Author: Rong-Chi Chen, MD, PhD, FANA
Affiliations: National Taiwan University School of Medicine, En Chu Kong Hospital, Taipei Medical University
Position: Professor/Consultant Physician
Address: En Chu Kong Hospital, #399, Fuhsing Rd, Sanhsia, New Taipei City 23762, TAIWAN
Phone: 886-963-602818
E-mail: rongchichen@gmail.com
[Key words] Hospice palliative care, Hospice palliative care act, Natural death act, Peaceful dying, Clinical chaplaincy, Taiwan coma scale, Community hospice care
ABSTRACT
The purpose of medicine is to prevent illness, cure disease, relieve suffering and maintain health. The duty of the physicians, is to rescue life, cure disease, relieve suffering and promote health. However, “birth, aging, sickness and death” are unavoidable path of human life. When a person has reached the end of his life, when death is imminent, the duty of medical professionals will be to provide loving and humanistic care for the patient, to relieve pain and suffering and provide a peaceful and dignified demise. The physician takes care of his patient from birth to death, (i.e. from “womb to tomb”). At the end of terminal care, physicians should maintain a religious and holistic spirit of “removal of suffering and provision of happiness” to their patients, as much as he could. Provision of hospice palliative care and terminal DNR according to medical ethics and law can ensure peaceful dying of the patients. Provision of clinical chaplains in hospice care and promotion of community hospice care will improve the quality of terminal care. To use the Taiwan Coma Scale can decrease the futile life sustaining treatment in the ICU.
PREFACE
“Birth, aging, sickness and death” are unavoidable path of human life. When a person has reached the end of his life, when death is imminent, the duty of medical professionals, including physicians, nurses and all others in the hospitals will be to provide loving and humanistic care for the patient, to relieve pain and suffering and provide a peaceful and dignified demise. The physician should save the life and also care the dying. The physician takes care of his patient from birth to death, (i.e. from “womb to tomb”). At the end of terminal care, physicians should maintain a religious and holistic spirit of “removal of suffering and provision of happiness” to their patients, as much as he could. [1] Provision of hospice palliative care and terminal do-no-resuscitation (DNR) according to medical ethics and law can ensure peaceful dying of the patients. Hospice palliative care is the most humanistic care and holistic care for the terminal patients.
BRIEF HISTORY OF INTRODUCTION OF HOSPICE PALLIATIVE CARE INTO TAIWAN
In 1983, Dr. David CH Chung of the Christian Mackay Memorial Hospital in Taipei introduced the concept of hospice-palliative care into Taiwan. [2]. In the same year, Chantal CS Chao started hospice nursing home care in the Catholic Sanipax Socio-medical Service & Education Foundation in Taipei. [3]. In 1990 the first hospice ward was opened in the Christian Mackay Memorial Hospital by Dr. David CH Chung and a palliative ward was established in the National Taiwan University Hospital in 1995 by Prof. RC Chen. [1,4]. Since then, the hospice palliative medicine gradually spreaded across whole Taiwan. We now have more than 50 hospice palliative wards in general hospitals with more than 700 beds, providing hospice co-care to other medical or surgical services and hospice home care.
COVERAGE BY THE NATIONAL HEALTH INSURRANCE
In 1994 a Congress Woman, Ms YW Chiang presented a plea to the President for promotion of hospice care. It was passed to the Ministry of Health(MOH). [3]. In 1995 a “Hospice care promotion team” was established in the MOH. In 1996 the National Health Insurance (NHI) started to pay for the hospice home care. In 2000, hospice care ward service was reimbursed by the NHI. Initially, it covered hospice care of cancer patients, then amyotropic lateral sclerosis and AIDS patients were enrolled. Since 2009, the NHI expanded payment coverage to terminal major organ failure patients.
LEGAL SUPPORT—“HOSPICE PALLIATIVE CARE ACT”
In 1999, Ms. YW Chiang became a legislator (senator) who asked the Ministry of Health to present a Natural Death Act to the Legislative Yuan (Senate). As “death” is a taboo in this culture, the Act was renamed as “Hospice Palliative Care Act). On May 23, 2000, the “Hospice Palliative Care Act” was passed by the Legislative Yuan and became effective law on June 7 after official signing by the President. The Act gave our people the right to sign an advanced order of DNR to ask physicians to withhold cardiopulmonary resuscitation(CPR) at the terminal stage. A family surrogate can also sign a DNR order according to the patient's previously expressed wish, if the patient fell into unconscious state or being no more able to express his will. The Law was revised for 3 times till 2013. Since 2006, with the person's request, the advanced DNR order could be registered in the NHI card which could be read whenever a patient asked for medical care in any clinic or hospital. This “Hospice Palliative Care Act” gives physicians legal permission: that it is legal to withhold CPR or withdraw life-sustaining-treatment (LST) for the terminal patient with a consent signed by the patient in advance, by one of the family surrogate or by a medical surrogate assigned in advance. If the patient did not sign a DNR consent, and no family is available, a DNR order can be prescribed by the attending physician after consultation with a hospice team.
It will be our duty to educate the lay men and the medical personells to respect the right of the terminal patient's refusal of futile CPR or extraordinary medical measures and to ask for a peaceful and dignified demise.[6] “In one's final momens, quality of life is more important than the prolongation of life. Physicians who respect patients' wishes and provide hospice palliative care, can foster a peaceful and dignified departure from life. Filial duty and love should find its expression in being with the family member at the end of his life, and in encouraging acceptance of disease, quiet life in his last days and peaceful passing. Where it is unavoidable, the death of a terminal patient is not a medical failure. Not being able to facilitate a peaceful and dignified demise is, however. “ [7]. We can help terminal patients to have a peaceful passing without suffering.
Whether it is in the ordinary medical or surgical ward, at the emergency service or at the intensive care unit (ICU), when facing a patient requiring CPR, if he is a terminal patient, a physician can discuss with the family with empathy: “The patient now requires CPR and endotracheal tube insertion to sustain his life. However, since he is in the terminal stage of cancer or severe organ failure, CPR can not rescue his life, but will definitely increase and prolong his suffering. Shall we consider to withhold the futile CPR and help him a peaceful dying?” If the patient already signed an advanced DNR order with or without registration in the NHI card, the physician should encourage the family to respect the patient's wish for peaceful passing. If a terminal patient in ICU, is maintained by a mechanical ventilator and remains in deep comatous state without hope of recovery, the physician should try to discuss with the family for withdrawal of the futile life sustaining treatments including ventilator. If no family member is available, the attending physician should consult the hospice palliative team to make a DNR order for the best interest of the patient according to the Hospice Palliative Care Act. This will decrease medical legal dispute at the final stage of life and also make more ICU beds available for those patients in need.
HOSPITAL ACCREDITATION PAYS ATTENTION TO HOSPICE PALLIATIVE CARE
After 2 years's trial, the Joint Commission on Hospital Accreditation of Taiwan (JCHAT) added several items of hospice palliative care in the accreditation protocol since the beginning of 2015 to require and encourage hospitals to provide good quality hospice care. It requires that each hospice ward should have in-charge physician and social worker. Each bed should have one nurse. All the professional workers require special training in hospice palliative care and yearly continual education. Special bathing equipment and special room for religious purpose are needed. Clinical chaplains are part of the team to provide spiritual care. The hospice unit should also provide hospice home care. The team should also go into other ward to provide co-care to terminal patients who can not or will not come to the hospice ward. It requires medical centers to take the responsibility of education and propagation of the concept of hospice care to community hospitals.
ESTABLISHMENT OF CLINICAL CHAPLAINCY PROGRAM TO IMPROVE THE QUALITY OF SPIRITUAL CARE
Sogyal Rinpoche in his The Tibetan Book of Living and Dying [8] urged: “One of the things I hope for from this book is that doctors all over the world will take extremely seriously the need to allow the dying person to die in silence and serenity. I want to appeal to the good will of the medical profession, and hope to inspire it to find ways to make the very difficult transition of death as easy, painless, and peaceful as possible. Peaceful death is really an essential human right, more essential perhaps even than the right to vote or the right to justice; it is a right on which, all religious traditions tells us, a great deal depends for the well-being and spiritual future of the dying person. There is no greater gift of charity you can give than helping a person to die well.”
In the Amitabha Sutra, Buddha said: [9] “Shariputra, those living beings who hear should vow, ‘I wish to be born in that country.’ And why? Those who thus attain are all superior and good people, all gathered together in one place. Shariputra, one cannot have few good roots, blessings, virtues, and causal connections to attain birth in that land.” “Shariputra, if there is a good man or a good woman who hears spoken ‘Amitabha’ and holds the name, whether for one day, two days, three, four, five days, six days, as long as seven days, with one heart unconfused, when this person approaches the end of life, before him will appear Amitabha and all the assembly of holy ones. When the end comes, his heart is without inversion; in Amitabha's Land of Ultimate Bliss he will attain rebirth. Shariputra, because I see this benefit, I speak these words: If living beings hear this spoken they should make the vow, ‘I will be born in that land.’
In the spiritual care of hospice palliative medicine, we wish to provide the terminal patient a “causal connection (i.e. good condition)” of “with one heart, unconfused, without inversion” to have better chance to be reborn in Amitabha’s Land of Ultimate Bliss. Since 1998 the Buddhist Lotus Hospice Care Foundation(Lotus Foundation) started a training program for Buddhist clinical chaplains at the Palliative Unit of the National Taiwan University Hospital (NTUH). This is the first complete training program for Buddhist monks and nuns to participate in the medical care in the more than 2000 years Buddhist history. It consists of more than 60-hour's classroom course and 80-hou's bedside practice in the hospice palliative service. So far more than 180 chaplains participated the training courses and more than 60 completed the training (including 2 Catholic nuns). 34 are serving in 41 hospice units in different hospitals throughout Taiwan. The Hospice Care Education Center of the Hospice of the Mackay Memorial Hospital also maintains a training program for Catholic and Christian clinical chaplains. The participation of the trained clinical chaplains of different religions greatly enhanced the quality of our spiritual care in the hospice services. [7,10,11]
It is hoped that every person lives a fulfilled life with virtues, cultivates good roots and good conditions while living. At the end of life, through the hospice palliative care with spiritual care provided by the clinical chaplains, every person can return to the Heavenly Kingdom of God or the Blissed Pure Land of Amitabha as he wishes. We are also encouraging the Buddhist Colleges to open training course for preparation of clinical chaplains. A new independent Buddhist hospital with 90 beds entirely for hospice care is now on the way of construction in central Taiwan. It is named Buddhist Chengte Hospital. Hope this hospital will start to function after 2 years and become a model Buddhist-style hospice and training center for more Buddhist clinical chaplains. [12] The training system of Buddhist clinical chaplaincy has spreaded to Japan in 2013 by Rev. H. Jin of the Zeinseikyo Foundation of Japan.[13,14].
TAIWAN COMA SCALE
Coma or unconsciousness is caused by insult to the brain. It is qualitatively described as mild, medium or deep coma. The Glasgow coma scale (GCS) proposed by Teasdale and Jennett [15] was widely used in Taiwan for quantitative measure of coma, especially in the Intensive Care Units (ICU). However, the GCS made the lowest scale to 1 for those “none” responses to eye (E), speech (V) and limb movement (M). The total lowest scale is 3. The family in Taiwan usually felt that there might be some hope for the scale of 3, and continued to wait for miracle to occur. It costed the patient to suffer from the continued toruture of futile medicine. I suggest a Taiwan coma scale (TCS) [16] which will make the “none” response in each category to 0. Thus the total lowest scale to deeply comatous patient will be 0. When the scale reaches 0 (zero), it might be easier to persuade the family members for the discussion of withdrawal of futile life sustaining treatment. Hope this will improve the quality of hospice care in the ICU in Taiwan and decrease the occupation of the precious life curing ICU beds by hopeless terminal patients.
PROMOTION OF COMMUNITY HOSPICE CARE TO ENSURE PEACEFUL DEMISE AT HOME
In the old days, it was a tradition for our people to die peacefully at home surrounded by the family members. However, with the development of modern medicine, most of the patiens died at the ICU of hospitals with endotracheal tube and many other tubes inserted. The NHI Service started to cooperate with local governments since last year to promote the community hospice care. It is hoped that more and more community hospitals and local practicing physicians will join in the hospice home care after training. Good quality hospice home care will increase the acceptance of the patients and family members for peaceful passing at home. Hope most of our people will have the chance to die at home peacefully as they wish without physical, mental and spiritual suffering as our ancestors used to do 60 years ago.
In 2010, Taiwan's quality of death and end-of-life care was ranked as the first in Asia and 14th in the world by the Lien Foundation of Singapore. [17]. We will continue to improve ourself and to join the international community for further improvement together.
REFERENCES
[1] Chen RC . 2009. Humanism in terminal care. In Tai CT, Lee MB. Medical Humanisties. Taipei: Ministry of Education. Pp 97-109. (in Chinese).
[2] Chung DCH. 1983. Introduction of Hospice.J Taiwan Medical Association 26(4): 37-38. (in Chinese)
[3] Chao CCS. 2007. Accompanying in the Hospice Path. Taipei: Bookzone. Pp 224-229. (in Chinese).
[4] Chen CY(Ed). 2007. Introduction. In Taiwan Academy of Hospice Palliative Medicine. Hospice Palliative Care-Theory and Practice. Taipei County: New Wun Ching Developmental Publishing Co. Pp 1-7.(in Chinese).
[5] Chen RC. 2014. Asking physicians to help patients dying peacefully. Taiwan People News (May 29, 2014) (in Chinese).
[6] Chen RC. 2006. Medical personell should actively promote the concept of terminal DNR. Tzu-Chi Med J 18:155-157.
[7] Chen RC. 2009. The Spirit of Humanism in Terminal Care Taiwan Experience. The Open Area Studies Journal 2: 7-11.
[8] Sogyal Rinpoche. 1994. The Tibetan Book of Living and Dying. San Francisco: HarperSanFrancisco. P 186.
[9] The Buddha Speaks of Amitabha Sutra
[10] Huimin Bhikshu. 2012. The role of mindfulness in hospice palliative care in Taiwan. Taiwan J of Hospice Palliative Care 17: 200-209.
[11] Chen CY. 2012. Clinical Buddhist chaplain based spiritual care in Taiwan. Taiwan J of Hospice Palliative Care 17: 300-309.
[12] Chen RC 2015. Congratulation of the construction of the Buddhist Taichung Chengte Hospital for hospice palliative care. Health E World. August 2015. (in Chinese).
[13] Chen RC 2015. Spreading of Buddhist clinical chaplaincy training system to Japan. Health E World 2015 May. (in Chinese)
[14] Chen RC 2015. From Taiwan to Japan: The cross national spreading of spiritual care. Lotus Life Bimonthly 132:2-6.(2015 July). (in Chinese).
[15] Teasdale G, Jannett B. 1974. Assessment of coma and impaired consciousness. A practical scale. Lancet 304: 81-84.
[16] Chen RC. 2014. Taiwan coma scale: A modified Glasgow coma scale. Taiwan J Hospice Palliative Care 19(2): 176-180.
[17] Lien Foundation. 2010. The quality of death, Ranking end-of-life care across the world. Economist Intelligence Unit, The Economist. 2010:1-36
Citation: Chen RC(2015) Policy of hospice palliative care in Taiwan. BOAJ Pall Medicine 1:009.