Tue, Aug 07, 2018 - Page 13 News List

Talking about it won’t kill you

With just five months to go before the Patient Right to Autonomy Act goes into effect, Taiwan’s medical community, patients and their families grapple with cultural attitudes towards death and the concept of holistic care

By Julianna Lai  /  Contributing reporter

Illustration: Angela Chen

When Sharlene Cheng (程劭儀) told her patient that her breast cancer had metastasized to her lungs, the doctor and members of the patient’s family nearly came to blows.

Cheng, an associate professor in the Department of Family Medicine at National Taiwan University, says that it is common for physicians to receive threats from family members of the terminally ill, resulting in a pervasive culture of fear over medical suits and ambiguous patient-physician relationships.

“We’re not in a culture where doctors can freely communicate with patients about their prognosis,” Cheng says. “A lot of families think that if the patient knows the truth, they’ll suffer psychological trauma or their health will deteriorate further. It’s a protective measure for the patient.”

But palliative and hospice care specialists agree that end-of-life conversations lead to higher patient-family satisfaction, less healthcare spending on treatments associated with patient suffering and, rather than exacerbating patient depression or anxiety, relieve emotional burdens on both patients and their families.

With the Patient Right to Autonomy Act (病人自主權利法) and the mandated Advanced Care Planning program for both patients and families set to begin on Jan. 6, 2019, Taiwan’s medical community has under six months to address serious challenges with transparency and open communication deeply ingrained in Taiwanese culture.

‘BAD THINGS HAPPEN WHEN YOU SAY THEM OUT LOUD’

Punished as children for broaching the topic during weddings, birthdays and other celebrations, Taiwanese are taught from a young age to avoid discussing death.

In many East Asian cultures, where the taboo of talking about death and mental health prevents patients from receiving adequate end-of-life and psychological care, doctors choose medical treatment — no matter how futile in prolonging the patient’s life — over communication.

Tsai Jaw-Shiun (蔡兆勳), president of the Taiwan Academy of Hospice Palliative Medicine and Director of the Department of Family Medicine at National Taiwan University Hospital, says that it is difficult for doctors to refuse families who request information to be withheld from the patient. But if families are allowed to obstruct communication between physician and patient, they run the risk of future regret.

Tsai says it is common for families to bring in treatment and symptom management advice from the Internet to counter professional opinions, underlining widespread distrust of healthcare providers in palliative and hospice care because families and patients aren’t receiving proper consultations from physicians about future healthcare decisions.

“There’s also the issue of low health literacy, especially in more rural areas,” he says. “Patients won’t ask about their prognosis themselves. They think that what they don’t know, they won’t fear.”

But Taiwanese are especially unwilling to take part in end-of-life discussions, leaving healthcare providers worried about implementing Advanced Care Planning once the Patient Right to Autonomy Act goes into effect.

In a cross-cultural study across palliative care clinicians in Taiwan, Japan and South Korea, Cheng found that 70 percent of Taiwanese doctors reported that they often experienced reluctance on the part of family members to discuss end-of-life issues — compared to just 50 percent and 59 percent in Japan and South Korea respectively.

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