No dying at home - the living aren't ready

16 Sep 2007, ST

By Bertha Henson

MY GRANDMOTHER died at home, surrounded by her children and grandchildren. We wept quietly and prayed silently as we watched her slip away slowly.

It was agonising to watch her, as her pauses in between breaths got longer and longer.

And when she finally breathed her last, all hell broke loose. The weeping became bawling, prayers turned into a chorus of chants.

A relative who is a doctor was asked to certify her death, then undertakers came to take her body away. When she returned in her casket, she looked beautiful.

I would like to think that she had a good death, even as the living found it hard to contain the emotions that filled the house for several days.

The upside for the family: Daily and nightly vigils had bonded the extended family together, long-lost and estranged relatives were contacted, soon-to-be spouses were brought to the death bed.

I don't know if my grandmother registered all the movements around her. But she was conscious enough to acknowledge the presence of other people, even to the point of turning her head away when someone whom she had a long-standing quarrel with was brought before her.

The bad side: It was emotionally and physically draining for everyone. Enough said.

She could have died in hospital, lingering in pain from liver cancer. It was the doctors who suggested that she return home, given her inoperable state. My family never thought it should be otherwise.

That happened more than 30 years ago when, I believe, it was far more common for people to live out their last days in their everyday surroundings. A hospice was practically unheard of. Hospitals were not places to stay, especially the C Class ward my granny was in.

Her dying had a huge impact on me, a little girl who had always slept in the same bedroom as grandma.

I thought then: So this is what dying is like, this is what looking at someone die is like.

Now, only three in 10 people die at home. Most die in hospitals, hooked up to machines and surrounded by uniforms. Or they die in hospices, where their last days are eased by professionals.

No study has been done in Singapore on how people would like their lives to end. But studies in the United Kingdom and Japan, both developed countries, show that most people want to die at home, but few get to.

Singapore shouldn't be too far different.

Is this a case of the living hiding behind the veneer of good intentions to thwart the wishes of the dying?

One reason espoused for the change in place of death is everadvancing medical technology, which offers hope against disease.

Or, to look on the darker side, perhaps, it is an excuse to keep the dying out of our homes and comfort ourselves that they are in professional hands. After all, we can afford it.

Another reason often cited is the inability of the living to cope, what with fewer children to share the job of looking after, say, a dying parent.

Some financial decisions might have to be made. Take leave from work? Hire a full-time nurse? A part-time maid? A foreign maid? A duty roster of relatives?

It can pose heavy financial and emotional stress and force changes to lifestyle.

I would wager though that even in the less well-off days in Singapore, these considerations weighed heavily. But somehow our parents and grandparents took them in their stride.

Why is there an increasing distaste or inability to deal with a death in the house?

Have we got so comfortable with our lives that we would rather not deal with other people's deaths? Maybe we have a lower threshold for pain, unable to cope with diaper-changing, foul smells and plaintive cries.

Maybe we think that the home should be a sanctuary for the living, not the dying; where young children should not have to see the ravages of sickness and only health and good fortune should pervade the house.

Maybe we are not strong enough to withstand the emotional and mental pain of watching someone die.

My father did not die at home or in a hospital or hospice. He died on the Bukit Timah Expressway of a massive heart attack. He went out of the house hale and hearty and returned home in a casket.

If he didn't die, I wonder if I would be able to hold up emotionally looking after him? Or would I take the easy way out and leave him in the care of other people? How much of myself and my lifestyle will I sacrifice for last looks, last words, last blessings?

You know what people say in such circumstances: 'At least he didn't have to suffer.'

I wonder if the honest truth we cannot confront is that we're glad it was the living who didn't have to suffer.

Dead man at Stadium carpark was S'pore Superband star

30 Jun 2007, New paper

HE was jovial, always cracking jokes to cheer friends up.

Ishi Lau Gek How, 26, was also described as the soul of his former five-man band, Soul.


Ishi Lau Gek How with his group Soul when they took part in the Superband contest last year.

They were runners-up in MediaCorp's Superband singing contest last year, but disbanded in January as Ishi wanted to strike out on his own.

So when Ishi's lifeless body was found in his car outside the National Stadium on Thursday, friends and family members were puzzled.

There were puddles of vomit near his Toyota Altis.

Miss Jasmin Chong, MediaCorp Studio's artiste manager, said: 'When reporters told me about it, I just sat there for about 10 minutes, refusing to believe the news.'

Miss Chong, who has worked closely with Ishi, said she had spoken to him a few weeks ago.

Ishi had called her to ask if he could take part in a dance competition organised by MediaCorp.

She recalled Ishi's jokes at the Superband rehearsals. 'He was naturally funny and his boisterous laughter was very infectious,' she said.

Mr Dennis Chew, one of the four judges in the contest, described him as a 'sunshine boy'.

'He attracted women. During the competition, the female fans would always scream his name. His name was always the loudest,' said the FM93.3 deejay.

In an interview with Channel U, the band members had said that Ishi was the first among them to have fans.

But it seems Ishi was also troubled about his love life.

When contacted, the former members of Soul were reluctant to speak.

One of them, Ashley Nawi Ismail, 26, said: 'The family members are distraught now, so are we. This is very sudden and there are lots of questions in our heads and we're all looking for answers. We're in no condition to talk to the media now.'

Ishi graduated from Nanyang Technological University's Wee Kim Wee School of Communication and Information last year. Earlier, he went to Victoria Junior College and Dunman High School.

During the Superband competition, Soul often received praises from judges for their sleek dance moves, which Ishi helped to choreograph.



DANCE INSTUCTOR

He was a part-time instructor at dance school Studio Wu. He had also been engaged as a dance instructor to coach the finalists for MediaCorp's Project SuperStar 2.

Part-time deejay Fu Junli said: 'He was very passionate about dance and told me his dream was to set up a dance school.'

But problems had apparently crept into Ishi's life.

One of his close friends, Miss Lee Shu Lin, said he had been facing emotional turmoil for about a year.

'He may be very jovial and easy going but he's also the kind who is silent on his problems,' said Miss Lee, 25, a marketing manager.

Ishi wrote in his blog, in an entry dated 26 Mar 2007: 'I know that life is full of ups and downs, and it's better to be optimistic such that you'll be a happier person.

'But if one has been pessimistic all his life, it's kind of difficult to change just like that, so give me time and I'll be a happier person.'

Another of his close friends, who declined to be named, said she last spoke to him on MSN a week ago.

She said Ishi was very happy when Soul emerged runner up in Superband. 'But nothing much came out of it. They didn't get any contracts. He was back to being a dance instructor.'

Shinmin Daily reported that Ishi had a girlfriend. He was then reportedly pursued by another girl. He later broke up with his girlfriend and fell in love with the other girl. However, she had already found someone else by then.

A family friend told the newspaper that a day before he died, Ishi had sent an SMS to this girl, wishing her happiness.

By 7pm yesterday, there were more than 10 anonymous posts on his blog about his death.

One of them said: 'Why did you do it? There are so many of us who love you so much! How can you just leave us like that?'

Family friends told The New Paper that Ishi's body was cremated yesterday.

The police have classified it as unnatural death and are investigating.

Man found dead at National stadium carpark

29 Jun 2007, New paper

Traces of vomit nearby. His car was there for at least 10 hours, say witnesses

By Crystal Chan

THE National Stadium, a landmark once alive with active bodies and healthy activities, is now a silent shell.

Yesterday, two days before its last hurrah, it was the scene of death.

The body of a man was found in the carpark of the soon-to-be demolished stadium.

The man was found slumped in the driver's seat of a Toyota Altis.

When The New Paper arrived at 6pm, the body was still in the car. This was 10 hours after the car was first spotted at the carpark by a Bangladeshi worker.

The dead man appeared to be Chinese, with a tanned complexion. He was dressed in a yellow T-shirt and black bermudas.



The dead man was slumped in the driver's seat of the Toyota.

Except for the police and some curious construction workers, the carpark was deserted.

The grisly find came just two days before the 34-year-old stadium's closing ceremony tomorrow.

Puddles of vomit were splattered on the parking lot next to Lot 603, where the car was parked.

At 6.15pm, a black Lexus drove up to the area that had been cordoned off. Both the Lexus and the Toyota bore the same licence plate number: 2222.

A middle-aged couple and a young woman got out of the car hurriedly, and dashed to the corpse.

The older woman's wails punctuated the silence, and she leaned on the younger woman for support.

Except for the word 'stupid', what the older woman was saying could not be made out.

Unable to stand up straight, she leaned against her car and stared at the undertakers who prepared to take the body away.

Her two companions were composed as they spoke to police officers.

But the older woman could not contain her grief and ran back to the Toyota to hug the corpse.

REFUSED TO LET GO

She refused to let go of the dead man and had to be led away by the younger woman.


A middle-aged woman, supported by others, cries uncontrollably after identifying the dead man. -- Picture: DOMINIC YING

The three then drove off, while the body was taken to the mortuary for a post-mortem.

A Bangladeshi construction worker, who declined to be named, said the Toyota had been parked there since 8am yesterday.

He said: 'We thought the man was sleeping so we didn't do anything at first.

'But when we saw that the man was still in the car at 2pm, we alerted our supervisor.'

Another onlooker, who said his job was to transport workers to the Nicoll Highway Circle Line work site, said he had seen the Toyota in the area previously.

UNIQUE LICENCE PLATE NUMBER

'I remember the car because the licence plate number, 2222, is unique,' said the man, who also declined to be named.

Police said they received a call at 3.30pm, about a man sitting motionless in a car.

Police spokesman Lim Tung Li said: 'Upon arrival, police saw the man, who is in his mid-20s, sitting in the driver's seat.'

Assistant Superintendent Lim said the man, who was alone, was pronounced dead by civil defence officers at 3.45pm.

Police are investigating the case as an unnatural death.

The National Stadium was a popular venue for events like the Malaysia Cup, the National Day Parade and pop concerts. The New Paper Big Walk, an annual event drawing thousands, was also held there for 16 years.

The stadium will be demolished to make way for a new Sports Hub.

The hub - a complex that will comprise a new 55,000-seater stadium, a 6,000-seat indoor aquatic centre and a 3,000-seat multi-purpose arena - is set to be ready by mid-2011.

Death of a Maltese

I read about this on STOMP. It's about the death of a Maltese and the interesting response given by the animal hospital.



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Philia's email to STOMP
(Posted on 09 May, 2007)

I had brought my 13 year old maltese, Koo Koo to M**** P***** Animal Medical Centre, a clinic at Clementi on 1st April 2007 and was advised by Dr Simon Quek that Koo Koo needs an operation to sterilize and remove his testicles.

As my dog was very old in age, I was rather hesitant at first as I was worried about the side effects and whether Koo Koo was able to take the toil. After discussing with Dr Quek, the decision was to go ahead with the operation. But this was an upsetting mistake.

After Koko had completed the surgery, he was whining and crying, seemingly in great pain. He could not even walk, sit or stood up. Every single bit of movement is extremely painful and unbearing for Koo Koo. I noticed that his private area was very swollen and red and there was even a patch of skin hanging. (I later checked with my friend who had his dog sterilized too, and was told that the skin should be patched back nicely !). Koo Koo was in so much pain that the black portion of his eyeballs went behind his eyes and only half black could be seen.

I was very worried and concerned with Koo Koo's health and consulted Dr Quek on the reasons why it was swollen. Dr Quek's reply was just a mere 'I don't know' ! As a vet, whose duty was to cure sick animals and their concern for animals should be innate, but what I am getting is a flat refusal and nothing was done to help check why Koo Koowas in extreme pain after the operation. Were there any other side effects or implications ?

I also found out from the staff at Clementi clinic that Koo Koo was unable to eat nor move for the few days that I left him in the clinic. Because of this, he was extremely weak and because he was unable to move, his urine and discharges were stuck in his coat and legs. He was in a very bad condition when I went to collect him. No one at the clinic had informed me that Koo Koo had not been eating these while.

Come next was even more atrocious. Dr Quek proposed an operation to treat Koo Koo's legs as her legs got worse after the operation. I consulted a senior vet in another pet hospital and was advised that for Koo Koo is not suitable for any operation at this stage as she is too weak to take it any further.

I am not pleased with the standard replies given by M**** P*****. They mentioned that there is no need for patching of skin after testicle surgery. Why shouldn't there be any patching back of scrotum (the skin which covers the testicles) if it had been cut in order to facilitate removal of testicles. It is absurd that the dog's skin is still hanging after surgery.

Also, M**** P***** replied that Koo Koo's abnormal positioning of its eyeballs were not due to pain, but because of anaesthetic effects. Why wasn't I informed in the first place that her eyeballs will be abnormal after the surgery. It came as a shock to me.

M**** P***** claimed that they would clean the animals cages every morning, and if the animals had soiled themselves, they would be given a wash as well too. But this was definitely not the case. Koo Koo was in a terrible state when I saw him. His coat were smelly and soiled with urine and feaces.

I am very disappointed with the services provided by M**** P*****. It is my fault that I had brought Koko to M**** P*****. If I had known, I would have brought Koko elsewhere for treatment and perhaps, I could have accompanied Koko for a few more years.

Koko had died few days after the surgery, in pain and suffering. I feel sad what they had done to my dog.

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M**** P***** Animal Medical Centre's Dr Heng Yee Leng not only responded to STOMP's query about this, but also sent Philia an email to clarify some misunderstandings she has about the case.

Koo Koo, says the centre had to have his testicles removed as he had testicular torsion, and was also suspected of having a hormonal problem.

The hanging patch was not removed as it was his scrotum; it would have been very painful for the dog and would shrink over time to normalcy. His genital area was red and swollen post-op, and would be all right over time.

His eyes appeared to be abnormal due to a reaction to the anaesthetic.

A second operation was recommended as he was suspected to have torn his ligament, a condition he had even before the operation.

Koo Koo was hand-fed by staff though he refused to eat.

The animals and cages are cleaned in the mornings; treatment is also administered then.

The centre appreciates her feedback, and says they will work towards achieving better standards.

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M**** P***** Animal Medical Centre's letter to Philia

17th April 2007

Dear

Re: Letter of Complaint

I refer to your letter of complaint against Dr Simon Quek.

As a senior veterinarian, I have been instructed by Dr Tan Hwa Luck to investigate your complaint.

Firstly, condolences to you on the demise of your dog. Thank you for your feedback. I have looked into the case regarding your dog Koo Koo and there appears to be some misunderstandings I hope can be clarified.

Koo Koo was brought into the clinic on 1st April 2007 with the complaint of swollen testicles. Upon examination by Dr Quek, castration was recommended. The castration had to be carried out NOT because of kidney implications as you had stated in your letter. The castration had to be performed as there was a high chance of the blood vessels supplying the testicle being twisted, a condition known as testicular torsion. During the visit, it was also noticed that the dog had a potbellied appearance and sparse hair coat. He was also informed that the dog was eating a lot, drinking and urinating a lot.

Based on the clinical signs, Dr Quek had suspected that the dog might have a hormonal problem, specifically Cushings Disease ( also known as Hyperadrenocorticism). He had recommended to you that a test be done to confirm the disease at a later stage. The dog had to be castrated as testicular torsion is a painful condition and can only be treated by means of surgery.

With a castration, the testicles are removed via an incision in front of the scrotum ( the skin which covers the testicles). In cases where by the scrotum is not damaged , as in Koo Koos case, the scrotum is not removed as it is a much more painful and bloody procedure. In older dogs or cases with an enlarged testicle( as with Koo Koo) , post operatively, the scrotum will appear as a patch of skin hanging between their legs. In your friends case, if the dog was castrated at a younger age or castration was not complicated, the scrotum will not be as well developed and will shrink to appear level with the rest of the skin, therefore you will not see a patch of skin.

Therefore, no patching of the skin is required. Post operatively, in most cases, there will be some degree of swelling around the surgical site and within the scrotum due to bruising and accumulation of blood as the testicles and scrotum is an area with a heavy blood supply. Injectable painkillers are given to help the animals with pain after surgery.

In your letter, you mentioned that Koo Koo's eyeballs were in an abnormal position. This is not because Koo Koo was in pain but due to the anaesthetic. When an animal is anaesthetised for surgery, the third eyelid comes across the eyeball, giving the owner an impression that the eyeballs are in an abrnomal position. The third eyelid is a pinkish membrane that is normally hidden in the corner of the eye so it is very normal for an owner to be shocked when this covers up part of the eyeball.

On the review dated 3rd April, your concern was of Koo Koo being in pain and unable to walk. When examined, Koo Koo was found to have a laxity in the ligaments in both his knees, with a possible rupture of the cruciate ligaments. Upon questioning, you replied that Koo Koo had always been weak in his hindlegs. As there were no other reasons for his lameness at the time of examination, Dr Quek gave you the option of performing another surgery on Koo Koo to repair the ruptured cruciate ligaments in his knee. He discussed with you the costs, risks and prognosis taking into account the condition of your dog at the time of presentation. While you were considering your options, Koo Koo was hospitalised.

During the time when your dog was hospitalised, pain killers were being given. The staff reported that Koo Koo did not eat on his own. It is standard practice for the staff at the clinic to offer the dog a variety of foods, both regular kibbles and soft foods to encourage them to eat. In cases where the dog does not want to eat, the staff hand feed them with a veterinary prescription diet, namely Hills Prescription Diet A/D which is formulated for recuperating animals.

All the animals hospitalised at the clinic are given an examination in the morning and given their required treatment, and their cages cleaned out. The animals that have soiled themselves would be given a wash as well. However, we appreciate your comments and will work towards achieving higher standards.

I hope this has cleared up your understanding of the situation.

Yours sincerely,

Dr Heng Yee Ling
BVM&S ( Edin.), MRCVS

cc. Dr Tan Hwa Luck

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M**** P***** Animal Medical Centre's letter to STOMP

8/05/2007

Dear STOMP team,

Please find attached our reply to the clients complaint.

We have included the correspondence to the client so that you may be able to understand the situation better. Upon receiving her letter of complaint, we investigated and replied to her accordingly. No professional negligence was found upon investigation. However, it appears that the client may not fully understand the medical condition her dog was in and thus does not understand the necessary actions that were taken.

It would have been helpful if she had communicated her concerns with Dr Quek initially so that such a misunderstanding would not have happened.

1. The client initial complaint was the dog having a swollen testicle. Upon examination, a swollen testicle was confirmed and diagnosed as a testicular torsion. This means the blood vessel supplying the testicle had become twisted upon itself, leading to swelling and pain of the testicle. Surgery to remove the testicles was necessary to alleviate the pain and inflammation. The incision was made in front of the scrotal sac as with a routine castration and skin was stitched with absorbable suture material. The flap of skin that the client had mentioned is actually the empty scrotal sac. This sac can become slightly swollen after castration, but subsides and retracts over time. On the second visit a few days later, the wound from the castration was healing well and the scrotal sac was still loose as expected at this stage.

2. In the clients letter to you,she mentioned that Dr Quek replied I dont know to her question. This happened in the first consultation even before surgery had been done to remove the dogs testicles. She had asked why would a condition such as testicular torsion occur. In reply to her question, Dr Quek said I dont know the exact cause of the testicular torsion. He went on to explain that there is no way to determine why the testicular torsion occurred to her dog, which the client failed to mention in her letter.

3. The client also mentioned that the dogs eyes were in an abnormal position indicating that the dog was in pain. After surgery the dog was put on painkillers to help with pain. With anaesthesia the third eyelid would come across the eyeball. This protrusion of the third eyelid can sometimes be present a few days after the anaesthesia as the dog is recovering from the surgery. The protrusion of the third eyelid would give the impression that the dogs eyes are smaller and owners may mistake it for pain.

4. On the second consultation, the dog was found to healing well from the castration. However another problem was highlighted. The dog was still not walking properly. It had lameness in both legs. The initial reluctance to walk was thought to be due to pain from the testicular torsion. That pain and inflammation from the swollen testicles would now have been eliminated. Further investigations were carried out and the dog was found to have ruptured cranial cruciate ligaments in both knees. It was also determined by further questioning of the owner that the dog had been lame for many months before presentation.

Dr Quek had given the client the options for treatment. The options include operating to repair the ruptured ligament, or conservatively to treat the pain as the dog was very old, or even an option for euthanasia. The client could not decide on the course of treatment and so the dog was hospitalised for monitoring. While at the clinic the dog was given painkillers for the knee problem. The client returned 2 days later and decided that she does not want to put the dog through surgery. It was decided that conservative treatment for the knee problem would be best for the time being. The dog was then discharged with more painkillers. The client did not return for any follow up after that.

5. All animals hospitalised at the clinic would be examined every morning and given their required treatment. If they had soil themselves overnight, they would be washed by the vet nurses.

I hope the explanation has illustrated to you in chronological order, the presentation, diagnosis and treatment options of the dog. It is understandable that she is upset by the death of her dog but as a professional organisation, we need to determine if there was any professional negligence in this case. The proper route of investigation is for her to direct her letter of complaint to the Agri-Food and Veterinary Authority ( AVA) which is the governing body for veterinarians. AVA will then make an independent investigation to determine if there was any case of negligence involved.

It is improper for the owner to send a letter to the press, such as yourself, before any investigations have been carried out. Such a letter, if published, would be defamatory to the individual and the organisation if there was no profession negligence found. The organisation and the individual vet would then reserve the right to take legal action against the owner and parties involved in dissemination of the story.

Please feel free to contact us if you require more information.

Sincerely,

Dr Heng Yee Ling
Senior Veterinarian
M**** P***** Animal Medical Centre (2004) Pte Ltd