Greek philosopher Epictetus once said, “I cannot escape death, but at least I can escape the fear of it”. In today’s fast-changing world, with all its technological and economical advancements, the topic of death can still be hard and heavy to talk about. End-of-life conversations entail the questions of when, where, and how. When and where will I breathe my last? Under what condition will I die? A recent study showed that while 90 percent of adults said that talking with their loved ones about end-of-life care is important, only 27 percent have actually done so[1].
In June 2022, Health Minister Ong Ye Kung announced Singapore’s aim to reduce the proportion of people dying in hospitals instead of at home or in palliative settings from 61 percent to 51 percent by 2027[2]. Mr Ong also referred to a survey done by Lien Foundation, which found that 77 percent of Singaporeans hope to die at home, but only 26 percent manage to do so[3]. The survey also revealed that the main barrier to considering hospice palliative care is the perception that it is expensive[4].
Against this backdrop, this article seeks to reflect on the country’s state of palliative care and its developments over the years. It also attempts to highlight several contemporary challenges and obstacles faced by healthcare workers in the end-of-life care scene.
PALLIATIVE CARE OVER THE YEARS: AN OVERVIEW
As a country with one of the most rapidly ageing populations in the world, Singapore has undertaken various initiatives to mitigate the impact of the ‘silver tsunami’. As the population ages, the number of patients requiring palliative care will also increase. Having an ideal and desirable palliative care service is therefore crucial.
Historically speaking, caring for terminally ill patients in Singapore dates back to the 19th century. Famously known as the ‘Street of the Dead’, Sago Lane housed many early Chinese immigrants who were living out their last days[5]. Generally, death houses comprise a living space on the first level and a funeral parlour below[6]. The conditions were morbid, and the dying had to bear the cost of their food, lodging, and medicine. Death houses were later banned in 1961, and most of them were demolished to make way for redevelopment[7].
The hospice or palliative care services in Singapore can be subsumed under two main categories: community- and hospital-based[8].
The first hospice in Singapore was started in 1985 by a group of Catholic nuns at St Joseph’s Home. It was equipped with 16 inpatient hospice beds[9]. This effort, a year later, received public attention after The Straits Times article entitled In Singapore, A Place to Die Peacefully, was published. The cover story piqued the interest of many Singaporeans to volunteer for the palliative care service, resulting in the formation of the first volunteer home hospice care group. In 1987, the first hospice home care service, Hospice Care Group (HCG), was built.
Another important milestone in the development of palliative care occurred in May 1995, when the Singapore Hospice Council (SHC) was established. It acts as the umbrella body for all organisations providing hospice and palliative care in Singapore[10].
The advent of hospital-based palliative care services took place in 1996, in the Geriatric Department of Tan Tock Seng Hospital. Three years later, the National Cancer Centre Singapore formed the first independent Department of Palliative Medicine. Thereafter, palliative care services are made available in all government acute care hospitals[11].
Today, palliative care services are available in all parts of Singapore. The services provided range from home to day and inpatient palliative care. Consultative services can also be found at most public hospitals[12].
THE RISE OF ‘COMPASSION FATIGUE’
With the ever-increasing demands and hefty workloads, the healthcare sector has never been easy. Already plagued with a manpower crunch, the emergence of COVID-19 has further exacerbated the condition. The palliative care sector is no exception. In a CNA interview, Associate Professor Tan Boon Yeow, Chief Executive Officer of St Luke’s Hospital, said that the adverse impact on a healthcare worker’s well-being exists on a spectrum, from compassion fatigue to physical burnout. For healthcare workers in the palliative care sector, the risk of compassion fatigue is inevitably higher. This is due to the fact that caregivers are required to exercise a higher degree of compassion and empathy when dealing with their patients. Dr Tan added that among the signs of such fatigue are regular tiredness and loss of joy at work[13]. According to Figley, the term ‘compassion fatigue’ refers to “a state of exhaustion and dysfunction biologically, psychologically, and socially as a result of prolonged exposure to compassion stress and all it invokes”[14]. To understand this phenomenon better, several defining attributes were derived, including an established relationship between caregiver and patient, empathy, stress, shared experiences, and psychological response. In sum, compassion fatigue arises from the change in the empathetic ability of the caregiver in reaction to the prolonged and overwhelming stress of caregiving[15]. Individuals who are at the highest risk of developing compassion fatigue are the ones who are most in contact with traumatised patients and exposed to their traumatic experiences. This includes medical professionals, therapists, first responders, and family caregivers.
The consequences of compassion fatigue can be detrimental to the well-being of both the caregiver and the patient. While it is their main job to deal with patients’ suffering and illness, it is this very work that puts palliative care nurses at risk of physical, emotional, spiritual, and psychological distress[16]. Consequently, several other repercussions will arise. These include increased absenteeism, decreased quality of patient care, and difficulty recruiting and retaining staff[17].
Although there is no official data reflecting the proportion of palliative care nurses experiencing compassion fatigue yet, the need for awareness regarding this issue is beyond doubt. In emphasising this, grief therapist Liese Groot-Alberts from the Asia Pacific Hospice Palliative Care Network underscored the importance of awareness and early diagnosis in picking up on compassion fatigue. She stated that staff may lose motivation to provide care for patients or feel reluctant when working in “those compassionate places where the heart really needs to come in”[18].
DYING IN PALLIATIVE SETTINGS: BARRIERS AND PERCEPTIONS
As mentioned earlier, Singapore is aiming towards reducing the proportion of people dying in hospitals instead of at home or in palliative settings. Ultimately, there are three factors preventing this from happening as outlined by Minister Ong Ye Kung during his speech at his ministry’s Work Plan Seminar last year; namely, low awareness among family members, challenging discharge processes and protocols, and low caregiver preparedness[19]. The lack of awareness of palliative care services comes in different forms. Some patients or their family members may have an inadequate understanding of the services offered in these settings. They perceive that home hospice services might not be able to fulfill medical and nursing needs sufficiently, hence making hospitals more favourable. Ironically, this lack of awareness also exists among healthcare professionals in Singapore. In a 2020 survey done by the Singapore Hospice Council, only 46.37 percent of the total respondents (who include doctors, nurses, and allied health professionals) were familiar with hospice and palliative care service providers and referral processes in Singapore[20]. Therefore, a lot more has to be done in terms of increasing the level of awareness among the general public and healthcare professionals.
In addition to the barriers mentioned above, there are other secondary factors hindering people from opting for palliative care settings. This includes bread-and-butter issues that do not allow low-income families to engage palliative care services. Some families may also face difficulties managing the medical and nursing needs of the dying person, notably when the symptoms worsen. As a result, dying in a hospital is considered a more hassle-free option.
LOOKING ON THE BRIGHT SIDE
In addressing these concerns, the Ministry of Health (MOH) has put forth a new approach to further support palliative care in Singapore. During the debate on his ministry’s budget this year, Minister Ong announced that MOH will extend the use of MediSave to patients receiving care at home from the second half of 2023. This will be benefited by close to 6,800 patients a year. A pilot programme to allow patients to receive timely and smooth care across various hospice settings will also be launched[21].
These efforts, in my opinion, are foundational to spur future developments in palliative care, which could make use of technological and medical breakthroughs to cater to the increasingly complex issues of dying. In fine, there are still areas that require improvement, such as coming to grips with the taboo around end-of-life conversations and educating the public on the importance of end-of-life care. ⬛
1 Carr, D. Commentary: End-of-life conversations can be hard, but your loved ones will thank you. CNA. 2022, January 31. Retrieved from: https://www.channelnewsasia.com/commentary/end-life-conversation-elderly-loved-ones-family-2427931
2 Lai, L. MOH to boost palliative care at home, better support caregivers. The Straits Times. 2022, June 2. Retrieved from: https://www.straitstimes.com/singapore/health/boost-for-palliative-care-fewer-people-to-die-in-hospitals-by-2027-ong-ye-kung
3 Lien Foundation. Death Attitude Survey. Singapore: Blackbox Research. 2014. p. 44
4 Ibid, p. 17
5 Poon, E. and O’Connor, M. Development of Palliative Care in Singapore: An overview. Singapore Nursing Journal, Vol. 36, 2009. pp. 48-54
6 Thulaja, N. R. Sago Lane. Singapore Infopedia. 2016. Retrieved from: https://eresources.nlb.gov.sg/infopedia/articles/SIP_299_2005-01-11.html
7 Ibid
8 Poon, E. and O’Connor, M. Development of Palliative Care in Singapore: An overview. Singapore Nursing Journal, Vol. 36, 2009. pp. 48-54
9 Singapore Hospice Council. History of Palliative Care Organisations and Services. Retrieved from: https://singaporehospice.org.sg/history/
10 Lin Goh, S. S. Singapore Takes Six Steps Forward in ‘The Quality of Death Index’ Rankings. Asia-Pacific Journal of Oncology Nursing, Vol. 5(1). January 2018. pp. 21-25. Retrieved from: https://doi.org/10.4103/apjon.apjon_66_17
11 Ibid
12 Singapore Hospice Council. Hospices and Palliative Services. Retrieved from: https://singaporehospice.org.sg/services/
13 Koh, F. Rise of ‘compassion fatigue’ risks pushing healthcare workers away from palliative care. CNA. 2022, November 23. Retrieved from: https://www.channelnewsasia.com/singapore/compassion-fatigue-healthcare-workers-nursing-attrition-mental-health-palliative-care-3095366
14 Figley, C. Compassion fatigue as secondary traumatic stress disorder: An overview. In: Compassion Fatigue: Coping with Secondary Stress Disorder in Those Who Treat the Traumatised (ed). 1995. pp. 1-20
15 Lynch, S. H., and Lobo, M. L. Compassion fatigue in family caregivers: A Wilsonian concept analysis. Journal of Advanced Nursing, Vol. 68(9). February 2012. pp. 2125-2134. Retrieved from: https://doi.org/10.1111/j.1365-2648.2012.05985.x
16 Melvin, C. S. Historical Review in Understanding Burnout, Professional Compassion Fatigue, and Secondary Traumatic Stress Disorder from a Hospice and Palliative Nursing Perspective. Journal of Hospice & Palliative Nursing, Vol. 17(1). February 2015. pp. 66-72. Retrieved from: https://doi.org/10.1097/NJH.0000000000000126
17 Hooper, C., et al. Compassion satisfaction, burnout, and compassion fatigue among emergency nurses compared with nurses in other selected inpatient specialties. Journal of Emergency Nursing, Vol. 35(5). May 2010. pp. 420-427. Retrieved from: https://doi.org/10.1016/j.jen.2009.11.027
18 Koh, F. Rise of ‘compassion fatigue’ risks pushing healthcare workers away from palliative care. CNA. 2022, November 23. Retrieved from: https://www.channelnewsasia.com/singapore/compassion-fatigue-healthcare-workers-nursing-attrition-mental-health-palliative-care-3095366
19 Ministry of Health. Speech By Minister for Health, Mr Ong Ye Kung, At The MOH Work Plan Seminar 2022, 2 June 2022. 2022, June 3. Retrieved from: https://www.moh.gov.sg/news-highlights/details/speech-by-minister-for-health-mr-ong-ye-kung-at-the-moh-work-plan-seminar-2022-2-june-2022
20 Singapore Hospice Council. 2020 SHC Key Survey Findings of Awareness of Hospice & Palliative Care among Healthcare Professionals in Singapore. 2020. Retrieved from: https://singaporehospice.org.sg/e-library/docs/2020-shc-survey-key-findings-of-awareness-of-hospice-palliative-care-among-healthcare-professionals-in-singapore-2/
21 Ying, L. L. Patients receiving home care can use MediSave to pay bills from second half of 2023. The Straits Times. 2023, March 3. Retrieved from: https://www.straitstimes.com/singapore/politics/patients-receiving-home-care-can-use-medisave-to-pay-bills-from-second-half-of-2023
Reza Idani Zainal Abidin is an undergraduate of Islamic Jurisprudence at Al-Azhar University, Cairo. He currently serves as an Executive Committee Member of the Singaporean Students Welfare Assembly in Cairo (PERKEMAS). His areas of interest encompass the traditional Islamic sciences, Arabic literature, philosophy, and political Islam.
