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Recently, I gained a lot of insights after reading two non-fiction books written by doctors, and thought a lot more about our mortality.

First book I read, I got it because I was intrigued by a review on it.

It was, Working Stiff: Two Years, 262 Bodies, and the Making of a Medical Examiner
by Judy Melinek, T.J. Mitchell. It's mainly about the cases Dr Melinek had encountered during her stint at the Office of the Chief Medical Examiner in New York.

There were young (unborn child) to old people. Healthy to unhealthy people (she mentioned that smokers' lungs are actually "crunchy"). Traffic accidents to freak accidents.

I cringed a lot as I read her book, especially when she described how those people may have felt before they died. Like how a girl's spine snapped and she bled internally to death, when the car she was in stopped abruptly as it crashed. Seat belt didn't save her, if I remember correctly, it was kinda part of the reason why her spine snapped as the car came to a sudden stop from the high speed it was going at. I cannot remember the details well, but I do remember that she didn't die instantly.

Then there was a man who was steamed or boiled alive in a sewer with a broken pipe. While he screamed for help as he was getting cooked alive, nobody, not even the firefighters could go down and save him... Not until they could stop the faulty pipe and clear the steam in the sewer. Apparently, his nerves wouldn't have been destroyed even as he was getting cooked inside out. Unlike burn victims, whose nerves may be destroyed as the fire burns their skin, he may have felt extreme pains all over as he was dying. The worst thing was, he was trying to help a woman when he got thrown down the sewer.

A few cases she mentioned made me cry. Like the pregnant lady who was ran over by a vehicle driven by a negligent driver. Both mother and child did not survive. The baby was too young to survive outside the womb. But its fingers and feet and toes were perfectly formed already. :(

Then, there was a supposedly healthy middle-aged man who collapsed and died suddenly. If I remember correctly, he exercised regularly and ate healthily, with no major medical conditions that is of concern. Except for a minor issue with his heart, that was not something that was supposed to be fatal or critical.

Reading the book was an eye-opening experience, and it was of course, also extremely morbid. But I started to think more about how short life can be.

We know, all of us know, we have limited time on earth. Yet, somehow, we would almost always forget about it as we trudge along in life.

Life, is so unpredictable. We may live till old age, only to die of cancer. Or we may die the next day because of an accident. Or as hard as it may be in this era, we may die of natural death in old age in the comfort of our home surrounded by our loved ones. It is harder to die in your sleep at home nowadays, because usually if we identify a medical condition, we tend to immediately seek medical treatment (regardless of the effectiveness of the treatment or the chances of it helping us to get back to our old ways/lives). Or we will make our loved ones seek medical treatment at a hospital if they should have any medical condition at all, whether truly treatable or not. So I think a lot of people are dying in hospitals or hospices/nursing homes instead of at home.

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Then, I went on to read a book written by Dr Atul Gawande, "Being Mortal - Medicine and What Matters in the End".

It was more about old people and their failing health, assisted living, hospices, palliative care, and what really matters for them in the end.

You know, when I got married and moved out, my biggest worry was (still is) my parents. I knew they are getting old. I realised I was losing time with them as I started to live apart from them. About a year after I moved out, there was once I was home, I looked at my mother and realised just how much older she looked. Her face, her arms... (she wouldn't like it if she sees this) had gotten so much wrinklier. I nearly burst out crying, but I controlled myself. On another separate occasion, I looked at my father and realised the same thing too. Both of them looked so much older and frailer than how I remembered them to be.

Then it struck me. As much as I hate to acknowledge it, they are not going to be there forever. Everyone is getting older. Including my parents.

Then I thought about their health conditions. Whether I will need to prepare for any possible emergencies (*touch wood*). How can I take care of them in their old age... in view that they have absolutely no savings and no insurance (except of course, for some Medisave)? I know that if they needed any help, I would do everything I can to help them. I may not be able to afford the best medical treatments or hospitals, but I know I will do what I can and seek for help from relevant organisations if need be.

Dr Gawande pointed out an important point in the book that I failed to consider. What really matters most to the old people when they are at their weakest or if they should require certain medical treatments that would have major side effects or include high risks in losing certain bodily functions... Would they want to pursue all possible treatments at any cost in hopes that they can live longer, or would they want to just have pain management and live on with what's remained of their health and time?

Being Asian, I find it hard to broach on such a topic. People may say it's bad luck to talk about such morbid stuff if everything is ok right now. They may even say you have a foul mouth or jinxed it if those things were to happen in the future. Of course, I hope it doesn't matter if I find out their preferences or not, and that they can live healthily for the rest of their lives. But, the reality is, a high percentage of old people do end up with several medical conditions that require certain decisions to be made.

So the question is, if treatments for their conditions do not guarantee that they can go back to how they were before, mobile and pain-free, instead, it carries certain risks of making things worse, like having extra tubes here and there... Would that be something they want to pursue?

What matters most to them will help us make better decisions. Do they want to be mobile, clear-minded and conscious for the remainder of their lives despite certain pain or discomfort from their medical conditions? Or would they not mind the risks, of being intubated, unconscious or being immobile due to the side effects or consequences of receiving certain treatments, to have a chance (however slim) at improving their conditions or extending their lives?

Whether to accept certain risky treatments, first thing we need to know is, what are their expectations after the treatment or surgery. Do they want to still be able to go gai-gai? To go to the kopitiam and drink coffee? To be able to sit up and watch TV? To be able to go to the toilet independently?

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If the risks of the treatments or surgery outweigh the "benefits" of not getting treatments/surgery to try and "fix" the problem, then perhaps it will be better not to take the risk. Like for example, if they do not receive treatment and they can live on for another year or so. Compared to if they were to receive treatment and the rough estimate of their life expectancy after treatment is also another 1-2 years. Would it be worth it to take the risk? Sometimes, the estimates are just estimates. Estimates are never for certain. Who is to say not receiving treatment, just getting pain management, and living life as they would like, would not help? What I believe is, our state of mind and emotional well-being definitely play huge roles in our physical health. So my belief is, it's more important to decide based on whether you would end up being happy, or helpless and depressed.

I remember in Being Mortal, it was mentioned that for families who took the risks and if their loved ones ended up being unconscious and intubated till they pass away, their level of guilt and regret would be much higher than those who just let them live on with what's remained of their lives, with assisted living and pain management from hospice care. Because for a lot of them, they tend to be happy or at least at ease till their last breath. They would have time to do what they want, say what they want and prepare for what's coming. And in turn, the families would be glad too.

The author mentioned some projects or communities that were developed in the US for old people who still very much want to live independently despite their conditions. To live in their own home, lead the life they so desire, keep their belongings by their side, and just live in a dignified manner for the last days of their lives. Instead of moving into a nursing home, with a small cupboard of belongings, having to adhere to routines, with no freedom and autonomy or independence. Which often leads to a loss of meaning or purpose in/to their lives. Without a meaningful purpose in life, they often spiral down with depression and worsened health. 

Those estates or communities the author mentioned, provide assisted living in the form of hospice care as and when required. So they remain in charge of their lives, free to have whatever purpose they want in their lives, and to live as happily as possible for the remaining days.

After reading about that, I began to wonder if we have such services in Singapore. I have never noticed such things before, so I assumed we were way behind. But come on, we've known ourselves to be an ageing population for years. How could we not have planned ahead for such stuff?

I began to realise we do have a wide array of choices for our older generation, if they choose not to live with their children and wish to live alone and etc.

The Singapore Hospice Council's website provides a lot of useful information. There are also a lot more BTOs with studio apartments for the elderly, with elder-friendly features like grab-bars and non-slip tiles in bathrooms, emergency pull-cords, and heat detectors that activate alarms.

Image taken by Mister Ko.
远水救不了近火, so I think it's great that there is such a feature at blocks with studio apartments for the elderly. Whoever notices the emergency first can take action immediately. Hopefully there are more people who would help out than those who would ignore.

Maybe due to our Asian culture, we often see hospice care, nursing homes and etc. as a cop-out for the children. That it is very unfilial if you don't take care of your parents personally. But sometimes, some people do have limitations, or their parents do genuinely want to live independently and apart from their children so they don't become the free "part-time maids" and can do whatever they want in their free time. Or they just don't want to be a burden to their children. 

Then here comes the question about how best to support them.

Because what should matter most to us ought to be their comfort and happiness. Thus, what we have to do is to provide the choices for them, advise them to the best that we can and allow them to choose what they really want... Instead of forcing our opinions on them to best suit our schedule and for our own convenience.

I am not saying hospitals and nursing homes are bad. Of course, if it's a critical condition, people must be hospitalised and receive the necessary treatments to save their lives. And as for nursing homes. My personal opinion is that, it's not the most conducive or the most pleasant environment for old people to be in for the remainder of their lives. However, if it's for them to be in during a recuperative period after surgery, I don't see why not.

When my maternal grandma was still around, she had a hip surgery. My mum and her siblings decided to put her in a nursing home temporarily while she recuperates as they believe the nursing home would be a better place for her to be in since they have the professional personnel who would know what to do to help my grandma. She can have the around-the-clock care as well. While she was there, they visited her often to ensure she was well inside. I followed my mother around a lot when I was young. Tagged along as she brought my grandma to the hospital for follow-ups, back to her home, to the nursing home to visit her, to my uncle's home... etc, so I know all these things as I was always involved in some way or another. Anyway, my grandma was not at all happy about being in the nursing home. She said the missy kept scolding her. They took her out soon. And whoever could (my 4th uncle and then my 3rd uncle), took turns to take care of her till her last days. They also shared the cost of a maid for my grandma.

Why do I think nursing home is not the best place for them to be in for the rest of their days? Well, as I've briefly mentioned in one of the paragraphs above, their personal items has to be reduced to being only what they could squeeze into a small cupboard. They have routine to follow, medicines to take, and a room to share with many others. How many of us would like this kind of arrangement? Perhaps some of them would adapt well and be ok with it. But, how many could and would?

In the book, Being Mortal, the author described how some old people will lose all motivation and their purpose in life once they get placed into a nursing home, and in turn become depressed. It's not their home and there is no freedom in doing what they really want to do. Their health, does not necessarily become better despite good professional care and medications taken on time, because their lack of good mental and emotional health may lead to deteriorating physical health.

So to me, it's not the best option.

We may have the best intention when we make decisions for our parents. But best intention does not mean we make the best decisions for them in terms of their mental health and emotional health.

How do we then, strike a good balance?

I understand it's subjective and very much depends on each family's situation...

Let's just hope we never have to be placed into such difficult situation. But if it happens, it will be best if we have already thought about it, talked about it and is capable of deciding on the best possible options under such stressful situation. 

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