“Die can, sick cannot”

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The Singapore limelight may still be focused on the government’s Pioneer Generation Package, but in its shadow lurks a real problem: the aged sick, with no family or social support. The plight of 24 unnamed kidney patients emerged in the Academy of Medicine’s journal, Annals last December.

Four doctors had undertaken a study of renal patients at Khoo Teck Puat Hospital who had turned down dialysis. Citing a common saying by chronically ill patients in Singapore (“One can die, but cannot fall ill”), the researchers said: “While many patients qualify for subsidies after means testing, the financial burden can still be hefty”.

However, the doctors found: “The main reason why patients or family decline dialysis was the lack of family and social support. … in contrast to our hypothesis that most patients decline dialysis because of financial reasons. (Only six of 24 declined for financial reasons.) This result is also in contrary to the results in (an Australian study) which found that the fear of being a burden is a common reason for patients to refuse dialysis.”

Examples of reasons stated include having no carer to administer peritoneal dialysis (which can be done at home) or transport patients for haemodialysis three times a week.
Only four patients refused dialysis because they did not want to be a burden. The patients who were included in this category said they were “old already” and they did not want to be a burden to their family.
While all the 24 patients were consulted and counseled on the initiation of dialysis, three of the decisions refusing were made by their family members for the patients. One of the three patients had no personal preference to treatment. The remaining two patients had indicated preference to initiate dialysis, but had left the decision to their family as they felt that the family would be the one taking on the burden of caring for them.
Concluded the doctors: “More must be done to improve social structures which help support patients and their families who desire treatment, particularly if it has been shown that it is a means of prolonging life meaningfully at this stage.”

The December issue of Annals said in an editorial: “It is a useful reminder that before the Human Organ Transplant Act (HOTA) was introduced in Singapore in 1987, there was an average of five cadaveric renal transplants each year. However, after the introduction of HOTA, the average number of cadaveric transplants increased to 45 yearly. This is a nine-fold increase. In 1987, we had about 300 patients on the waiting list, today we have about 900 patients. A patient with blood group O would have to wait for a much longer time since there are many more patients with blood group O, compared to a patient with blood group AB which is less common. When one considers all these factors, the chances of getting a cadaveric kidney are much better than before and for the time being, it behooves those patients on the cadaveric kidney transplant waiting list to maintain themselves well on dialysis, keeping faith with their dialysis schedule and other medication as well as their renal diet in preparation for the day when they are called upon to receive a kidney transplant.”

One way of making renal care more convenient, the editorial suggested, was to train more general practitioners in providing such care. As the Pioneer Generation package will be making subsidised GP consultations more widely available, renal care for dialysis patients should be cheaper too.

Unsubsidised dialysis costs $2,500 to more than $4,000 a month.