Thai "right To Die" Laws?

[wpcoe]

A friend of mine in Pattaya is attending to the affairs of a farang friend of his who was seriously injured recently in a moto-sai accident. The injured fellow is in Intensive Care at Bangkok Hospital Pattaya and it has been determined that he is dying.

My friend said that the hospital advised that Thai laws only provide for a dying patient to have medications stopped, but not something more direct like disconnecting the breathing apparatus.

The question bothering my friend and me is: is BHP simply drawing out the death process which they have said may take five to ten days if medication is withheld (versus the few minutes it would take if the ventilator were withdrawn) in order to rack up the hospital charges?

Are there "Right to Die" and/or "Do Not Resuscitate" laws, and if so, are they being accurately being presented by the hospital?

[Mario2008]

There is an article on living wills in Thailand by Thailawonline:

http://www.thailawonline.com/en/inheritanc...rective-medical

It also has several links to other articles. Hope it helps. But make sure you read the footnote beneath the article! It is unsure if the law has been enacted yet.

[wpcoe]

Thanks for that quick reply! I was interested to see the sample living will they suggested in that article, and in particular that it only indicates the need for "Your signature, the date, the place, 2 witnesses, their addresses and occupation."

My friend had indicated that the dying friend's living will from his home country had been faxed to Thailand. As long as it has "[His] signature, the date, the place, 2 witnesses, their addresses and occupation," I wonder if it would be admissible and valid in Thailand?

[Mario2008]

I don't see a reason why not, as it would comply with Thai law. But at this moment I'm not sure if the law has been enacted! you could ask thailawonline. They are very helpful.

[wpcoe]

Based on your recommendation (sounds like you've been in contact with them before?), I just sent them the following message:

I read with great interest your online article "Living Wills in Thailand," (http://www.thailawonline.com/en/inheritance-and-wills/living-wills-in-thailand-thai-physicians-directive-medical) in that a friend of a friend is dying in a Pattaya Hospital and the question about his right to die is in the forefront right now.

As a follow-up to the above-referenced article, can you please tell me if Thailand has yet passed any Living Will legislation since the comment "On December 8th 2009, the cabinet approved a draft."

[Mario2008]

Many members had good dealings with them and I myself find them always helpful when I have simple questions.

My sympathies with you and your friends family and friends.

[Sheryl]

First of all, the Hospital is incorrect in stating that Thai law does not allow them to turn off life support. There is no such law on the books; this is their own intrepretation. However there is also no clear law stating that it is legal to do so except at the patient's own request, which is why some doctors and hospitals are fearful. Their concern is more along the lines of law suits than criminal prosecution. That said, there are many instances where Thai doctors and hospitals discontinued life support, but almost always these are cases where they have the clear permission of the family and enough trust in the family to feel assurred they will not later turn around and sue (which in fact has also been known to happen). In a case where no immediate relative is on the scene most doctors and hospitals will be very hesitant to take such a step; with a foreigner perhaps all the more so as they don't know what relatives this patient may have back home and what they might later do. Also, individual doctors vary in whether they personally feel comfortable with termination of artificial life support, and of course it also depends on the specific medical circumstances i.e. how clear it is that there is no possibility of survival.

The Health Act of 2007 specified the right of patients to refuse life support n advance through a "living will" but the directive operationalizing this law is still in draft form. See this pinned notice and links:

http://www.thaivisa.com/forum/Patient-Righ...;hl=living+will

Now in terms of this specific situation, and assuming it is in fact the case that there is no possibility, not even a slim one, of the patient recovering, here are my recommendations based on prior experience with such situations in Thailand:

1. Get a relative (preferrably the closest relative) on the scene if at all possible. Lacking that, get them to send a notarized power of attorney to someone in Thailand along with a notarized letter to the hospital to the effect that:

1. They have authorized so-and-so to act on their behalf (attach notarized copy of Power of Attorney)

2. They want life support to be discontinued given the terminal prognosis and the patient's own stated wishes (referencing and attaching the living will)

3. They release the doctor and hospital of all liability in so doing.

3. If these instructions are not followed they will:

- not pay for further hospital costs

- initiate legal action against the hospital for forcing unwanted treatment on a patient against their stated wishes (again referencing the living will) and against

the wishes of the family.

Ideally, hire a lawyer draft and send such a letter. If unable to afford this, send it directly but with copy to the relevent Embassy and to a lawyer or law firm.

Family should also contact the Embassy directly themselves to explain the situation. Someone else can make the initial contact but the Embassy will want to confirm with the legal next of kin.

If all this fails, transfer to a different hospital and doctor after first ascertaining the willingness of the receiving facility and doctor to honor the wishes of the patient (as expressed in his living will) and the family. Effecting this transfer will require the active participation of next of kin, or someone with a power of attorney, or whomever is paying the bills.

Speaking of which, if it is being paid for via insurance, the relevant insurance company should be brought into the loop at once and advised that the expensive treatment being given is contrary to the patients' and family's wishes. That may work miracles provided the hospital also has the written instructions and release of liability from the family.

[wpcoe]

Sheryl, thanks for that ton of advice! Also, thanks for clarifying that the Living Will law is still in draft form. I hadn't been able to track down whether it had been passed into law since the December 2009 reference in the linked article above.

Sadly, but mercifully, the injured person I initially posted about passed away last night.

I could write an anti-BHP rant, but I want to keep the focus of this thread on Living Wills/DNR in Thailand.

FWIW, the issue of transferring the patient to another hospital was broached with BHP, and amongst other things they said he had to wait until Monday, as such transfers cannot be done on Saturday or Sunday. (???)

The patient's Thai wife was on the scene and very involved with his care. The patient's Living Will from overseas had been faxed and presented at the hospital, and that's when the doctor said they could only withhold medication, but could not disconnect life support. It could well be their concern about litigation from overseas relatives driving a local hospital policy, but it was communicated as if it were the letter of Thai law.

Again, Sheryl, thanks for your valuable input. I'm going to forward a copy of your post to my friend. He and I have now had serious talks about our own Living Wills and your recommendations seem very reasonable and sound. Your (first and second <g>) points #3 are, I think, the critical points missing in the case I initially opened this thread with.

[wpcoe]

I received an e-mail from ThaiLawOnline acknowledging receipt of my query and stating they would get back to me next week about any new developments on the Thai Living Will law.

[Sheryl]

My condolences on the loss of your friend.

For future reference of others,

Transfers can be done any day of the week, and are, altho non-urgent transfers are often delayed to a work day because of reduced staff on weekends. However it is perfectly possibly to effect an elective transfer on a weekend.

The hospital was stone-walling, probably because they figured (correctly as it turns out) that the patient would die before Monday thus removing the need for them to deal with this issue.

If wife was on the scene, she had an absolute legal right to remove the patient from that hospital, Saturday or Sunday notwithstanding. Anyone faced with this sort of problem in the future:

1. Tell the hospital that you (the wife or next of kin) have decided to transfer this patient to hospital X right away. Don't ask, tell.

2. If the hospital stone walls, says it can't be done today (for whatever reason), tell them you will not pay another cent for care in this hospital, they do not have the family's consent to treat this patient anymore, and you will sue them for holding and treating a patient against the family's wishes. Say all this to the person in charge and go on up the chain of command until you either get satisfaction or have reached the very top.

3. Follow this up with a letter saying the same thing, sent by a courier service that requires signed receipt, addressed directly to the hospital CEO. If possible drafted by a lawyer/legal form, which could also advise on how to officially "serve" the hospital with this letter.

Notice that no more $ is forthcoming usually works wonders with this type of problem in private hospitals.

By turning it into a discussion of choice of hospitals you bypass the more contentious and complicated issue of stopping life support as there is no legal ambiguity whatsoever around the fact that people have the right to choose which medical facility they we\ant to be treated in/have their family member treated in.

[wpcoe]

Excellent information, Sheryl! Thank you very much.

[wpcoe]

As a follow-up, I received a reply from ThaiLawOnline (Isaan Lawyers Co. Ltd.):

"We made a quick search and couldn't find the regulation. We check on the website of the royal gazette and with google in Thai language.

The regulations was announced in the newspapers late in 2009 but it was still a project. You might find more information on the website www.thailivingwill.in.th but everything is in Thai."

[thailoneus]

Sheryl,

I am in the process of finalizing my Thai Will and have a couple of questions.

1. There have been many threads re. Wills which indicate the following ...(1) A Will should be done by a lawyer, but one should not trust any lawyer because they are in this for themselves. (2) You can do a Will yourself with the necessary 3 witnesses, and file it at the local Amphur Office.

I used Stickman's very old draft (from TV) and modified it. If I decided on option (3) , do you feel that its a valid Will in Thailand?

2. Can a pararaph/s be inserted into the same Will that details my wishes of a Living Will? All your points especially 3 and 3 make sense. Would it be appropriate to insert those as statements?

First of all, the Hospital is incorrect in stating that Thai law does not allow them to turn off life support. There is no such law on the books; this is their own intrepretation. However there is also no clear law stating that it is legal to do so except at the patient's own request, which is why some doctors and hospitals are fearful. Their concern is more along the lines of law suits than criminal prosecution. That said, there are many instances where Thai doctors and hospitals discontinued life support, but almost always these are cases where they have the clear permission of the family and enough trust in the family to feel assurred they will not later turn around and sue (which in fact has also been known to happen). In a case where no immediate relative is on the scene most doctors and hospitals will be very hesitant to take such a step; with a foreigner perhaps all the more so as they don't know what relatives this patient may have back home and what they might later do. Also, individual doctors vary in whether they personally feel comfortable with termination of artificial life support, and of course it also depends on the specific medical circumstances i.e. how clear it is that there is no possibility of survival.

The Health Act of 2007 specified the right of patients to refuse life support n advance through a "living will" but the directive operationalizing this law is still in draft form. See this pinned notice and links:

http://www.thaivisa.com/forum/Patient-Righ...;hl=living+will

Now in terms of this specific situation, and assuming it is in fact the case that there is no possibility, not even a slim one, of the patient recovering, here are my recommendations based on prior experience with such situations in Thailand:

1. Get a relative (preferrably the closest relative) on the scene if at all possible. Lacking that, get them to send a notarized power of attorney to someone in Thailand along with a notarized letter to the hospital to the effect that:

1. They have authorized so-and-so to act on their behalf (attach notarized copy of Power of Attorney)

2. They want life support to be discontinued given the terminal prognosis and the patient's own stated wishes (referencing and attaching the living will)

3. They release the doctor and hospital of all liability in so doing.

3. If these instructions are not followed they will:

- not pay for further hospital costs

- initiate legal action against the hospital for forcing unwanted treatment on a patient against their stated wishes (again referencing the living will) and against

the wishes of the family.

Ideally, hire a lawyer draft and send such a letter. If unable to afford this, send it directly but with copy to the relevent Embassy and to a lawyer or law firm.

Family should also contact the Embassy directly themselves to explain the situation. Someone else can make the initial contact but the Embassy will want to confirm with the legal next of kin.

If all this fails, transfer to a different hospital and doctor after first ascertaining the willingness of the receiving facility and doctor to honor the wishes of the patient (as expressed in his living will) and the family. Effecting this transfer will require the active participation of next of kin, or someone with a power of attorney, or whomever is paying the bills.

Speaking of which, if it is being paid for via insurance, the relevant insurance company should be brought into the loop at once and advised that the expensive treatment being given is contrary to the patients' and family's wishes. That may work miracles provided the hospital also has the written instructions and release of liability from the family.

[Sheryl]

I can't advise you re a regular will as I have no expertise in that area. I think it has been discussed in TV many times before, probably in the general forum, could try a search there.

regarding a Living Will:

1. No, do not insert into your regular will. Make a totally separate document. Your regular will com es into efect when you are dead, the "living will" needs to be employed while you are (at least technically) alive. Plus, you do not want a lot of clutter in that document, it is a new enough concept in Thailand without some future doctor or hospital administrator having to wade through other things to find the relevant part.

2. As previously noted, there is not yet a directive for how living wills should be worded etc although one has been drafted and should be issued soon. Yet another reason not to put it into another document as you might then need to revise everything.

3. You can if you like go ahead and do a living will now, understanding that it may have to be changed later once the guidance is out since still better than nothing. Be sure to have it witnessed and certified and with copies in both Thai and English.

4. Even more important that a living will in my experience is a health care power of attorney -- a document in which you provide someone else with the authority to make decisions on your behalf if you are incapacitated and unable to speak for yourself. Frankly -- speaking from experience in countries where living wills are well established -- doctors and hospitals don't really care that much what a person who they know will not recover wanted, even if legally documented, since that person can obviously not make any trouble for them. They are concerned with what the living may do. The presence of someone with a clear power of attorney threatening to sue counts far more than anything the patient signed his name to. (Conversely, I have many times seen a patient's living will disregarded because the next of kin asked the doctors to do so. Not really legal, but they are too afraid of what the next of kin may do if they don't obey). Obviously, anyone you give a power iof attorney to must be someone you trust and who thoroughly understands your wishes.

You can include a statement to the effect that you release the hospital from any liability in carrying out your wishes, and that you direct your (person with POA and/or next of kin) and insurance company not to pay for any costs that result from a failure to honor the wishes set forth in your living will --- but when such a situation arises it may still need a separate letter from your next of kin/POA for the same reason just mentioned: they, and not you, are the ones who would initiate such a lawsuit or refuse to pay. Also at that point the hospital can be referred to by name. So rehearse your next of kin/POA in all this ahead of time.

Keep in mind the need to review the government directive on living wills once it is released to be sure your complies and to revise it as necessary.

Since that directive is already approved in draft form, there must be some lawe firms who know what's in it. Maybe you can find one (if you do, post it here for the rest of us). There is also a Thai organization promoting the right of patients to make such decisions and they might be able to help advise, they have a website but it is entirely in Thai, google Thailand + "living will" and you should be able to find it.

[Mario2008]

Sheryl,

I am in the process of finalizing my Thai Will and have a couple of questions.

1. There have been many threads re. Wills which indicate the following ...(1) A Will should be done by a lawyer, but one should not trust any lawyer because they are in this for themselves. (2) You can do a Will yourself with the necessary 3 witnesses, and file it at the local Amphur Office.

I used Stickman's very old draft (from TV) and modified it. If I decided on option (3) , do you feel that its a valid Will in Thailand?

2. Can a pararaph/s be inserted into the same Will that details my wishes of a Living Will? All your points especially 3 and 3 make sense. Would it be appropriate to insert those as statements?

More inforamtion on Thai wills can be found here: http://www.thailawonline.com/en/inheritanc...law-living-will

They will soon update this info, see: http://www.thaivisa.com/forum/Farangs-Thai...83#entry3417483

for more information.