Death In Thailand By Old Age

[jaideeguy]

Some wording that is in my Pop's 'living will' that I will include in mine when it ever becomes law and if I'm still of sound mind

I finally tracked down my Pop's living will that was in my brother's possession and had him send it to me via PDF attachment. I wish I could simply copy and paste the paragraphs that are relevant at this time in his life, but will have to type it the slow old fashioned way.

4. If I loose the ability to communicate concerning medical decisions, but the condition is considered curable or reversible, I want treatment with the goal of accomplishing such cure or reversal, but leaving me without the need of custodial care and with freedom from constant pain and suffering. I want my improvement towards this goal evaluated periodically, and if such improvement is not evident, I want treatment discontinued.

5. The quality of my life is important to me. I do not want to be kept alive if I have a terminal condition, or if I loose the ability to communicate concerning medical treatment decisions, or if I have any other incurable or irreversible mental or physical condition which seriously or totally disables me with no reasonable expectation of recovery. This includes brain disease or brain damage such as I am unable to recognize people and to speak understandably or to communicate feelings other than pain or suffering or delusions. My condition does not have to be terminal in order for these instructions to apply. These instructions apply even if I could be kept alive indefinitely by medical treatment.

6. If I have any condition described in paragraph 5 above, I direct that all procedures which might prolong my life to be withheld or withdrawn, with only the performance of any medical procedures necessary to provide me with comfort or to alleviate pain. Specifically, but without limiting myself, I do not want surgery, medication [except for pain and suffering], cardiopulmonary resuscitation, antibiotics, kidney dialysis, blood transfusions, radiation or chemotherapy or a mechanical respirator.

7] I have also considered whether I want artificial [including tube] feeding and fluids to be provided, and my decision is shown by putting my mark or initials in the space provided.....

[his choice]

I do NOT want my life prolonged by tube or other artificical feeding or fluids if my condition is as stated above in paragraph 5.

The above are the exact words of Pop's living will [signed, witnessed and when he was of sound mind] that I would like to honor, but we are living in Thailand where there is now no living will and they do not honor a LW from another country. There is a new Thai LW law drafted that MAY come into law by June 2011.

Seems to me that 'quality of life' and 'don't go to extreme heroics' are the essence of his wishes.

[jfchandler]

Jaidee, a couple of thoughts about this...

1. When the final form of the forthcoming Thai regulations on living wills are public and known, there may well be some format or wording required for one's living will to meet the standards of the Thai law... You can't automatically assume that language used elsewhere will necessarily suffice here... I think we'll have to wait and see on the outcome of the law, or more particularly, the final regulations promulgated putting the law into effect.

2. For my tastes, I had the feeling the language you quoted above seems a bit complicated with too many variables and too many things that could be left open to interpretation or options by others. I think my preferred form would be a bit more direct and straightforward, along the lines of, ...In the event I am unable to communicate my own wishes at the time, I do not wish any extraordinary measures to be taken for longer than a period of XXXXXX to prolong my life, if I am otherwise unable to survive unassisted.

Probably somewhat more detailed that that and covering some other potential scenarios.... but more in the direct, declarative style... I'll be interested to see what the final regs say and how they say it.

[anterian]

I would agree the language in that sample of a living will was too complex, too many variables.

What is important to me is sensory input, how much could I lose and still have an acceptable quality of life? Taste and smell I could easily live without, but sight and hearing are a different matter, as is the ability to speak and feel.

Sight I feel is the most important sense to retain, then hearing, then speech.

Mobility is also important, independence in simple matters like washing, using the toilet and eating.

I would give each of these factors a loading, say 10 for sight, 9 for hearing, 8 for speech, I would adjust these figures such that they totalled 100.

Then I would have to decide how low that figure would have to drop before life was no longer desireable, 50%, 20%? This is the problem, as we get older we adjust and our expectations change.

[jsflynn603]

I've addressed more than "death by old age" here and hope that is ok because it is such an important issue.

I'm not afraid of dying; I just hope that I'm not there when it happens!

I'll admit that many years ago I was fearful of death. Then after spending part of a semester tagging along after a in-home hospice nurse, that fear dissipated. Modern pain control, (opioids and their synthetic analogs) and other appropriate medications along with some education (for the surviving family, such as what to expect and what not to fear, i.e. agonal breathing (the odd and frightening end of life breathing pattern)) has made "end of life" pretty comfortable for most in Western countries. These days I envision spending my last years in LOS and now I'm fearful of dying again.

I'm not even sure it's a scenario like Sheryl pointed out where medicine simply lags behind the Western world. I think it's fear of misuse of drugs. It might be fair to say that what I might consider "corruption" in Thailand, might better be thought of as "the way things work here, and the way they have for centuries." Perhaps that environment leads to what I almost think is a radical fear of illegal drug use.

Comfort at end of life, especially for those with cancer, is often directly related to pain control and thus related to opioid medications. All of these which include morphine, oxycodone, hydromorphone, etc. have extremely high potential for abuse. Combine this potential for abuse with Thailand's culture and it seems that a transition towards adoption of opioid's for palliative pain relief is not just around the corner—but it may be that it may never be adopted.

Sheryl gave some good practical advice.

Indeed there are plenty of pain control meds for palliative care such as fentanyl patches. Fentanyl also comes in a lollipop form and a buccal form (sublingual or tucked back in the cheek cavity) but fentanyl bucccal tablets are even more restricted then fentanyl patches so this will never be an option. Fentanyl is about 100x more potent than morphine and its potency brings problems. The fentanyl buccal tablets are only used for "break-through" pain and only if a person is on opioid's already. The reason is simple (and here, sadly paradoxical) you give a patient one buccal tablet for break-through pain—if after 30 minutes the pain is not relieved you give another. Give the patient a third and there is about a 30-50% chance of death due to respiratory depression. Morphine and synthetic opioid medication use at home will probably not be a likely scenario in Thailand.

Buddhism may be partly involved here, after all, one hears "life is suffering." If suffering is normal then "mai bpen rai"("no problem"). I suspect that in years past opium smoking was a common ticket to tranquility (for the dying and for those who also are present since the opium comforted the sufferer). But this route seems closed and will stay closed. Buddhism forbids the taking of life but it is ok to eat meat, as long as the person did not kill the animal. "Out of sight, out of mind," is culturally inherent here.

Tokay has posted: "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." If the death was due to old age (multi-organ failure) I'll accept the statement, but with many cancers most will die unpleasantly without opioid medications.

Nobody wants to hear that Grandma died a horribly painful death—nobody even wants to remember, if that was the case—so one virtually always hears that a person died pleasantly, even if this was not the case. It's a real issue.

Tokay added: "I'd go out of my way if someone wanted drugs, even illegal ones." I can appreciate this point of view and would be pleased if he was my relative, but here in LOS the "out of my way" place might be a mosquito infested prison.

Jaideeguy wrote: "Who knows......this info may be of some use to others here on thaivisa when the time comes........" Indeed, for each of us who decide to stay here, at some point it will be an issue.

I can only hope that if home hospice does not come into being in Thailand, that small "home environment-like" hospice entities might come into being as these work quite well in America and don't have the expense or the drawbacks that being in a hospital does. Since such places have two or more staff around, narcotic control is much easier and this could lead to more appropriate end of life usage. Though not at home, these places can be very home-like which is comforting for the patient and for the family.

From a practical point-of-view if you can squirrel away enough money to get you back to a place where good palliative care is available is a wise decision. If cancer is involved and it is a type where pain is an issue (especially cancers that metastasis to the bone) try to get out of Thailand. If it's a death due to old age, pain is not likely to be a huge issue, in this case try to find a good, experienced nurse.

We focus on the pain issues, but in my experience one end of life situation comes to mind: the poor guy was just outside death's door (he was expected to live only a few days) and he was absolutely miserable. He didn't mind the pain he was used to, but in this case he was horribly constipated, a more or less easily correctible situation. He didn't seem to mind dying, but he was sure unhappy about being constipated. A nurse visiting every few days would pick up on the cause of this fellow's misery, and know how to correct it, whereas the family might not.

I like the way many in the Republic of Philippines deal with this issue. A family (and often extended family) will put one aspiring student through medical school and then the family ends up having a personal physician. I suspect that in Thailand members of a physician's family and close friends die rather comfortably here. A small community group of farang living in Thailand might consider this option, though the payback is uncertain.

Jaideeguy though your issue is not one due to terminal illness, still, a good book might be: "A Good Death - A guide for patients and carers facing terminal illness at home by Dr Elizabeth Lee, published by Rosendale Press (10 Greycoat Place, London SW1P 1SB, tel 020 7 222 8866), 1995, 188 pages, £8-99 (£1 extra for p&p), ISBN 1 872803 16 4. See: http://www.globalide...aft/B&A-13.HTML (other books are discussed also)

An excerpt from the above link:

The Natural Death Centre has many books in its library on care of the dying. .... top-scoring books, in my no-doubt biased view, are: The Natural Death Handbook which has more details on aspects such as Living Wills, financial preparation for dying, family-organised funerals and Near-Death Experiences), Coming Home by Deborah Duda (American and more spiritual than Dr Lee's book), Green Burial by John Bradfield, Grace and Grit by Ken Wilber (about the death of his wife from cancer) and Who Dies? by Stephen Levine (on the theme of conscious living and dying).

Thai Law for Foreigners is a book that I started to read before coming to Chiang Mai and wish I had brought it with me. The book stinks! I mean that the book, direct from the publisher stunk so badly that I had to put it, with pages fanned open" over a radiator for several months before I could stand to read it. Eventually whatever in the ink dissipated and once it became non-offensive I found that it was a rather delightful read (though I have only read part of it) and not anywhere near as "stiff" as I had expected. I vaguely remember that there was a section on death and dying in Thailand aimed at the time of death and after, such as death certificate and cremation--very important aspects to understand before a death. For instance in Thailand, from what I understand, burial is almost an impossibility.

I heartily recommend that a person does her research long before it is necessary. I was lucky knowing that my father would die within a year and so I had plenty of time to look at what was available. His funeral expenses in America came only three thousand dollars--but I came across undertaker after undertaker where it was quite evident that the cost could have been ten times the price. I hate to say it but it is pretty obvious to me that (some, many?) the undertaking business here in America will prey upon those who are unprepared. I was told that embalming was necessary--yet in that state it was not. The range of casket and their prices in my estimation was surreal. Even the cost of the funeral home where visitors paid their last respects varied by over $4,000 and frankly the +$4,000 was not as nice as the one that ended up costing less than $800.

Lastly, this post was a bit of a wake up call for me--As we age, each year statistically, death is more and more likely and I realize that I have work to do. My father's death was organized and frankly, though it might seem odd to hear, the aftermath was fun--really. His death was long expected, everything was in order and I even had the funds in hand (his funds) to pay for everything. Though there was sadness, the gathering of family and friends was a very positive experience--as it should be.

My mother's father died without such organization and it turned out to be a horrific mess with family members sneaking into his house in the night to ferret away what they "thought" should be theirs--to this day some in the family still will not talk to the others. So if you want certain items to go to certain people--spell it out, or better still--gift it. We came into this world with nothing and we will leave the same way. Better that family and friends get one's life work rather than the uncle that not too many American's enjoy--Uncle Sam. (Though in reality sometimes it's more a state by state issue, and of course a country issue if you aren't American).

[jfchandler]

Good post...