April 4, 2009
Dying well
Life is fragile, yet most people avoid thinking or talking about death. But a new study shows that people in Singapore are now more willing to break that great silence.
By Radha Basu
IT IS way past his bedtime, but little Toby Raza, three, is perched on a sofa, his nose buried in a coffee table book containing photographs of his family.
'This one's my favourite,' he chirps, a fat little finger pointing to an image of his mother who is captured in midair, jumping into a swimming pool on a sunny morning.
His sister Josie, six, sprawled nearby, turns the pages to a photo of herself, nestled in the warmth of her mother's lap. 'I like this one,' she says softly, gently touching the cold, glossy page. 'She's beautiful.'
The children's mother, former TV-producer-turned-housewife Shin Na, died of cancer in the family's Siglap condominium on Jan 27. She was 42.
Their father, American finance professional Tony Raza, lets on that at one time, the family took more than 6,000 photographs a year. 'It's easier now, I guess, than it would have been 15 years ago,' he sighs, referring to the physical and digital treasure trove of memories they are left with.
With two young children, a soulmate for a husband and a happy home, Ms Na was 39 - at the prime of her life - when she was diagnosed with breast cancer in December 2005.
Yet, despite the threat of it all being wrenched away, she lived the rest of her life without regret or recrimination.
By her own account, her final years were her happiest, when she savoured life and love with an intensity she had not known before.
Even as she battled the deadly disease, the tenacious American of Korean descent, who was a Singapore permanent resident, compiled a rich archive of blog posts, letters, journals, videos and photos. They now serve as a priceless legacy of her life for her family and friends across the world.
After her diagnosis, her loved ones put their own lives on hold to spend time with her. Mr Raza, 41, who is of Pakistani-American descent and has lived here for 13 years, quit his Merrill Lynch research job and took a six-month break from work.
Together with Toby and Josie, they travelled all over the region and visited friends and relatives in the United States and South Korea.
Ms Na's best friend, Australian Michelle Ring, 38, flew in from Sydney many times to spend time with her. 'I think my death was worth it,' Ms Na wrote in a letter read out at a memorial service after she died.
'I know that sounds terrible but I would not trade in these past two years for a hundred more years of living an ordinary life, not knowing what amazing creatures we human beings are capable of being.'
As others rallied around her, Ms Na opened her heart to the world, posting her thoughts online about life, love, disease and death thrice a week in a blog that often got about 1,000 hits a day.
As in many societies, death has long been considered a taboo subject in Singapore. However, new research shows that many are now open to the idea of talking about death - especially their own.
More than 60 per cent of 800 people interviewed here in the first large-scale survey on attitudes towards death and dying said they were comfortable with discussing their own deaths. Commissioned by the Lien Foundation, the survey results were made public yesterday.
However, roughly the same proportion - 60 per cent - were reluctant to discuss death with someone else who was terminally ill.
People here also considered dying well as being free of pain, surrounded by loved ones, conscious and able to communicate, in that order.
CONSPIRACY OF SILENCE
About 17,000 people die here every year. Cancer is by far the single largest cause of death, followed by heart disease and pneumonia.
Most people go about life regarding death as a 'necessary but ignorable ill', as a recent Newsweek article put it. But a campaign, launched by the Lien Foundation last month, is under way to enhance care for the dying here.
The foundation's chief executive officer Lee Poh Wah says discussing end-of-life issues has been a 'long neglected niche' in Singapore.
'Death has become a stranger and enemy that is feared. But the fear will be less paralysing when we can talk more openly about it,' he says.
'We will be a better society when all people are assured that they will be well looked after in life's final chapter.'
The foundation has also produced a caregivers' booklet, documentaries, radio talk shows and advertisements on what it is to 'die well'.
He acknowledges that while public awareness campaigns attempt to take the sting out of dying, they do not attempt to sugarcoat what remains one of life's saddest certainties.
'Dying is a messy, protracted and difficult life episode,' he says. 'No death is truly 'good', but we are talking about making the best of a difficult and very human event.'
Indeed, many caregivers like Mr Raza say the current conspiracy of silence on the topic leaves many patients imagining the end is far worse than it actually is.
His wife, for instance, became anxious when she heard about a fellow cancer patient who died on a plane: 'Her husband said it was so horrible that they could not talk about it.'
But when her own end came, she was free of pain. 'She said her goodbyes, the morphine worked well and she was at peace,' he says.
But is it really possible to die well, even in cases where death is premature and untimely?
Dr Tan Yew Seng, medical director of Assisi Hospice, reckons that if dying well is to be free of pain - as many respondents in the survey hoped - the goal is very achievable. More than 90 per cent of pain during the last stages of terminal illness can be controlled by modern medicine.
Dying well is also about living well, says senior principal medical social worker Crystal Lim at Singapore General Hospital, who counsels terminally ill folk and their families.
'People need to remember that preparing for death is not to die more quickly. Talking about death does not hasten death,' she says.
The Lien Foundation survey showed a marked rise in the awareness of palliative care, which seeks to alleviate suffering rather than to cure. About eight in 10 said they had heard of hospices which provide in-patient care for the terminally ill. About half had also heard that hospice services can be provided at home. Barely four years ago, only about one in three people had heard of palliative care here.
But while awareness of services and physical care is increasing, many families still struggle to understand the emotional needs of loved ones at death's doorstep. For instance, caregivers often confuse 'talking about death' with overloading the patients with information on their medical condition, says Ms Lim.
'They talk about what needs to be done, the treatment effects and so forth. But the patient may want to talk about how he or she is feeling.'
POWER OF POSITIVITY
Being open about death helps many to overcome fear.
Mr Chua Buay Lim, 55, for instance, is approaching his illness with the same equanimity and courage as Ms Na.
For the past three years, the chief executive of a local company that makes sanitaryware has been living with end-stage liver cancer, a condition that is known to kill in six months. He still works and is in relatively good health. The secret, he says, is that he has remained 'positive' without 'hoping too much'.
High fever - which the doctors suspected at first to be dengue - signalled the onset of his disease. Since there were no overt signs whatsoever, the prognosis, made in early 2006, came as a shock.
But instead of becoming mired in depression or asking 'Why me?' endlessly, Mr Chua tackled the disease just as he would a challenge at work. 'My attitude was: Let's see what the doctors can offer,' he says.
He has begun preparing his wife, Madam Quek Chay Hoon, 47, for when he is not around, telling her how to handle their finances, which undertaker to use and what he wants for his funeral. They have no children.
Yet, even as he prepares for his own demise, the staunch Buddhist prays for 'some more time to do good'.
'Each day is a bonus. We must all die some day so what's there to be frightened about?'
Not everyone who is terminally ill, of course, is eager to learn every little detail of their illness and take charge of their treatment. Older folk, especially women, tend to leave all that to their children.
All Madam Kua Seh, 93, for instance, knows is that she has an 'old person's disease' but nothing about her end-stage ovarian cancer.
'We're afraid that she will not be able to take the news,' frets her eldest son, Mr Dew Eng Seng, 60.
She may be physically frail and hard of hearing, but her mind is still alert. The proud grandmother of 11 says she looks forward to Sundays when her grandchildren come to visit. 'They chat with me and give me massages,' she says in Hokkien.
Her only wish now is to get a chance to see more of her grandchildren get married and to become a great-grandmother. Two of her grandchildren are planning to get married this year.
She would be thrilled if her last wish came true, but Madam Kua is content with the way her life has turned out. She has no regrets, since she has successfully fulfilled her biggest temporal duty - raising her four children.
'I'm ready to go,' says the Buddhist calmly. ' All I ask is to go in peace.'
Mr Mohamed Said Sahari, 56, also has wish fulfilment on his mind - just that they are his wife's wishes, not his own.
A heavy smoker for the past 40 years, the former delivery man suffers from chronic obstructive pulmonary disease, a lung disorder. Shortness of breath and a near-death experience last year, that led to emergency hospitalisation, changed his outlook on life.
'Now that I know I may go any time, I want to take good care of my family while I can,' says the father of two.
Not only did he give up smoking, he recently spent over $40,000 renovating their five-room Jurong West HDB flat, buying new furniture and a new 38-inch flat screen television, which his wife wanted.
'Previously, when I asked to buy anything, he would just wave me off and say: 'Next time'. Now whatever I want, he will buy for me,' beams his wife, Madam Zubaidah Abdullah, 56.
DYING YOUNG
Even though Singapore has one of the highest life expectancies in the world - more than 80 years - cancer is still reaping a grim harvest among the young.
According to the Ministry of Health, an average of 4,886 people under 65 were diagnosed with cancer here every year between 2003 and 2007. Of them, about 440 every year were below 35. Figures for 2008 are not available yet.
At 38, Madam Azizah Mohmad knows she is on her last leg of life. Her fourth-stage breast cancer has spread to her bones.
But she believes remaining positive will help win her a fresh lease of life.
'Being angry or upset will not make the illness go away,' she says, touching her left breast where the tumour first took root. 'So why bother?'
Instead, the former salesgirl and mother of two is concentrating on living life to the fullest, even against her doctor's wishes.
Till a couple of months ago, the feisty woman with a love for the outdoors used to regularly swim and cycle with her daughters, Nur Afiqah, 15, and Nur Athirah, 11.
The disease has made her bones brittle and a fall could prove fatal. But Madam Azizah is undeterred. 'Enjoy now, suffer later,' she says quietly, wiping away a stealthy tear.
Her appearance masks her inner pain.
The sensuous fragrance of Chanel perfume clings to her pretty pink shirt. The colour and the perfume are her favourite. She loves 'girly things like dressing up'. She still goes out to eat or shop with her girls, albeit with a nifty walking stick that doubles as a stool.
There have also been a couple of trips out of Singapore to Malaysia. 'Staying in bed will make me even more sick.'
As she chats easily at a cafe in a Woodlands mall, wearing a white tudung and impeccably-applied makeup, it is hard to fathom that just a couple of days earlier, she was huddled in bed, drained by radiation therapy, too weak to move.
There have been plenty of dark days, she admits candidly. The early part of the chemotherapy was especially difficult, when she would scold her children for the 'smallest things'. At Afiqah's suggestion she picked up the Chinese martial art taiji, which calms her down, she says.
Indeed, even as public awareness campaigns like the current one by Lien Foundation try to soothe frayed minds, caregivers acknowledge it is near impossible to watch calmly as a once-vital loved one fades away.
For all her zeal to share her cancer woes with the world and help others heal, Ms Na - like Madam Azizah - also had occasional angry and tearful breakdowns.
One evening early on in the illness, for instance, Mr Raza returned home to see her in a rage, throwing plates against the wall, upset that the ongoing renovation of their home was not going the way she wanted.
Another night, watching baby Toby sleeping peacefully, she broke down and cried at the thought of the little boy being left motherless soon.
Knowing full well that duelling with death was futile, she then set about creating her little treasure chest of memories for her children.
Aside from the blog posts, videos and photos, she put together a 'memory box' laden with letters, cards and gifts for her children, to be opened on special occasions.
The biggest gifts are reserved for their 16th birthdays - Josie will get a Tiffany locket containing a photo of herself and her mum, and Toby will get a Tiffany keychain, also with a photograph.
'The only reason leaving behind any kind of legacy is important to me is for my kids,' Ms Na wrote on her blog.
'It's about giving the kids something, anything, to replace the mother who had to leave them too early.'
A celebration of life against all odds
By Radha Basu
LIFE has been a rough ride for Ms Zoe Christian, 45, these past few years.
She is separated from her husband. Her two children live abroad. She has no home of her own, and no money to buy or rent one. And she has terminal breast cancer. 'But you just have to look deep within and find the strength to carry on,' the dancer and actress says, ensconced in the spare bedroom of her sister's Marsiling HDB flat.
'When we are healthy, many of us sleepwalk through life like the living dead,' she observes. 'You can see us in the MRT, on the way to work. Unsmiling. With vacant stares. Just like zombies. From where I am now, that seems like such a waste.'
Her spirit is strong, but physically, Ms Christian is not doing so well. Her breast cancer - diagnosed in December 2007 - has spread. She may have just months to live, but is determined to continue pursuing her passions.
For one thing, she dances as often as she can. In the mid-80s, she graced the grand stage of the now-defunct Neptune Theatre. A tiny strip of space between the bed and the dresser in her bedroom is her stage now, not that she is complaining.
The biggest worry she has now are mounting treatment costs. With the help of friends in the entertainment industry, she has been trying to raise funds to pay for the therapies keeping her alive. Her next fund-raiser, which includes dinner and performances by well-known dancers, will be held on Tuesday.
She also worries about her children. By a sad twist of fate - Bethsheba, 20, and Bartholomew Lind, 12 - live thousands of kilometres away in Sydney. She and her New Zealander husband were legally separated in Singapore in 2005. After which, she relocated with her children to Sydney as she wanted them to study there.
Bethsheba works in a Sydney law firm while Bartholomew is at boarding school. 'They both love it there, so I don't want to uproot them,' she says of her children, who are also close to and supported by their dad.
When she first felt a lump in her right breast in August 2007, she neglected to get it checked in Sydney. 'I kept hoping it would go away,' she says ruefully. 'It did not.'
She returned home to Singapore in December that year and had a scan. The diagnosis confirmed her worst fears. 'I came back with two suitcases and have never gone back.'
Around the same time as her diagnosis, her husband lost his regional sales manager job. 'He was supporting the kids and me, so it was a very dark time.'
After the diagnosis, she first tried a myriad of alternative therapies for six months, ranging from ayurveda to acupuncture. But none worked. By August last year, her tumour, originally the size of a fingernail, had grown to resemble a fist. It also began to bleed.
Chemotherapy, which she had initially dismissed as an option, became her only hope, just to contain the cancer. Around the time she started treatment, she began a blog in a bid to share her experiences of battling the disease and to raise awareness - and funds - for her treatment.
These days, when mired in pain and unable to dance, she sits and watches dance and theatre videos. She also surrounds herself with her most precious possessions, such as a copy of a bright yellow masterpiece by Austrian artist Gustav Klimt, of a mother sleeping with her cherubic child. It reminds her of the time her daughter was born.
She has told friends what to do to remember her once she is gone. She wants a party, with food, friends and wine, instead of a funeral. 'I don't want them to mourn my death,' she says smiling, 'I want them to celebrate my life instead.'
Log on to http://zoechristian.com/projectlife to buy tickets for the fund-raiser on Tuesday.
He worries not for himself, but for his family
ONCE an active man, former human resource professional Phua Hock Seng, 63, is now a shadow of his former self.
He is unable to walk, talk or even move a muscle.
Mr Phua's dramatic degeneration - the result of motor neuron disease, a nerve disorder - took place over three years. There is no cure and the condition is usually fatal.
Ask his wife and caregiver, 57-year-old Lai Yien, exactly when he stopped walking, and she pauses to think, a tad surprised that the answer doesn't spring quickly to mind. 'You know, I'm not sure. It's like my brain does not want to remember the sad things.'
There is plenty, of course, that she wants to remember - the shy young kampung boy she met at work and married one Sunday afternoon in September 1973. There is also the birth of their two sons and more recently three grandchildren, their holidays abroad and a shared passion for dancing.
In a bid to preserve memories of their time together, Mrs Phua consulted her husband and called the Lien Foundation last year, after reading an article in The Straits Times asking readers to nominate terminally ill loved ones to receive 'legacy albums'.
Made up of photographs and interviews with friends and family, these albums are unique, personalised tributes to help those who are seriously ill or even close to death to reflect on their lives.
One evening last week, Mr Phua received his own legacy album, a glossy coffee table book chronicling the highs and lows of his eventful life.
Dressed in a bright yellow polo shirt, he looked intently on as his wife slowly turned the pages. He laughed out loud when Mrs Phua showed him a photograph of them dancing together. 'This is his favourite,' she said, peering at the image of herself in a dazzling orange gown, twirling in the arms of her tuxedo-wearing husband.
The picture had appeared in the Chinese daily Lianhe Zaobao when the couple won an international dancing competition.
But his biggest smiles were reserved not for the book, but for little Yi Jun, three, who jumped into her grandmother's arms to give her beloved grandfather a kiss.
Since Mr Phua's condition is relatively rare, the couple drifted from test to test, for 10 months before an accurate diagnosis was made in June 2006. He finally learnt that his condition was 'terminal' not from a doctor, but from insurance papers.
The only time he broke down, he wrote to his doctor later, was 'not because of the disease, but because I foresaw the effort and care that would fall to my wife and family members'.
A man unafraid to share his inner turmoil as he faced his biggest challenge, his note to his doctor is filled with startling poignancy: 'I cannot enjoy my retirement and the fruits of my hard work.
'My hopes to see my grandchildren grow up have been dashed. How is my wife, who is so dependent on me, going to live after this?...How am I going to live the remaining days as my illness gets worse? It is scary.'
Previously not a religious man, Mr Phua has learnt to cope by turning to Buddhism.
Coping with the disease's relentless progress has been hard on Mrs Phua too. As her husband's main caregiver, her days and nights are spent tending to his many needs as she watches his heartbreaking transformation from 'protector and provider' to someone as helpless as an infant.
She copes by taking each day at a time: 'You can't put yourself in a position of self-pity, or you'll feel miserable.'
From panic to peaceful exit
SITTING on a deserted, windswept stretch of East Coast Park beach one morning in December 2004, Mr Ng Kok Song told his wife, Patricia, how he would want to spend his final moments.
'I would like to die at home, surrounded by children, grandchildren and you,' he said.
Mr Ng raised the delicate topic, not so much to address the manner of his own death, but rather that of his wife's.
The mother of his three children listened in silence, before saying simply: 'Me too.'
A poignant pause and more wishes flowed forth. 'I also pray that you will be there to hold me in your arms when the time comes,' she said softly.
The words were important. Mrs Ng had end-stage stomach cancer.
Two months later, she slipped away peacefully on Valentine's Day, a month short of her 57th birthday.
Her final moments? Exactly as she had hoped they would be.
'She had lived a beautiful life and she died the same way,' says Mr Ng, 61, who is the managing director and chief investment officer of the Government of Singapore Investment Corp.
Picking up the pieces, living without the woman who for so long had been the emotional anchor of the family, was hard. 'But there was no grief, only sadness.'
When Mrs Ng was diagnosed in July 2003, her doctors gave her three months to live. But aggressive treatment, combined with her sheer strength of will, helped her defy death for another 16 months.
But it was not easy, especially in the early days. When the doctor first held up three fingers of his hand - indicating how few months Mrs Ng might have left - she wept in panic. It was the classic 'Why me?' syndrome.
But within days, with the help of her family's love and support and her deep faith in God, the devout Catholic picked herself up. 'She soon began asking 'why not me?' 'What is so special about me?' ' says Mr Ng, smiling wistfully.
In an interview she gave on her illness about a year after she was diagnosed, Mrs Ng spoke with uncommon courage and candour about her innermost feelings. 'I'm scared of suffering and I'm scared of dying and so I try to replace this fear with positive thoughts,' she said.
The housewife said her fear of death stemmed from having to face judgment when she was not ready. 'But I can imagine that life outside this body is even more wondrous and God had got great things planned for us,' she told her interviewer, Father Laurence Freeman, who taught her Christian meditation. 'So I trust and just leave it in His hands.'
Aside from physical and spiritual pain, Mrs Ng was also afraid of the emotional pain of the impending separation from family and friends.
She was able to cope - and eventually move 'from panic to peace' - by living in the present moment, meditating daily and basking in the love of her family.
'I can't think of the past. I dare not think of the future,' she said, adding that she took each day at a time, and could not even think 'in terms of a month'. 'But this is a beautiful way to live.'
For the Ngs, life took on an intensity they had never known before. The months between diagnosis and death were fraught with suffering, but there was also joy.
'We had known each other 39 years, but those 19 months were our happiest,' says Mr Ng. 'I know it sounds paradoxical, but that's just how it was.'
He adds that in the rough-and-tumble chase of academic excellence, career goals and material pleasures that often define modern life, it is easy to forget how fragile life is.
If we are to live our lives 'sharply in focus', we should always 'keep death in our field of vision', observes Mr Ng. 'Only then will we live life more meaningfully, with a greater sense of priorities.'
Showering love and spending time with each other soon became a focus in their family. Mr Ng began taking mornings off from work to spend more time with his wife. There were quiet strolls on the beach and breakfasts of kway teow soup or kaya toast at their favourite hawker stalls.
There were also family dinners and Christmas parties.
Every time their two older children, Terence, now 36, and Deborah, 32, who were married and had flown the coop by then, visited, Mrs Ng would just go up and give them a hug because those moments were so precious, recalls Mr Ng.
The children reciprocated in kind. At Christmas in 2003, Deborah, who had been married just four months earlier, went up to her mother, gave her a small gift and told her the bigger gift was 'coming in nine months'. A few months later, Mrs Ng's daughter-in-law, Ling Fong, also announced that she was pregnant.
The impending arrival of her first grandchildren gave Mrs Ng new strength. 'She wanted so much to cradle those two babies in her arms,' says Mr Ng. 'And she did.'
Family and friends can do a lot in caring for the dying, says Mr Ng. 'If a dying person feels loved right till the point of death, there is a sense that life is worth living.'
His wife's journey has made Mr Ng himself conquer the fear of death. 'For me, death is not the end of life, but a transformation of being,' he says.
...OR NOT
Unnecessary suffering that could be avoided
HER cancer had spread. She was in constant pain. In the intensive care unit of a pricey private hospital, a machine was helping the 60-year-old's pneumonia- racked lungs to breathe.
Each day's treatment cost $8,000.
There was no reasonable hope of recovery. Yet, her son and daughter pleaded with Dr Ong Kian Chung to 'do everything possible' to keep her alive.
She was kept on the ventilator. Thin, plastic tubes were stuck in her throat, neck and chest. She was put on continuous dialysis and given a blood transfusion.
Dr Ong, a respiratory physician at the Mount Elizabeth Medical Centre, told The Straits Times: 'The relatives were so emotional, they thought intubating her in the ICU was the only way to keep her alive. But for how long?'
Mercifully, she died within the day, but what happened, said Dr Ong, was a classic case of 'palliating the relatives, rather than the patient'.
As his work often involves taking care of Intensive Care Unit (ICU) patients, DrOng has seen more than 100 patients die painfully in his 22-year career. 'In many such cases, the pain was unnecessary,' he said.
In Singapore, people have the option of drawing up a legal document in advance to inform doctors that in case they become terminally ill and unconscious, they do not want any extraordinary life- sustaining treatment.
But as of late last year, fewer than 10,000 here had signed the Advance Medical Directive, or AMD. In the absence of one and when the patient is too ill to express his or her wishes, Dr Ong said that doctors can do little but to follow the distraught family's orders.
Most patients, he said, want to die at home, spending their last moments with family and friends, rather than be hooked to machines in an ICU. 'But all too often, they do not get a chance.'
In yet another case, a 40-something with advanced cancer was dying. 'The doctor tried to paint a factual picture, the husband could not take it and wanted her transferred to another hospital.'
She hung on for four weeks, with no improvement before dying, leaving behind heartbreak and a huge hospital bill.
Money is another common issue that brings disharmony during death.
Dr Ong knows of a case where the family of an elderly dementia patient with kidney failure had a shouting match in the hospital lobby. Some of them wanted him to be taken off life-sustaining machines, others did not. By then, his hospital bill had escalated to $300,000.
Dr Ong believes that one way to avoid a bad, painful death is to sign the AMD. 'We also need more awareness that life-prolonging procedures will definitely add to the patient's suffering.'
ICU treatment is worth it when a patient has a reasonable hope of recovering to a lucid and pain-free state, he said.
Physical suffering, of course, is not the only thing that causes people to depart in distress. Unresolved anger, recrimination and regret also cloud many deaths, said Sister Geraldine Tan from St Joseph's Home and Hospice in Jurong West.
Bickering family members can also cause unnecessary pain for the dying.
Once, an elderly resident at the hospice wanted to see his two sons - who were estranged from each other - together at his bedside. The men always visited him separately but they reluctantly agreed.
But the visit did not go as planned. As the elderly man waited with one son, the second son entered the room and left within seconds, unable to bear the sight of his estranged brother. The old man died shortly afterwards.
Ms Rose Lee, a pastoral worker at the same hospice, said relatives sometimes make the final moments of a loved one difficult by weeping uncontrollably. 'They cling to the patient and howl 'don't go, don't go', knowing full well that when death comes, it cannot be controlled.'
RADHA BASU
Don't act like it's not happening
1 Don't maintain a conspiracy of silence and pretend that the Grim Reaper is not in the house. The majority of people who are dying know that they are dying. Keeping it a secret means that what can be a time of closeness and intimacy between the dying and their families instead becomes a period of isolation and loneliness.
If a dying person wants to talk about death, he or she should never be rebuffed with 'Let's not talk about such things'. How people die lingers in the memories of those who live on.
Avoidance and denial of death may lead to lifelong regrets, unresolved guilt and prolonged grief for those who live on.
2 Don't busy yourself fighting death, instead of living. 'Quality of life' should not be sacrificed in pursuit of the elusive 'quantity of life'. Dying isn't the problem to solve. The problem to solve is the refusal to die and conspiring to do anything but die, which creates suffering.
3 In cases where patients are unable to express their views, family members should ask: 'What would he/she want me to do' rather than 'What do I think should be done?'
4 Seek help from hospice palliative care services. Home hospice services in Singapore are free. Doctors and nurses visit terminally ill patients regularly to manage their pain and help the family cope with caregiving. The number of visits depends on the condition of the patient, and could go up to several times a week. But accept that dying involves physical, psychosocial and spiritual suffering, some of which may not be alleviated.
TIPS FROM LEE POH WAH, CEO, LIEN FOUNDATION
Work towards peaceful death
Is it possible to die well? Have you been moved by the death of someone? How did it change your life? Is there anything about people's attitudes to death you would want to change?
Radha Basu posed these and other questions to seven well-known people here
Health Minister Khaw Boon Wan, 56, a Buddhist
'To me, after a full and fulfilling life, a departure without pain, suffering, in the company of loved ones, in one's own home, completely at peace with myself would be dying well.
But such a peaceful death does not happen naturally. It has to be worked at.
For some, it starts with realising that the current life is merely transient, a journey to a better final destination.
Alas, many people confuse the temporary with the permanent and cling on to material things, causing much suffering to themselves and others.
My father, who ran a small business, died a good death at 81. He went into a coma after suffering from a brain haemorrhage in front of the television and drew his last breath a few hours later.
He had lived a full and active life and brought up his eight children well. He was honest, with no vices, and was responsible and caring.
He was not rich materially, but richer than most spiritually.
His sudden death was, of course, painful for the children to bear initially.
But deep inside, we all wish that when our time comes, we will similarly pass away painlessly and suddenly in such a manner, rather than being bedridden and suffering pain for months or years, with little quality of life.
Maintaining a healthy lifestyle is crucial. It does not guarantee no suffering at old age, but enhances our chances of being able to live and age well.
We should have a mature attitude towards death, acknowledging it as a natural part of life. Making it a taboo subject will only make the dying process worse.
I am glad that this is slowly changing and many Singaporeans can now discuss death openly and comfortably, without feeling 'pan tang' or superstitious. We should 'die-logue' more and then act on it by preparing for our eventual departure.'
Live well to die well
Dr R. Theyvendran, 64, a Hindu and well-known Tamil community leader, is chairman and managing director of printing, publishing and trading firm Stamford Media International.
'Death is inevitable. We have to be prepared to accept it as part of living.
To die well, you must live well, striving to make a better life not just for yourself but for others too.
My father's death was a good example. A retired civil servant, he died about 20 years ago at 63 in my mother's arms, with no suffering.
He raised all his 10 children well and with the right values, on how one should go forward to help others in need.
Death is not the end. As a Hindu, I believe in reincarnation. I believe you will return once more and get a chance once more to do good in life.
So death is just like changing clothes. In the next life, one may be back to do more and better things, fulfil other desires that could not be achieved in this lifetime.'
Seeing death in a different light
Dr Noreen Chan, 42, a Buddhist, spearheads the palliative care programme at the National University Hospital.
'My views about death and dying have changed. I used to think that I should be helping people 'accept' their situation, and would get frustrated if they chose not to. Then I came to realise that we die much as we live, and the beliefs and habits of a lifetime don't change just because you get a lethal illness.
The notion that somehow we have this epiphany and everything falls into place makes for a nice movie. But in reality, we all struggle to find meaning.
If I could choose my terminal illness, it would be something long enough for me to tie up loose ends, say goodbye, do something nice - like go on a special trip, but it's OK if I can't - and yet not so long that I feel like things are dragging.
I'd like to be as comfortable as possible, surrounded by love and laughter, not be subjected to interventions that don't add to my quality of life and, when my time comes, be allowed to pass on peacefully.'
Dying process is part of life
Mrs Ann Wee, 83, who helped pioneer social work here, is a Christian and former head of the Department of Social Work, National University of Singapore. She still holds an honorary position with the department.
'The 17th-century English preacher and writer John Bunyan wrote: 'Please Dear God, Let me be alive till I die.'
I think it's a beautiful phrase that encompasses what a lot of us feel. We want long healthy lives, a short period of illness, and then off we go. Geriatricians call this a 'rectangular' life. No one wants a long, slow deterioration.
I am grateful that both my parents who lived in a village in north England went quite quickly after they fell ill.
For my father, it was instantaneous. He was an avid gardener and one morning he was checking the temperature gauge in his garden and he just fell down and was gone. He went doing something he enjoyed.
It was extremely difficult for my mum at first, but she eventually realised that he would have hated being a patient, so in his case, it was a blessing in disguise.
My mum lived to her 90s. The doctor gave us some warning by telling us she was winding down. She too was aware of it. She told us she had had a good innings - using a phrase popular in cricket - and that we were not to mourn her.
I think it is good to talk about death and dying, but not when it is imminent, unless the dying person initiates the conversation.
It is also important to view the dying process as an important part of life. I get a feeling that death is nowadays treated as something of an obscenity in England, where I grew up. The British abhor death.
I am glad that is not the case in Singapore. Singaporeans are comfortable with sickness and dying. One good thing is many don't hesitate in having children around sickness. This not only cheers up the sick but the kids too grow up knowing that dying is just a part of the normal life cycle - which is how it should be.'
Seeing death as the will of God
Hajah Fatimah Azimullah, 63, is a Muslim and immediate past president of PPIS, or Young Women Muslim Association - the oldest Muslim women's group here. She is also involved in community organisations such as Mendaki and the Pertapis girls' home.
'For me or any Muslim, dying well means to die 'in Islam', meaning believing in Allah and the Prophet Muhammad.
An aunt died last year at the age of 84. She was getting weaker and weaker and when taken to the hospital, refused any kind of invasive treatment.
She was given medication to make her comfortable and died at home in the presence of family members. I consider her death a good death. It gave her close family members time to accept her death calmly.
Death is something we Muslims accept as the will of God. So, however and wherever one dies, it is something Muslims accept.'
Accepting it however it comes
Professor Wang Gungwu, 78, is an eminent scholar of Chinese history and chairman of East Asia Institute, National University of Singapore. He has no religion.
'The ideal thing is to die in your sleep with your mind still functioning normally and your body reasonably healthy. But that is probably asking for too much.
We must also not fear death, knowing that it will come to all of us. Therefore, we must do what we can to ensure that our family and friends are not left with a lot of mess when we go.
Not to suffer too much and make your family suffer over a protracted illness would be the best. But we don't always have a choice there and must be prepared to accept death, however it comes.'
A fulfilling life, no burdens left behind
Mr Imram Mohamed, 64, a Muslim, is a Malay community leader and chairman of the Association of Muslim Professionals. A retiree, he used to work as a senior airline executive.
'Dying well to me is, firstly, ensuring that I do not put any unnecessary burden on my family members whom I will leave behind.
As far as possible, I'd like to ensure that my finances are in order.
It also means that family members who are dependent on me will be adequately provided for.
To me, dying well also means to have lived a fulfilling life; that I have done my part in contributing to the community and that I have fulfilled my social and religious obligations...
Great men are remembered for their achievements but ordinary folk are cherished for their kindness, love and the joy they bring to others.'
What to say to the dying
How to begin the conversation
Ask how treatments are going, for example: 'What does your doctor plan on doing next?'
If the answer reflects an optimism regarding a cure that seems unlikely, given what you know of the person's condition, let the matter rest, at least for a while.
How to keep it going
A lot of important questions can be asked without challenging the dying person's optimism. If, for instance, he or she responds to an open-ended 'How are you doing?' by reporting that 'Dr Chan says the tests all look better,' you might say something like: 'Do you mean there's hope to really beat this thing?'
The person's response will likely clarify whether he/she has avoided talking about not getting well to protect you, or if he/she is too focused on the cure and is at present emotionally unable to consider the alternative.
Another gentle way to follow up is to inquire about events in the future, such as where and how a person wants to celebrate a birthday, Christmas or other holiday, or if he/she is still planning a trip which had been previously mentioned.
Listen closely
Listen for discouraged or exasperated comments along the lines of 'I don't know why I'm going through all this!' or 'I wish this would all be over with.'
These statements should be recognised as openings to important conversation. Dismissing such remarks ('Oh, you don't really mean that') or covering them over with simplistic reassurances ('You're going to get better, I just know it') effectively closes conversation and isolates the person in despair.
If the dying person provides an opening, consider stating the obvious: 'What you're going through sounds awful,' and let him or her know you can listen: 'I would love to hear how you're really doing.'
In asking the hard questions, of course, you or your family must be willing to hear hard answers. Often, what people need most is for someone they love to simply listen.
Don't romanticise death and dying
Being ill, and deteriorating, can be tough. It is not sailing off into the sunset. As director Woody Allen said: 'It's not that I'm afraid to die. I just don't want to be there when it happens.' And 16th century scholar Michel de Montaigne wrote: 'It is not death, but dying, that alarms me.'
Be honest and say that dying is tough, it's okay to be afraid, angry or upset, but maintain that there's help.
Take care to avoid pushing your own agenda
However, it is almost always okay to say how you feel. 'I love you so much and I'm scared of losing you' is a very direct statement that, nevertheless, respects personal boundaries.
Tips from well-known palliative care expert, Professor Ira Byock, director of Palliative Medicine, Dartmouth-Hitchcock Medical Centre in New Hampshire, United States, and Dr Noreen Chan, senior consultant of the National University Cancer Institute, Singapore.
What to avoid when talking to a cancer patient
Tips from breast cancer patient Shin Na, who died in January
1 Don't tell them stories about people you know who've had cancer and died.
2 Don't tell them about miracle cures and say they must try them.
3 Don't tell them God will heal them. God didn't promise he's going to heal anyone.
4 Don't accuse them of giving up if they don't try whatever crazy concoctions or exotic alternative therapies you've discovered on the Internet.
Keep in mind that cancer patients go through phases. When I was first diagnosed, I was angered by people referring to chemotherapy as 'toxic poison'. I didn't want to hear that the drugs they were putting into my body were toxic and poisonous. But now I realise I was being overly sensitive. Chemo is toxic. It is poisonous. But I wouldn't say that to a newly diagnosed cancer patient. It sounds too scary.
If someone had asked me how long I had to live just after I was diagnosed, I might have been offended. Now, I have no problem with that question. Some people just don't want to talk about their cancer. Some want to talk about it all the time. If you're unsure, ask them: 'Do you want to talk about it, or would you rather talk about something else?'
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