The legislature recently passed amendments to the Hospice Palliative Care Act (安寧緩和醫療條例) that allow terminally ill patients to die with more dignity. In the future, terminally ill patients will be able to sign a letter of intent to receive medical care in the form of palliative and supportive therapies, and avoid receiving cardiopulmonary resuscitation (CPR) and life-sustaining treatment when they become more critical.
For terminally ill patients who are in a coma and thus unable to express their wishes, one of the patient’s closest relatives must sign a consent form on behalf of the patient.
In recent days, various media outlets have reported, incorrectly, that patients who are bedridden for a long time, have muscular atrophy in their upper and lower limbs, and those who are unable to live with dignity are likely to become prime targets for discontinuing CPR or life support in an attempt to cut down on National Health Insurance expenditure.
For patients to qualify for hospice care, they must be deemed “terminally ill,” a state defined as having a serious sickness or injury that a doctor has diagnosed as incurable and which will soon lead to death. Medical evidence to support any such diagnosis of unavoidable death must be provided.
This means that most patients in a vegetative state, those suffering from amyotrophic lateral sclerosis, bedridden stroke patients and patients who need a respirator to stay alive are not deemed “terminally ill,” because with the right treatment, they can live for years.
Even if two doctors declare a patient terminally ill who is bedridden, suffers from muscle atrophy and is living without dignity and one of their family members signs a consent form, removing them from life support systems is still illegal.
This is because the status of a terminally ill patient is not something that a doctor decides on alone. There must be sufficient medical evidence for their status that can to stand up to judicial review. For example, in 1997, a judge presiding over a case ignored that the patient’s spouse had signed a consent form for the discontinuing of support and instead tried to find out why the doctor did not proactively treat the patient. That is to say that the judge in question did not believe this patient was terminally ill.
On the surface, not performing CPR or removing life-support systems of non-terminally ill patients may appear to be an attempt to maintain a patient’s dignity, but this process could be carried out to save on healthcare resources by discontinuing long-term treatment that is both time-consuming and costly. Such disregard for human life could make it much easier for euthanasia or murder to take place.
Medical directives written in advance allow patients who are sick to leave the world with dignity, and as such are worthwhile. However, the premise for these directives must be that the patient is terminally ill with a life expectancy of less than six months.
The real significance of hospice and palliative medicine lies in respecting life and avoiding a situation in which a patient has to suffer for longer, due to human error, than they otherwise would. More importantly, situations in which patients who are not facing imminent death are inappropriately given up on must be avoided.
The real challenge will lie in how to educate the public and doctors on the issues of death in the eyes of the law and the importance of ethics so that no patient dies unnecessarily.
Lin Pyng-jing is a professor of surgery at Chang Gung Memorial Hospital.
Translated by Drew Cameron