Death In Thailand By Old Age

[jaideeguy]

First, I would like to request that the mods leave this post on the general topics forum for a day or so before moving it to the 'health forum' so it will get a little more exposure.

Without the help of hospice here in LOS, I would like to find out what others have observed or experienced re: dying by natural causes at home Thai style.

I asked my Thai wife what she knew and she says that most Thai old folks just fade away at home and don't go to any heroics unless there are complications and then an ambulance is called to take them to the hospital....then they return home [if they are lucky].

My concern is because I am the primary caregiver of my 92 yr old Pop and he is getting closer to death and with the absence of the western luxury of hospice I will have to deal with it my self. He has made it clear that he doesn't want to [ever] go into the hospital and wants to die at home and I would like to honor his wishes.

A very helpful member of this forum informed me of the western hospice procedure and it involves several drugs to reduce the pain and agony and to make the 'transition' easier, but some of the drugs may be difficult to impossible to get here for home use and I would like to get some details on Thai style death at home.

Who knows......this info may be of some use to others here on thaivisa when the time comes........

Thanks in advance for only serious replies.

[mstribling]

Well we had a cousin who died of aids in her home. She was just placed back in the kitchen with a mosquito net thrown over her.

We have an aunt dying in Rayong right now. They are having her taken off life support and brought home.

No "transition" drugs that I'm aware of. Maybe some opium up north perhaps.

From my observations your on your own.

[jaideeguy]

Opium up North......no way!! We are in Chiang Mai [formerly the golden triangle] and those kind of drugs are harder to obtain [legally] here than in the US because of the heavy DEA influence and the war on drugs. You can't get anything more potent than paracetamol for a tooth extraction.

"your on your own"....so true with many things that we take for granted in the west.

[mstribling]

I mean't the locals may get some opium from up north, illegally to aid in the ease of suffering. Your absolutely right nothing OTC.

I can tell you that dying in Thailand sucks for Thais.

We just got back from seeing our aunt in the general hospital in Rayong. <deleted>*k that!

[robblok]

Hmm its good to see many people agree about helping someone on its way. When its my time and im hurting i hope someone would send me on my way just like they do in Holland my home country. We miles ahead there in comparison with the rest of the world.

Wish i could help you recently the father of my wife died. I think they gave him something for the pain they kept him asleep while they waited for him to die (Did not speed it up). They just stopped giving new blood (he had destroyed his organs with drinking too much)

[jaideeguy]

Yeah, living in LOS is good, but it seems that dying in LOS is not too good. I think that lots of their disregard for the suffering has to do with the Buddhist belief that 'we are here to suffer and there is no speeding it up'.

Excuse me, but I don't believe in anyone's suffering.

You can't even euthanize a dog that is suffering from a terminal illness.

[mstribling]

That's not really what is meant by the suffering but I understand what you mean.

This is odd. Aunt is kept alive by a breathing apparatus. Her son has decided it is time for her to die. But they have to go to the police station to get permission to take her off support. Odd but interesting.

[robblok]

That's not really what is meant by the suffering but I understand what you mean.

This is odd. Aunt is kept alive by a breathing apparatus. Her son has decided it is time for her to die. But they have to go to the police station to get permission to take her off support. Odd but interesting.

Its good that there is the option to end it however it would be better for the aunt if some sedative is given instead of just taking her of the breathing apparatus. It would be more humane.

[mstribling]

I agree.

[jaideeguy]

Here is a short list of what hospise uses in the west and I will try my best to source them out legally.

Halperidol for restlessness

Lorazepam for restlessness

Morphine Sulfate for wheezing

Hyoscyamine for secretions

and there are more

Does anyone know of the availability of these drugs here??

[jaideeguy]

I might add that Thailand has finally drafted a living will, but won't go into effect untillater in the year, if ever......

[Tokay]

Opium up North......no way!! We are in Chiang Mai [formerly the golden triangle] and those kind of drugs are harder to obtain [legally] here than in the US because of the heavy DEA influence and the war on drugs. You can't get anything more potent than paracetamol for a tooth extraction.

"your on your own"....so true with many things that we take for granted in the west.

Most of the Thais I know who died of old age or cancer died at home, usually in some sort of pain even with some basic meds the local doctor gave them. None of them died unpleasantly. But I can't imaging dying being good any way you slice it unless you are lucky enough to go in your sleep.

Edited January 25, 2011 by Mario2008
comment about illegal drugs removed

[Mario2008]

Moved to health forum

[FBN]

Afraid that none of the drugs required in this situation can be administered legally (in Thailand) outside of a hospital environment. Morphine usually only in an ICU or high care unit environment at that. Lorazepam you may acquire from a hospital after assessment and prescription but probably not on behalf of any one other than yourself.

[jaideeguy]

That's not really what is meant by the suffering but I understand what you mean.

This is odd. Aunt is kept alive by a breathing apparatus. Her son has decided it is time for her to die. But they have to go to the police station to get permission to take her off support. Odd but interesting.

That's really sick, cruel, barbaric and needless in this age IMHO. and anoter reason to stay out of hospitals........ if possible

[CM4Me]

Check out this site, maybe has some good advise http://www.exitinternational.net/

[Wrong Turn]

Opium up North......no way!! We are in Chiang Mai [formerly the golden triangle] and those kind of drugs are harder to obtain [legally] here than in the US because of the heavy DEA influence and the war on drugs. You can't get anything more potent than paracetamol for a tooth extraction.

Sorry to be off-topic, but I want to learn more about the DEA's intrusion onto Thai culture and Thai law.

Can someone point me in the right direction. (I do not like the DEA, by the way.)

[Tokay]

Afraid that none of the drugs required in this situation can be administered legally (in Thailand) outside of a hospital environment. Morphine usually only in an ICU or high care unit environment at that. Lorazepam you may acquire from a hospital after assessment and prescription but probably not on behalf of any one other than yourself.

The way I see it, I'm dying. Screw what's legal. Bring me drugs to ease the pain.

I'd go out of my way if someone wanted drugs, even illegal ones, if it would help them die in a little less pain.

[nephron]

One of the big impracticalities is that people at the very end are often unable to take oral medications. Getting injectable versions, and getting someone able to deliver through a non-oral route, may be difficult.

That said, if someone is able to take oral medications:

Tramadol as a painkiller seems to be widely prescribed- although it may possibly contribute to more delirium. If pain was a large issue, that might be a possibility.

Possibly lorazepam or one of the benzodiazepines could be prescribed if the patient could be brought into the hospital as an outpatient? It could be impractical to bring someone close to the end to a hospital for outpatient care, though.

Hyoscine butyl bromide is widely used for abdominal cramps as well as reducing secretions, so possibly available even over the counter.

Haloperidol is primarily an antipsychotic, probably not a "restricted" drug per se, but doctors may be reluctant to prescribe without seeing a patient, especially outpatient and especially given its sometimes nasty side-effect profile.

[jaideeguy]

One of the big impracticalities is that people at the very end are often unable to take oral medications. Getting injectable versions, and getting someone able to deliver through a non-oral route, may be difficult.

That said, if someone is able to take oral medications:

Tramadol as a painkiller seems to be widely prescribed- although it may possibly contribute to more delirium. If pain was a large issue, that might be a possibility.

Possibly lorazepam or one of the benzodiazepines could be prescribed if the patient could be brought into the hospital as an outpatient? It could be impractical to bring someone close to the end to a hospital for outpatient care, though.

Hyoscine butyl bromide is widely used for abdominal cramps as well as reducing secretions, so possibly available even over the counter.

Haloperidol is primarily an antipsychotic, probably not a "restricted" drug per se, but doctors may be reluctant to prescribe without seeing a patient, especially outpatient and especially given its sometimes nasty side-effect profile.

Thanks for the info nephron....it seems quite accurate but can some of the meds be in a transdermal patch form?? Maybe only in the west??

Still not too much info on Thai style hospice or if any meds, herbs or other folk remedies are or were used to help with the transition??

[Sheryl]

It can only be pre4scribed by a doctor and obtained from a hospital pharmacy, but oral and sublingual forms of morphine and morphine-like drugs (temegesic being most common) and patches (e.g. fentanyl) can legally be used as an outpatien provided it was so prescribed and obtained.

[jaideeguy]

Thanks again Sheryl.....

[Sheryl]

Haloperidol is OTC in Thailand in oral form, controlled if injectable. Lorazepam and all serious analgesics are controlled.

As another poster mentioned, oral administration is not feasible in final stages. IV is best but Thailand is not yet in the modern era when it comes to home health care period let alone hospice which it doesn't even have in hospitals.

There are 3 ways you can manage to use oral preparations in a person no longer able to swallow (and these are sometimes resorted to in Western hospice care especially programs trying to keep costs low):

1. Almost anything given orally can be administered sub-lingually (place under the tongue and dissolve) provided it is not enteric coated or the pills too large. I have successfully given, for example, morphine tablets sublingually to dying people with adequate results. The previously mentioned temegesic tabs are available in Thailand in tiny tablets specifically intended for sub-lingual use. Not as good as morphine but a close second.

2. Likewise almost anything that can be given orally can be given rectally as long as not enterically coated and as long as the person is not having frequent diarrhea. To turn it into a suppository, embed it in a bit of butter or margarine. Put on a glove and insert , push it up about the length of your index finger.

3. A tube inserted into the stomach -- either through the nose or through an incision into the stomach directly (gastrostomy tube) makes it possible to give any type of m=oral medication even when the person is unconscious or semi-conscious. However needs a medical person to insert, and if through the nose it is uncomfortable for the patient so best resorted to only after they aren't too aware. The tube into the stomach is much more comfortable once in place, usually doesn't bother people at all, but the insertion involves a minor surgical procedure.

Your challenge is to find a hospital-based doctor who understands anything about palliative care to prescribe those drugs which are not OTC, as many of them can only be given through a hospital pharmacy.

For sure they aren't going to do so without seeing the patient so you would do well to bring your father to see one while it is still possible to transport him (i.e. bring for putpatinet5 consultation, not admission). Unfortunately I cannot suggest a doctor but perhaps your GP, who I gather is supportive, might be able to.

I have to take issue with the idea that this problem has anything at all to do with Buddhism. I think it is just a case of the Thai medical profession being very far behind the times. It was exactly like this in the US when I first trained as a nurse. Several highly publicized books and strong advocacy by a few people, backed by public opinion, led to changes. And, ironically, the pressure to cut medical costs/maximize profits, which generally have hurt quality of care, helped in this regard especially in terms of more things being done in the home. There are things now routinely done in the home -- by family members trained and sporadically supervised by occasional nurse visits -- that 30-40 years ago weren't even allowed in hospital wards, only ICUs.

There have in the last few years been some stirrings towards change in Thailand, a few workshops among medical professionals on the topic. now the new Living Will provisions. There is a even a Thai advocacy group pushing for such reforms. It is going slowly though and obviously reforms will come too late for your Dad. Hopefully not too late for you an me though when our times come....

I'm afraid traditional Thai approaches that reduce suffering (which I gather was what you hoped to find) aren't much if anything. It is either die at home in pain or die in a hospital where you may get adequate pain killers but will also have your death unnecessarily prolonged and be subject to invasive and unpleasant measures to no benefit.

A TV member recently went through this with a spouse dying of liver cancer. Got morphine in hospital but sent home with milder analgesia. Despite paying a lot of money and bringing in nurses from a pricey "international" hospital, when it got to where his pain needed IV morphine, the hospital's response was that he had to be admitted. the very idea of doing it in the home -- even by hospital affiliated RNs under doctors orders -- was alien to them.

[jaideeguy]

Again, thanks Sheryl for your experience and input. I finally did manage to connect with a Dr Morgan [Thai dr married to falang and speaks perfect English and she is making a housecall this morning to advise me on Pop's latest problem......possible staph infection on his legs even tho he is on the Bactrim]......immune system failure?

And re: pain, Pop says he is not in pain as long as he is in bed, but when transfering or anyone touching him his pain is quite obvious.

Re: Buddhism being responsible for not supporting Hospice........an impression that I made from my wife's statement that we are all here to complete our suffering before moving on.

Re: morphine......Pop's GP did Rx me 10 morphine tabs......not sure of the strength at this moment.

"It is either die at home in pain or die in a hospital where you may get adequate pain killers but will also have your death unnecessarily prolonged and be subject to invasive and unpleasant measures to no benefit."

both Pop and I would prefer to die at home and I am aware of the Thai corporate med trap and who would want to spend their last days in a hospital room??

[Sheryl]

If you have morphine tablets, these can be given sublingually as described before so you are in better shape than most. As to dose, elderly patients without prior use of it usually respond to very low dosing so I'd start with just 1 tab and then adapt to response. From the sounds of it, not needed know but when he gets to the final stages it will be needed, if not for pain then certainly for troubled breathing. It will not stop the breathing from being labored but it will relieve the anxiety associated with that and the urge to struggle to breath will be reduced, you'll see by his facial expression that he looks much more comfortable and peaceful.

May or may not need more than 10 tabs when it gets to that stage, depends on how long that phase lasts and impossible to predict. To be on safe side sometime before then you'd do well to ask for a refill, and better not wait too long as doctor may not be willing/able to prescribe unless he sees the patient at the hospital (outpatient) so don't leave it too long, do while still possible to bring him there.

That leaves the hyoscine, which as mentioned you can get OTC even (apparently) in injectable form, question is can you get the peripherals (needles syringe) and do you or anyone in family know how to inject. (An insulin dependent diabetic would know, for example.The injection can be subcutaneous (just under the skin), exactly as insulin is injected. This is only for the final stages and only if you hear gurgling type noises ("death rattle"), it dries up the mucus which at that point the patient is no longer able to cough out or swallow. Makes the patient more comfortable and the situation less distressing for the family to hear/watch.

[anterian]

In England I self prescribe, although my GP has to write the the prescription. If I need a hospital test, for example PSA, I simply turn up and request it. As I am 75 years old all this is free of an charge.

In Thailand the main difference is that I don't need a prescription and I have to pay for medications and services.

I have seen several people die in my village simply because they could not afford adequate treatment or could not be bothered to seek it.

I object strongly to cremation, I wish my nutrients returned to the soil from which they came rather than polluting the air. So I will either die in England or be returned as a corpse

[rixalex]

In England I self prescribe, although my GP has to write the the prescription. If I need a hospital test, for example PSA, I simply turn up and request it. As I am 75 years old all this is free of an charge.

In Thailand the main difference is that I don't need a prescription and I have to pay for medications and services.

I have seen several people die in my village simply because they could not afford adequate treatment or could not be bothered to seek it.

I object strongly to cremation, I wish my nutrients returned to the soil from which they came rather than polluting the air. So I will either die in England or be returned as a corpse

I have to say, i didn't see that smiley coming.

[jfchandler]

Anyone have any links to practical, useful and/official sites re the Thailand living will issue?

[FBN]

Anyone have any links to practical, useful and/official sites re the Thailand living will issue?

Check the Pinned Topic "Patient rights" in this forum.

The following link: http://thailawonline.com/en/family/living-wills-in-thailand.html has the legal info.

[jfchandler]

Thanks much for that link... It seems to have all the essentials....