mental-health – Dementia, Caregiving and Life in General

This post is about death, disability, disease and decision-making.

There comes a time when someone is ill or dying, and decisions have to be made about treatment and whether or not to prolong life, or suffering, as the case may be. Who makes the decisions? When? How? Singaporean not only love acronyms, they like things neat and orderly. And so several laws and programs have been put in place to help people do things properly.

Unfortunately, the introduction of these new programs have been muddled up with rules, details and legal jargon. Let me try to demystify it a bit…

Last will and testament

This is obvious. This is a legal document determining how to distribute one’s worldly possessions upon death.

Example – Aunty Helen died, and in her last will and testament, left her house to her son, her jewellery to her daughter, her bank account to her chauffeur and favorite charity, and only $100 to her constant companion, whom we all knew was after her money.

Advanced Medical Directive (AMD)

This is legal document you sign to request your doctor to let you die, in the event your are unconscious and death is imminent. Once the document is registered, your wish will be recorded in a secure and secret place. Only when you are seriously ill, about to die and unconscious, will you doctor be able to request to check whether you have made an AMD. An AMD can be revoked anytime, verbally.

Example – Mr. Shia Vo had a bad car accident and was brought to hospital unconscious from a smashed skull. They managed to hook him up to a ventilator and revive him, but his organs are failing one by one and he’s not going to recover. The doctors checked and found he had an AMD, but his mother is adamant he revoked the AMD last week when she discussed life and death matters with him. The doctors have no choice but to leave him on the ventilator until his heart stops in about a week.

Lasting Power of Attorney (LPA)

This is a legal appointment for someone to take charge of your affairs should you lose your mind. Also used in the case of adults with mental incapacity. A person holding the LPA (called the donee), cannot make serious* healthcare treatment decisions.

Example – When Aunty Dora realised 3 of her siblings had developed dementia, she quickly gave her son Sam the LPA because she was worried about herself. It was lucky she did that early, because a couple of years later, she became demented rather rapidly, and Sam was able to go to the bank and stop the swindlers from cheating her of all her money. He further arranged for Aunty Dora to receive round the clock nursing care at home, and paid for it from her bank account.

Advance Care Planning (ACP)

To express one’s wishes and values to loved ones, so that when the time comes, your loved ones are able to make your healthcare decisions, consistent with what’s important to you.

Example – Mr Gar had kidney failure and needed renal dialysis three times weekly. It was hard for him, but he coped with it. A nurse there got the family involved in ACP, and Mr Gar told everyone how much he hated being dependent, and how he would rather be dead than bedridden and unable to talk, unable to eat. A few months later, Mr Gar developed sepsis and was admitted to the Intensive Care Unit (ICU). He was very weak, and doctors gave him powerful antibiotics. However during the second week of ICU he developed a severe stroke from a large bleed in the brain. Mr Gar’s family knew from the ACP what Mr Gar would want, and requested his doctors switch from aggressive treatment to comfort care.

Story Combining All

Mrs K was found to have a brain tumor 3 years ago. Before her brain surgery, the neurosurgical nurse conducted an ACP session and spoke to her about appointing a surrogate decision maker in case of complications. Mrs K, chose her daughter, Sara, who was close to her. Mrs K expressed she was willing to live with moderate disability, as she was looking forward to her son Dan’s graduation from law school, Sara’s upcoming wedding, and grandchildren.

Before going into surgery, Mrs K called her lawyer and revised her last will and testament, and made an LPA appointing Dan the donee (Sara was hopeless with money matters). The surgery went well and Mrs K was as good as new. That is, until several months ago, when the tumor recurred and Mrs K developed behavioral abnormalities. She became apathetic and could no longer handle her household affairs. Her children were deeply saddened, but because they had already discussed it, cared for her as she had wished.

When Mrs K deteriorated, Sara arranged for home nursing, called the doctors in when required, and decided against hospitalisation as that was against her mother’s stated wishes. Dan paid the bills and managed his mother’s finances.

An AMD was not applicable and no one sought to check if Mrs K had one, because Mrs K declined gradually and death was not “imminent”.

Conclusion

See, that wasn’t so difficult, was it?

* The donee in an LPA can only make basic healthcare decisions and cannot make any decisions which involve refusing life sustaining treatment or treatment required to prevent
a serious deterioration in the condition of the person lacking capacity – see Guidelines. (edited 20 Jan 2015)

Have you heard of mindfulness meditation? It is about being present, to be wholly concentrated and aware of the present moment instead of having your thoughts winging off somewhere else whilst you’re doing something else.

Practising mindfulness has helped me be a better listener – to focus on the person and what’s being said, to be less judgemental, and to concentrate.

When I drive, I sometimes turn off the radio and just… drive. I try not to let my mind float but to focus on the activity of driving itself. Apart from being more aware of my car and the vehicles around me, I hear so much more. There is the sound of the wind blowing, and the sound of the wheels on the road. I notice the color of the sky, the road, the road divider, the buildings beside the road. I just drive, and notice so many things I would not have paid any attention to.

To my amazement, practising mindfulness has helped bring me peace. I become aware of the world that is, and not the world I wish it were.

I’ve noticed somewhat belatedly that Mom is mindful. When she makes a cup of tea, she is fully concentrated on every step of the process. Taking her cup, getting the tea bag, putting the tin back, pouring hot water, getting the spoon, and the bottle of sugar. Putting things back. Every movement is thought through and deliberate. She thinks of nothing else other than making that cup of tea as she is making it.

Mom is practising mindfulness, everyday, every moment that she is awake. Perhaps dementia has robbed her of the ability to hold many thoughts at once, and she holds just the one thought, that of the present moment. Or perhaps her years of studying and learning concentration and focus is helping her to cope now despite her dementia.

I believe that if one were to practise mindfulness before dementia set in, it would mitigate the dementia symptoms. Something to think about.

Tag: mental-health

My 2015 Word

ACP, LPA, AMD and the last Will and Testament