Friend wants no resuscitation

[cheeryble]

Hi

I have an friend in his mid 80s who has been talking to me and a couple of mutual physician friends about leaving this life by design.

He has learned how to do it.

He has various health concerns but is not what you'd say suffering pain just annoyance at lack of mobility and for another example he has a shaking hand problem for decades and cant type an email say.

He is particularly concerned about his eyes. He has macular degeneration which is too far gone in one eye and the better eye is being sustained with occasional injections. I have set up his computer as best I can with font enlargement programs but it's clumsy to say the least. I have promoted audio like podcasts and audiobooks but he still has great concern about his eyes.

He doesn't speak Thai and also feels that if he was blind he is in the wrong place for simple communication.

He is very well looked after by a wife but I dare say may be considering himself a burden.

He has previously spoken of finishing his life......which given triple bypass, valve replacement etc, he says is probably limited to 5 years (I agree that is probably his limit)

He is extremely intelligent and entirely rational, he is not depressed (says that himself and he is a former clinical psychologist), so I don't see that I can tell him his decision is wrong.

Anyway.

He has decided that given the advances in mèdical science coming thick and fast to hold off on any purposeful demise, but he is in any case concerned that if .....well, when.....he has a major medical event he should not be kept going against all the odds.

He has asked me to be his voice when this happens.

I in turn have replied I don't know about the law here.

I might add I have previously made an agreement in England not to resuscitate my father and he died at 89 unconsciously with no discomfort of any type as I would wish for anyone. Only a week earlier he had been driving himself out every day and making his bets on the horses. Perfect.

So I did a search for living will on TV and nothing came up.

Could anyone inform me about all this.

Is no resuscitation or a living will possible?

Can I have any authority like power of attorney?

Thanks!

Edited September 15, 2013 by cheeryble

[Sheryl]

This is a very new concept in Thailand. A law was passed only recently, and the regulations thereunder came into effect only a year ago. You can get an unofficial English translation of those regulations at this link http://www.udonmap.com/udonthaniforum/living-wills-new-regulation-for-thailand-t19632.html

Your friend should definitely have the relevant documents prepared by a lawyer. And you need to be prepared for Thai doctors to be unfamiliar with the new law and to have had no past experience with it so it may be tough going. The new law is still largely unknown to the thao publisc, it's only a handful of farnags that have drawn up a living will to date.

In short, posisble but it will not be simple as in the West. Thailand is more than 50 years behind the times with regard to this sort of thing (as well as with regard to the use of pain killers etc in end-of-life care).

Best for your friend to find a doctor who understands his wishes and indicates a willingness to abide by them well in advance. Shop around as necessary to find the right doctor. Be sure that doctor has a certified copy of the advance directive naming you and has clearly indicated his willingness to abide by it, and then only ever let your friend be taken to a hospital where that doctor is on staff, nowhere else.

And be prepared to have to be assertive on his behalf. It is not hopeless, since there is now a law and regulatory framework in place, but it may be hard. You may even have to ask the lawyer who drew up the documents to intercede though that is not likely to require much more than a few phone calls.

All the main legal firms geared towards expats claim to be able to draw up the necessary documents, but if any readers have had personal experience with one or the other it would be good to get some firsthand recommendations.

[Gladiator]

Cheeryble,

I have sent you a PM

Gladiator

[JohnC]

http://thailawonline.com/images/documents/living_will_regulation_%28Thailand%29_English_by_Isaan_Lawyers.pdf

http://www.thaivisa.com/forum/topic/433055-living-wills-in-thailand-new-regulation/

Pretty much what Sheryl has told you.

[cheeryble]

Hi Sheryl

thanks for your reply which could not have been more helpful.

I know and am friendly with a suitable Thai hospital physician (in fact introduced my friend to him as a GP and my friend, who used to train physicians, liked him a lot).......so after swotting the literature will have a chat with him at my own next visit.

On the run right now....Gladiator, will reply to PM later thank you

Edited September 15, 2013 by cheeryble

[Suradit69]

I have a friend in the US who was just admitted to hospital following a heart attack. His age and numerous other conditions suggest that he will not last much longer. His wish and that of his family is that the DNR, Do Not Resuscitate, option be in place, which restarted me thinking about that issue for myself in Thailand. A search on TV produced a couple of short threads started some time ago, including this one.

Like the person mentioned by the O/P I have the wet form of macular degeneration, so far only in one eye and its progression has been slowed/halted by injections of Avastin at Bangkok Pattaya Hospital. While my health otherwise is fairly good, I have thought about eventually being in a situation where I would want to depart gracefully rather than prolong a dubious existence on all sorts of mechanical life support.

Also thought I remembered seeing a note from Bangkok Pattaya Hospital on the subject of living wills and indeed found this at their website, the full newsletter is available at the link below the quote.

So to the ‘Living Will’. It is only recently that the Thai authorities have authorized this document, allowing you to have a say in ‘how’ you want to slide out. This covers your feelings on Cardiac Resuscitation, Tracheostomy, Mechanical respiration, Feeding tube and others. For example, if you are in a terminal situation, do you want someone jumping up and down on your chest to restart your heart? For what?

...

We have copies of the new Living Will form available at the hospital, where you can lodge it with our registration staff for inclusion in your clinical records

http://www.bangkokpattayahospital.com/enewsletter/eNews_1stJuly11.html

I'm totally OK with the realization that sometime in the next 5 minutes to 15 years I'll certainly "shuffle off this mortal coil," as Hamlet said, and some mornings I feel that the sooner the better. But usually after a mug or two of coffee I decide I can hang on a bit longer. So I am a tad leery about filling in a Living Will at BPH, where I can "lodge it with our registration staff." While I assume that most doctors BPH would apply my instructions with caution, I wonder if such decisions are made in consultation with several other physicians or some established panel? I'd rather not leave it to some overly enthusiastic emergency room doctor who's gone 48 hours without much sleep. On the other hand, I would like to have something in place that would not leave me vegetating in limbo (although some of those above mentioned mornings I feel I might already be in pseudo-limbo).

Anyone have any experience or inside information on how these things have actually been handled at the bigger "international" hospitals?

Edited April 18, 2014 by Suradit69

[Sheryl]

This is a very new thing so experience with it in Thailand is limited, but I can tell you that anywhere in the world, it is important that you have a person willing and able to advocate on your behalf, preferrably a relative. In the West "health care power of attorneys" are used to designate the person you want to make decisions on your behalf, and are much more effective/important than advance directives (dead people don't sue hospitals or otherwise make trouble - live ones do. So the person with POA has far more influence than a document signed by someone not expected to survive.). In Thailand there is AFAIK no system for Health Care POAs per say, though you can (and should) make a durable power of attorney covering all your affairs in someone's name unless you are married and comfortable having your spouse handle everything.

In my experience Thais are not as legalistic as Westerners and will tend to accept the legitimacy of the views of any close relative who is present and speaks up without expectiung to see a written POA. They may not give the same weight to a non-relative (sometimes even if empowered with a legal POA). It is sometimes a good idea, if a friend is filling this role, for them to present themselves as a brother/sister (assuming they are also farang....after all, we all look alike!)

That said, having completed a Living Will certainly gives your health care advocate, whomever that may be, a good leg to stand on. Obviously you need to be sure s/he understands the concept and your wishes, and has a certified copy of the living Will.

If you have a primary physician -- or a specialist who is handling a potentially life threatening condition of yours -- discuss this issue with him/her and provide the doctor with a certified copy of your living will, assuming they are comfortable with the idea. If they are not -- change doctors. Note that this does not remove the need to have someone be your advocate. A Thai doctor is very unlikely to be comfortable acting on a Living Will without having gotten a "go ahead" from a relative.

If you do not have such a doctor and are old enough (or have a serious medical condition such that) this is a matter likely to arise in the forseeable future, it would be worthwhile to shop around now and find one, making their willingness to honor a Living Will one of your criteria.

I don't see any point or advantage to keeping a Living Will on file with an institution. Not concerned that they will misuse it, just that it will very likely be overlooked -- Thai doctors are often not at all thorough in reviewing things that are in the chart from before the current illness/hospitalization. Nor are they usually very comfortable acting on the basis of a document on a sensitive matter that they have not been able to discuss first with the patient...and in many cases the doctor may never before have even seen a living will.

I would not worry abut doctors being "too eager" to declare your condition terminal/let you die. In Thailand, any errors will be very much in the opposite direction - as that is what they are used to doing.

So: choose a friend or relative (and if possible another one for back-up) who you trust, ask them if they would be willing to serve in this capacity and if so explain to them thoroughly what your wishes are. If they are of your own age, you might make it a mutual arrangement. Would also be wise to acquaint them (or other person if you prefer to split out the functions) with the basics of your financial and legal affairs and a durable power of attorney that takes effect if you are incapacitated. Bear in mind that there are an almost infinite number of scenarios that can occur and in my experience it will be one you didn't think of that will, so while you may not have any in mind in which there would be a need for someone to be able to pay your bills or access your bank account, trust me -- there can be.

[Suradit69]

This is a very new thing so experience with it in Thailand is limited, but I can tell you that anywhere in the world, it is important that you have a person willing and able to advocate on your behalf, preferrably a relative. In the West "health care power of attorneys" are used to designate the person you want to make decisions on your behalf, and are much more effective/important than advance directives (dead people don't sue hospitals or otherwise make trouble - live ones do. So the person with POA has far more influence than a document signed by someone not expected to survive.). In Thailand there is AFAIK no system for Health Care POAs per say, though you can (and should) make a durable power of attorney covering all your affairs in someone's name unless you are married and comfortable having your spouse handle everything.

In my experience Thais are not as legalistic as Westerners and will tend to accept the legitimacy of the views of any close relative who is present and speaks up without expectiung to see a written POA. They may not give the same weight to a non-relative (sometimes even if empowered with a legal POA). It is sometimes a good idea, if a friend is filling this role, for them to present themselves as a brother/sister (assuming they are also farang....after all, we all look alike!)

That said, having completed a Living Will certainly gives your health care advocate, whomever that may be, a good leg to stand on. Obviously you need to be sure s/he understands the concept and your wishes.

If you have a primary physician -- or a specialist who is handling a potentially life threatening condition of yours -- discuss this issue with him/her and provide the doctor with a certified copy of your living will, assuming they are comfortable with the idea. If they are not -- change doctors. Note that this does not remove the need to have someone be your advocate. A Thai doctor is very unlikely to be comfortable acting on a Living Will without having gotten a "go ahead" from a relative.

If you do not have such a doctor and are old enough (or have a serious medical condition such that) this is a matter likely to arise in the forseeable future, it would be worthwhile to shop around now and find one, making their willingness to honor a Living Will one of your criteria.

I don't see any point or advantage to keeping a Living Will on file with an institution. Not concerned that they will misuse it, just that it will very likely be overlooked -- Thai doctors are often not at all thorough in reviewing things that are in the chart from before the current illness/hospitalization. Nor are they usually very comfortable acting on the basis of a document on a sensitive matter that they have not been able to discuss first with the patient...and in many cases the doctor may never before have even seen a living will.

I would not worry abut doctors being "too eager" to declare your condition terminal/let you die. In Thailand, any errors will be very much in the opposite direction - as that is what they are used to doing.

So: choose a friend or relative (and if possible another one for back-up) who you trust, ask them if they would be willing to serve in this capacity and if so explain to them thoroughly what your wishes are. If they are of your own age, you might make it a mutual arrangement. Would also be wise to acquaint them (or other person if you prefer to split out the functions) with the basics of your financial and legal affairs and a durable power of attorney that takes effect if you are incapacitated. Bear in mind that there are an almost infinite number of scenarios that can occur and in my experience it will be one you didn't think of that will, so while you may not have any in mind in which there would be a need for someone to be able to pay your bills or access your bank account, trust me -- there can be.

Thanks for your comments.

Unfortunately no relatives in Thailand and the person who is the beneficiary of my Thai will regarding possessions is unlikely to be forceful in such matters. I do have several doctors who I see regularly at BPH, including the one treating my Mac Degen and a cardiologist, the latter being the only one so far who is likely to make any life & death decisions. I wouldn't want to change him solely because of his views on terminal care since I've been seeing him for a number of years ... so I guess I will need to hope that I will have some fair warning before I am non compos mentis and that I am able to impress on whoever is treating me at the time to not get too carried away employing extraordinary measures, or even better still that I simply don't wake up one morning while in my own bed at home.

I had thought about not wanting to put a doctor in a position where his/her ethics or religious beliefs were compromised regarding the end of life, but then I guess they would have to have figured out how to deal with such things long before I appear on the scene.

On a distantly related point I know it's virtually impossible (or so I've heard) to get a vet to terminate an animal's life no matter how bad their condition, so I guess on the human level decisions regarding removing life support would be at least as difficult.

Maybe if the hospital's accounting office is a party to decision making, as the available funds for hospital bills run out ... I'm being facetious, sort of.

[Sheryl]

Even with a Living Will, and even if you have previously discussed with a doctor, if you are non compos mentis the hospital and doctor will be very hesitant to refrain from life support unless they know your family will not object. They are going to want some input from a relative.

You may not have any in Thailand, but in a critical illness situation where you are unable to speak for yourself, the hospital and your Embassy are going to try to track down family members in your home country. Suggest you think this through now and devide who is the best person back there to be in this role...before they wreck haoc by contacting the wrong one. They will not necessarily have to fly to Thailand (though that would help especially if there are issues/problems with the doctor or hospital) but they need to be able to talk to the doctor on the phone in the role of relative.

Or, appoint a farang friend as honorary "sibling".

[cheeryble]

Hi Suradit69

I am sure Sheryl has given the best advice available on DNR and all to do with it.

When I see you have mac degen I wonder if you….like my 86yo friend….have concerns about quality of life if, say, vision got worse or nil.

I will suggest to you what I push with him……the wonder of the audio material becoming more and more available as we speak in the form of podcasts and torrent downloads.

These terms may mean little or nothing to you but I suggest they can change your life regardless of visual ability.

I base this on a couple of things I take as granted.

One is that I suggest that audio material is not inferior in some way to video, but superior.

(As they have said for a long time, the pictures are better on the radio.)

The other is that, almost like a miracle as we happen to be getting up there in age, I believe it is now possible with the aid of things like podcasts and audiobooks to live a completely satisfying life spread across a variety of interests essentially in an armchair. (I'm doing a course in Special Relativity as we speak).

lf this raises any interest in you I'd say now……while sight is still working…..is the time to get into it.

Depending on your interests I can suggest a lot of resources.

You'd do worse than start with the BBC, look up BBC podcasts…..or WNYC.

There are tons of others, and it will get bigger and better.

Just a suggestion.

Edited April 19, 2014 by cheeryble