physiotherapists and clinical psychologists are aimed to enhance the quality of the care and offer the patient a more peaceful dying process. According to the legislative council (2017), HA has strengthened different dimensions of palliative care service in 2014 to 2017, the number of inpatients or discharged and died patient has dropped from 8, 254 to 6, 006. The end of life care services are bolstered by the Social Welfare Department, it also gradually alter the subsidy amount for the residential care homes for the elderly (RCHEs).

Legal, Ethical and Professional Issue

For the legal issue, there are Advance Directives (AD) and Advance Care Planning (ACP), mental health ordinance (Cap 136), powers of attorney (Cap 31) and enduring powers of attorney in the stage of anticipation and preparation. The AD often involves when it comes to the duration of validity, option to revoke a previous decision and refusal of life-sustaining treatments only or also basic care, it operates under the common law framework but not legislated yet. On the other hand, the ACP has no formal legal standing which makes their wishes not binding. According to the Powers of Attorney Ordinance (Cap 31), it currently only allows the attorney to handle financial matters before and after the patient becomes mentally incapacitated. At the end of life care delivery stage, there is a Fir Services Ordinance (Cap 95), it is obligated to perform resuscitation if needed, despite having completed Do Not Attempt Cardiopulmonary Resuscitation (DNACPR), ACP or AD documentation. In the stage of death and post-death, with reference to Coroners Ordinance (Cap 504), it stated there are two conditions of death including, dying at Residential Care Homes for the Elderly (RCHE) and dying at home. The difference between those is the death at RCHE automatically reportable while dying at home is reportable but can be exempted.

There are different aspects for the ethical issue, patients and doctors can be both struggling with their own decisions, it depends on what they believe and values the most and how they feel. The four pillars in medical ethics are autonomy, beneficence, non-maleficence and justice. Autonomy ethic means the patient has the right to choose or refuse to undergo the treatment. Beneficence ethic refers to a doctor should act in the best interest of the patient, for example, the effective pain and symptom management and acknowledgment of the person as a unique human being to be respected and valued. The non-maleficence ethic emphasizes the concept of doing no harm such as unnecessary physical pain and psychological distress. The justice ethic concerns about the equity of health resources distribution, it may sometimes serve to limit autonomy, including the patients’ choices, wishes and feeling may not be possible or allowable in the context of the society. Apart from those four pillars, there are few additional values that will be considered when making a decision, it includes dignity, truthfulness and honesty. It is important that the patient and the persons treating the patient have the right to dignity, the informed consent and telling the truth is essential either. There are ethical dilemma appears it came across the dying or the end of life care process, for example, the doctors may struggle to feed or not to feed patients as there is no evidence that artificial nutrition can prolong survival in chronic disease, but they cannot ignore the patient feeling of hunger. For example, the tube feeding is needed for the patient, although the fluids will not prolong their life, it is the expectation of the relatives to keep feeding while they think the fluids will not cause harm and bother the patient. On the other hand, when it comes to the dying process the organs of the patient will slow and stop working, the fluids that intake will be accumulated. It can cause or worsen pulmonary edema, lung secretions, ascites and lymphoedema. Besides, the patient is suffering the pain of the needle sites and they may be incontinent or require catheterization. The relatives also needed education on the reason of not feeding the patient and the other ways to take care of the patient. Also, the other ethical dilemmas are withholding or withdrawing the treatment and symptom management at the end of life. If treatment is no longer effective, it should be stopped and this may serve to remove resistance to the natural dying process, a doctor is not ethically obliged to provide a treatment that is unlikely to benefit the patient. The patient also has the right to be freed from suffering and the care provider has a responsibility to see what happens. Nevertheless, there is no right or wrong answer on the ethical issues, it depends on the different point of view of people.

Besides, there are some specific issues including hydration and nutrition supplementation, palliative sedation, limitation of treatments, advance care planning or cardiopulmonary resuscitation. The hydration at the end of life including the symbolism of food and fluid, fear of starvation, organs slow down in preparation for death, the burden of hydration outweighs the benefits. The hydration has slightly related the hunger and dry mouth, it may require mouth care with familiar tastes to facilitate the patient cultural or spiritual background. Therefore, it is needed to train more medical staffs or healthcare workers on the decision of treatment that given to the patient, it takes a variety of consideration to make the best choice for the patient but respecting the patient will always come to the first place.

End of Life Care in England

In 2015, a report written by the Economist Intelligence Unit rated the UK the best place to die out of 80 countries. According to Hunter and Orlovic (2018), most of the UK citizen would prefer to die at home, it shown that the location of care outweigh the other factors or consideration when it comes to dying. However, some of them believed that dying at the hospital may have better cared, lower financial cost and in non-clinical settings. It also mentioned the factors that influences the location of end of life care, it depends on the workforce training on the end of life care, the integration of services and the funding for social care. The medical team play a crucial part of the end of life care, it would be favorable if the location includes professional and well-trained medical staff.

Discussion

There are several barriers in the current end of life system, it has the low uptake and lack of formal status for AD, the lack of standardized policy, protocol, and formal status for ACP, uncertainties of the end of life prognostication and lack of continuous end of life care conversation. When it comes to the end of life care, there are inadequate capacity, support and resources for the end of life care in the community, it needs improvement on the manpower, equipment, facility and space, transportation, there are inadequate non-emergency transportation to the hospitals for the end of life patients who require sub-acute attention. In addition, there are only 19 palliative care specialists in Hong Kong, it also shows the inadequacy for supporting the end of life care in the hospital settings and insufficient coordination and communication between the different departments. If the patient is dying at a hospital, it has limited space and flexibility of visiting hours at a public hospital, the general practice to transfer or rush back patients from community to hospital to die. It has insufficient understanding and coordination between Accident emergency and other care when the patient at the end of life.

Conclusion

The patient is the top priority at the end of life decision making, their wishes are needed to be heard and respect. There are rooms of improvement of the end of life care in Hong Kong, the government can refer to the other countries such as England, to enhance the end of life services performance and offer a peaceful and comfortable environment to the patients. The shortage of human resources and spaces are urged to be solved, the government should cooperate with different department to facilitate the end of life policy in Hong Kong. In this study, it evaluated the current end of life situation, discussed the legal, ethical and professional issues of it, the limitation and recommendation of end of life care in Hong Kong, it still need legalization on the end of life care and the public awareness are needed to be raise to educate them the importance of the end of life care.

References

• Chung. R., Threapleton. D., Lui. S. F., et al. (2016). Overview of end of life care in Hong Kong now and to the future. Retrieved from http://www. socsc. hku. hk/JCECC/conf2017/wp-content/uploads/2017/03/Roger-Chung_Overview-of-End-of-Life-Care-in-Hong-Kong-Now_publicversion2. pdf
• Hong Kong e-Legislation. (2012). Cap. 136 Mental health Ordinance. Retrieved from https://www. elegislation. gov. hk/
• Hong Kong e-Legislation. (2018). Cap. 31 Powers of Attorney Ordinance. Retrieved from https://www. elegislation. gov. hk/
• Hong Kong e-Legislation. (2018). Cap. 95 Fire Services Ordinance. Retrieved from https://www. elegislation. gov. hk/
• Hong Kong e-Legislation. (2018). Cap. 504 Coroners Ordinance. Retrieved from https://www. elegislation. gov. hk/
• Hunter. J., Orlovic. M. (2018). End of life care in England. Institute for Public Research. Retrieved from https://www. ippr. org/files/2018-05/end-of-life-care-in-england-may18. pdf
• Legislative council. (2017). Palliative care services. Retrieved from https://www. legco. gov. hk/yr17-18/english/panels/…/ltcp20171212cb2-476-2-e. pdf
• Macleod. R. (2019). Ethical issues in palliative care. Retrieved from https://www. pharmac. govt. nz/assets/ss-palliative-care-3-ethical-issues-in-palliative-care-prof-rod-macleod. pdf