Terminally ill Covid-19 patients who wish to die at home should be allowed to where possible: Experts

SINGAPORE – Terminally ill patients who test positive for Covid-19 should be provided support to stay at home if they wish, Professor Dale Fisher, a senior consultant at the National University Hospital’s Division of Infectious Diseases, told The Straits Times on Tuesday (Nov 2).

Emphasising that he was not referring to any specific case, Prof Fisher, who is also a professor of medicine at the National University of Singapore’s(NUS) Yong Loo Lin School of Medicine, said: “Now Singapore is in its transition phase, it is not enforcing the isolation of positive cases as strictly, so I believe Covid-19-positive terminally ill people should be provided the support to stay at home. It is better for the individual, families, and for the health system.”

On Monday, ST reported the case of a 99-year-old terminally ill man who asked to die at home, but he was tested positive in an antigen rapid test shortly before dying. The family kept him at home until his death, according to his wishes.

The man’s doctor and family highlighted the lack of clear protocols on what to do during the episode.

Although it is unclear what the official protocol is, Covid-19 patients aged 80 years and older are not typically eligible for the home recovery programme, and are expected to be transferred to external facilities.

But the man had earlier made his family promise that he would be allowed to die at home.

Additionally, the doctor who attended to the case, Dr Choo Wei Chieh, told ST that sending the man to hospital would “increase the burden to already busy hospitals”.

Dr Choo, who is co-founder and chief executive of home-care provider Ninkatec, added that given the man’s unstable condition, he would likely have ended up in the intensive care unit, exacerbating the workload there.

An expert from the NUS Centre for Biomedical Ethics, Dr Anita Lim, pointed out that there is no legal mandate for Covid-19 patients to be hospitalised.

“It is a medical decision, based on the clinical condition of the patient and weighing all the relevant factors,” she said.

End-of-life conversations for patients who are terminally ill will involve discussions on their preferred place of death and constraints to be addressed, said Dr Lim.

But she added that any flexibility in the decision-making needs to take into account the safety of the patient’s caregivers.

Asked who should have the final say in what happens to terminally ill patients, Dr Lim said that while the patient’s wishes and those of their caregivers should always be discussed, considered and recorded, decisions should be made by the most qualified caregiver, who is usually the senior clinician.

This decision should be made in consultation with other clinicians, she said, adding that a second opinion may be beneficial at times.

But she acknowledged that in urgent situations, it may not be possible to obtain all the necessary information.

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“In these circumstances, decisions should be made according to the patient’s best interests, following ethical principles as fully as possible,” she said.

Some readers had also raised the question of why the 99-year-old’s body needed to be bagged, given Singapore’s high vaccination rates and the shift towards living with endemic Covid-19.

The National Environment Agency had earlier told ST that this is done for safety. In addition to being bagged by healthcare workers, the bodies must be placed in sealed coffins and then collected by funeral service providers who have been trained by the National Centre for Infectious Diseases.

Prof Fisher noted that as Singapore transitions towards living with endemic Covid-19, it is gradually removing various restrictions.

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“Ultimately, management of dead bodies needs to revert to standard precautions. Like everything else, I would be confident that these measures will be normalised in time,” he said.

He added that while the risk of infection from a dead body is relatively low, it is not zero.

Covid-19 is mainly transmitted through droplets, such as when a person sneezes or coughs. But the virus could still be on the surface of a body or in its secretions, cautioned Prof Fisher.

Still, he added: “These are certainly restrictions that can be wound back now that we are in a new phase.”

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