Father on ventilator in Nakhon Sawan - Sawan Pracharak Hospital

[belkristi]

My father, who has resided in Thailand for the last 5 years is currently on a ventilator - practically life support - and I'm hoping for some advice. Whilst he does have a Thai partner they are not married and I'm his only next of kin. They have been sustaining him since 1st January when he was admitted with septic shock, there has been no improvement at all. He is being tube fed and can't breath unassisted.

I'm based in Australia and went over to see him in January but my hands were tied with the language barrier and as it all happened to suddenly I was slighly unprepared on what my rights were. Do I have any rights at all ? They won't cease medical intervention or turn off the ventilator. Any advice/recommendation would truly be appreciated as he is suffering and I know this is not what he would want at all.

[NickJ]

I went through this with my Mom. You can sign a DNR.......You have to fight for your rights if they seem to be keeping him alive for money. I feel for you its a sad situation.

You can PM me and I will try to give you any advice I can.

Edited April 15, 2016 by NickJ

[Sheryl]

As the closest relative your wishes carry some weight but you would need to be present in Thailand to effect that, and it will take some persistance.

Others in this situation have eventually prevailed but it takes time and effort, as you need to persuade the doctors that this is the family's wishes. If your father had made an Advance Directive (Living Will) that would greatly help. If his Thai partner is not in agreement, this will be a big problem.

How is his care being paid for? As making it clear that the family does not agree with the treatment and will not pay for it can help.

[johnatong]

If your father is being actively ventilated it is unlikely he is 'suffering'.

I understand your feelings but fear you have very few rights in the situation described. Even the presence of a legally completed Advance Heath Care Directive which specify's an individuals wishes in the event of a catastrophic health occurrence is not a guarantee that those wishes will be acted upon especially in smaller "up country" hospitals.

Your fathers Embassy may be prepared to seek details of fathers illness/prognosis from the hospital doctors but it is unlikely that the Thai medical staff will want to reduce or withdraw treatment.

Do you know if your Dad has medical insurance cover ?

[belkristi]

Unfortunately he has no insurance and you can imagine the mounting medical costs associated with all of this, none of which either I nor his partner can afford to pay.

I take some comfort in knowing that he is probably not suffering but prolonging the inevitable just doesn't make sense to me when it's clearly evident there is no improvement at all and never will be.

The Embassy have been assisting me with updates every 3-4 days from either the nurse or the treating Dr, but they are scarce with giving details.

Unfortunately he never made an Advanced Directive (probably didn't know he could), however I do hold Power of Attorney in Australia - which probably doesn't mount to much. Should I seek legal advice in regards to my wishes being granted as his next of kin ?

Edited April 15, 2016 by belkristi

[johnatong]

Unfortunately he has no insurance and you can imagine the mounting medical costs associated with all of this, none of which either I nor his partner can afford to pay.

I take some comfort in knowing that he is probably not suffering but prolonging the inevitable just doesn't make sense to me when it's clearly evident there is no improvement at all and never will be.

Unfortunately he never made an Advanced Directive (probably didn't know he could), however I do hold Power of Attorney in Australia - which probably doesn't mount to much. Should I seek legal advice in regards to my wishes being granted as his next of kin ?

Before spending money on legal advice try speaking to the people in your fathers Embassy. They are used to dealing with similar events and may be able to provide you with advice.

[Sheryl]

I don't think legal advice will help you much in the absence of an advance directive or other document signed by your father. To my understanding there is no legal framework in Thailand that gives relatives the power to make end-of-life health care decisions, only (and quite recently) a law allowing the patient to decline treatment through an advance directive (and patients have always had the result to refuse treatment at the point of care if able to make their wishes known).

Power of persuasion is pretty much all you have, and it is much harder to get a doctor/hospital to discontinue life support than the not start it in the first place.

[offset]

I think the best thing that you can do it to make sure the hospital know that you are not going to pay for any more treatment (do it in writing) and if they want to keep him alive they do so at there own cost I do not think that they will chase you for payment and as he is not married to his Thai partner she has no responsibility for his debts

[NancyL]

I think you may have to come here to advocate for him in person. I've seen similar situations in Chiang Mai and unfortunately, once the doctors put someone on a ventilator, they are very reluctant to take them off. They probably will not "pull the plug" (really that means remove the ventilator) in the hospital, but perhaps they could be convinced to allow you to "take him home to die".

What we've done here in Chiang Mai in similar situations is to have someone transferred to McKean Rehabilitation Center, which is run by a Christian organization and has handled numerous end-of-life cases. The patient is transferred to McKean still on a ventilator and it's removed at McKean. There, at McKean the patient is kept out-of-pain and able to live out his final hours or days with his family.

I don't like the necessity to have to make this transfer by ambulance. It would be so much kinder for the patient and family if the patient could simply be moved to a private room at the hospital and the ventilator removed, according to the family's wishes. Apparently with Thai patients on ventilator, it's sometimes common for the family to decide at some point that they've done everything they've done and to request to bring their loved one home to die. This is the procedure followed. The problem with us expats is that often we don't have a family or home here close to the hospital to return to die in comfort, surrounded by our loved ones.

[chubby]

so he made a POA for healthcare in Australia, but didn't make a medical decisions directive, seems like people usually make a directive at the same time they make a POA for healthcare.

fwiw a vent IS life support, during which people are on anesthesia propaphol usually, and unconscious, depending on how he is handling it, what is his age and his health status otherwise before this?

good luck, my father went in a similar way, eventually, even when the doctors would do, what we would ask of them ....... hopefully, they are able to prevent bed sores, which are almost inevitable in situations like these

[hanuman2543]

I experienced 3 times a similar situation with foreign friends of mine here in a Thai Government Hospital. Every time it became clear that there was no more money for all the "lifesupporting" measures lifesupport was shut down immediately. The involved embassies were never good for anything but creating more trouble and confusion.

[belkristi]

so he made a POA for healthcare in Australia, but didn't make a medical decisions directive, seems like people usually make a directive at the same time they make a POA for healthcare. fwiw a vent IS life support, during which people are on anesthesia propaphol usually, and unconscious, depending on how he is handling it, what is his age and his health status otherwise before this? good luck, my father went in a similar way, eventually, even when the doctors would do, what we would ask of them ....... hopefully, they are able to prevent bed sores, which are almost inevitable in situations like these

Unfortunately he already has numerous bed sores, some which are ulcerated and none of them are clearing up. He is 73 but has been in poor health for a few years and it all came to a head on 1st Jan when he was admitted with an ulcer on his leg that was so bad it was down to the bone - hence the septic shock. His POA was made in Australia before he resided in Thailand, but he never had a will made in Australia or in Thailand.

[Sheryl]

Is it specifically a Health Care POA or just a general one?

If you are certain that no amount of pressure from you, in person, including written notification of refusal to pay for the costs, will get the hospital to discontinue life support then arranging a transfer to a long-term care facility may be the best option. While some distance away, McKean as mentioned by Nancy is a good option.

[NancyL]

If he has ulcerated bed sores, then surely he is being treated with antibiotics for infection. Would the hospital be willing to stop using antibiotics and "let nature take its course", provided he is kept comfortable and out of pain? Or at least not start treating any new infections.

Also, it needs to be made clear that you do not want any additional new procedures like cardiac resuscitation, kidney dialysis or other extraordinary procedures used to keep him alive.

Here in Chiang Mai, it's a problem to stop the ventilator once started and it appears that's the situation at the hospital in Nakhon Sawan also. Doctors have explained to me that "its their Buddhist culture" not to take an active role in discontinuing a medical treatment once started. But, they were willing not to start on a new medical treatment when requested. Frankly, to me it seems like "splitting hairs" and disrespectful of our western beliefs of not wanting to prolong the suffering of an elderly person, but we're in Thailand and it's their hospital.

[belkristi]

Thank you everyone for your advice and suggestions. My dad has finally passed away and is now at peace. A feeling of relief and grief, I'm so glad he is now at peace.

I have a question about the next part of my battle which is the unpaid hospital account. I've been informed they won't release the body for cremation until it's paid. I'm not in a financial position to pay this account (approx $5K).

Does anyone know how long they hold the body for - is it indefinitely ? What happens if the bill remains unpaid ?

Thanks again in advance for everyone's responses.

[NancyL]

Thank you for the update and the news that your father is at peace at last.

Sheryl may be able to address what happens in the hospitals where she has worked, but here in Chiang Mai it is indeed standard practice that a body isn't released for cremation until the hospital bill is paid. The government hospital will keep a body for quite a long period of time while waiting for payment. Meanwhile, they will put pressure on the Embassy and others around the deceased (like your father's Thai partner) for payment. Needless to say, this is often quite traumatic for people like your father's Thai partner if they are devote Buddhists who want to do the right thing and organize a proper cremation, but don't have the funds to pay the hospital bill.

Here in Chiang Mai, if a body is unclaimed after a long period, it is eventually given a simple, dignified cremation by a local Buddhist charity, but the family or friends aren't notified. The body is considered unclaimed, after all.

[KC 71]

Sorry for your loss belkristi- I hope everything works out for you.

[Sheryl]

Sorry for your loss, but glad he is at peace.

Re the body, it is as Nancy says. They cannot force you to pay (and his Thai partner, not being married to him, has no legal liability either) but they can and will withold the body as leverage and this may be very upsetting, especially to her as many Thais believe a proper funeral to be necessary to enable the deceased to travel onward to the next life, and also to prevent them from coming back to haunt the living (Thais believe strongly in ghosts). Once they realize they won't get paid they will arrange disposal of the body but without any family involvement.

Hospitals will however usually agree to release a body in exchange for a signed payment plan in which the amount owed is paid back a little at a time.