Editor’s Preface to the Singapore Bioethics Casebook,
May 2017
The 2017 Singapore Bioethics Casebook features 10 new cases under the theme of Caring for Older People in an Ageing Society, developed in consultation with over 180 healthcare and social care professionals from 40 organisations serving the healthcare and rehabilitation, home- and day-care, residential and social care needs of people growing old in Singapore. This collection enriches an earlier set of 12 cases under the theme of Making Difficult Decisions with Patients and Families.
The original 12 cases focused on the clinical context of decision-making, and were developed in collaboration with over 70 physicians and allied healthcare professionals to guide professionals in understanding key ethical challenges in the care of patients at the end of life and in other complex life-limiting circumstances. The expanded and revised Casebook guides professional and non-professional caregivers and other readers in appreciating care needs and care transitions for chronically ill people in an ageing society.
Each case is supported by expert commentaries highlighting ethical issues and a perspective by a Singaporean healthcare or social care professional offering practical insight. Additional support is provided by informational backgrounders, a glossary of terms, and a teaching and learning guide.
Funded by the Lien Foundation, the project has brought faculty from the Centre for Biomedical Ethics (CBmE) at the Yong Loo Lin School of Medicine, scholars from The Hastings Center in New York and Oxford University’s Ethox Centre, and Singapore healthcare practitioners together for in-depth sharing of healthcare practices in acute, community, and home care settings, and for collaborative development of its teaching cases and other learning materials.
A note on the 2017 website: Designed to be easy to use in formal and informal teaching and learning in clinical departments and broader care settings, users reviewing the website have found it to be simple to navigate, with case studies that can be printed in a single click, and a teaching and learning guide that suggests ways of approaching ethics discussions with classes and clinical groups. This web-based resource is an open-access work, freely available to interested readers everywhere. Users can also log on to the mobile- and tablet-friendly versions of the website. Written in an accessible style that reaches out to professional and lay audiences, this team hopes that it may also serve as a platform for public, patient, and policy education in healthcare and social care ethics.
The original website was designed and created in 2014 by Jacob Moses, a former Director of New Media at The Hastings Center. In the 2017 edition website by Chee Soo Lian and designed by Drake Lim, the 12 cases and commentaries in Making Difficult Decisions with Patients and Families have been updated, and linked to new and revised background essays and an updated topic list in the Browse by Topic section. The 10 new cases reflecting healthcare and social care obligations in increasingly integrated care settings in Singapore have been skilfully incorporated to enhance the website’s continuity, functionality, and ease of navigation.
Finally, the Teaching and Learning Guide has been enhanced in the 2017 Casebook to ensure that components that support teaching and learning (e.g. the ABC toolbox for ethical thinking) are user-friendly and presented in ways that reflect the different practice settings in which people teach and learn about healthcare and social care ethics. This includes, for example, leading a teaching session for colleagues, facilitating a group discussion with colleagues, or simply learning in one’s own time.
The cases
Making Difficult Decisions with Patients and Families (Volume I)
These 12 cases introduce diverse ways in which serious and life-limiting illness is experienced by patients and their healthcare providers; the intimate involvement of the family, and the needs of caregivers; the provision of complex multi-professional integrated care; and legal rules and principles in healthcare practice. They cover a mix of patients of different ages in the acute, community, and family practice healthcare settings, and reflect some of the most difficult but common, everyday practical and ethical challenges that face healthcare professionals in Singapore.
Case summaries:
Baby Arun: This case concerns an extremely premature, critically-ill newborn. It explores prognostic uncertainty in the neonatal ICU setting, and the challenge of communicating frequently-changing medical information while providing support to the baby’s parents and other concerned relatives.
Faizal: This case concerns an undergraduate whose traumatic brain injury results in locked-in syndrome. His doctors, nurses, and home carers must meet the challenges of understanding his wishes, while coping with repeated hospitalisations.
Lina: This case concerns an adolescent with recurrent leukaemia, and physician-parent conflicts over her treatment plan. It explores the rights of the adolescent patient and the possibility, consequences, and ethics of seeking judicial intervention in the best interests of a child.
Mrs Kuan: This case concerns a middle-aged professional and parent with metastatic cancer for whom potentially beneficial, highly expensive treatment has failed. It explores clinical uncertainty over how to discuss the goals of care when few options for effective treatment exist.
Mr Lim: This case concerns a middle-aged hawker’s assistant with severe and progressively worsening arthritis who relies on steroids and other anti-inflammatory medications to enable him to continue to work, but is suffering from the chronic and potentially life-threatening side-effects of the long-term use of these drugs. His polyclinic doctor is challenged to understand the coping strategies of her patient and how best to advocate for him.
Mr Bok: This case concerns a middle-aged professional and single parent whose multiple health problems are exacerbated by his smoking and alcohol use, and who is viewed as a ‘difficult’ patient by hospital and clinic providers. The patient’s health problems could be alleviated by transplant surgery, but the hospital staff is uncertain whether this patient will adhere to the post-transplant regimen.
Mrs Khoo: This case concerns a single parent with a previous history of drug addiction who has completed a programme of drug rehabilitation and is working in a halfway house. The patient is seeing her general practitioner periodically as follow-up to specialist treatment for hepatitis. The patient’s mother, who helps with childcare while her daughter is at work, phones him with a problematic request.
Ms Mendez: This case concerns a foreign domestic worker hospitalised for diagnosis and treatment of suspected pneumonia. Her health insurance coverage is likely to run out before she can be safely discharged, and her doctors are uncertain about this patient’s options and their responsibilities as advocates.
Mdm Lee: This case concerns an elderly nursing home resident with advanced Alzheimer’s disease who, while she was competent, completed an advance care plan that documented her explicit refusal of artificial nutrition and hydration. Confusion and family conflict arise after a staff member makes an ad hoc decision to insert a nasogastric tube.
Mr Shi: This case concerns an elderly retired businessman who has long been concerned that he would develop Alzheimer’s disease. The man had expressed general preferences about his future medical care to his eldest son, and he has now developed some memory problems. When the patient’s general practitioner diagnoses a comorbid medical condition, the patient is referred to a specialist. His son and other family members are uncertain how decision-making about treatment for this condition should proceed.
Mr Yung: This case concerns a middle-aged professional and parent in a minimally conscious state, his wife’s emotional and practical challenges in making decisions on behalf of her catastrophically-injured spouse, family conflict, and the responsibilities of the healthcare team.
Mdm Wu: The case concerns an elderly retired teacher with decision-making capacity who leaves decision-making to her eldest son after she declines surgery to repair a fractured hip. Conflict erupts between the eldest son, who lives overseas, and his sister, who is their mother’s main caregiver. The healthcare team must resolve the conflict while addressing the caregiver’s concerns about whether the care plan reflects an informed decision.
Caring for Older People in an Ageing Society (Volume II)
Of the 10 cases under this theme, 5 feature relatively independent older people living with chronic health conditions or age-related frailty. Three cases highlight older people with significant cognitive impairments due to dementia or stroke, and two cases are set in the same nursing home and focus on discussions among bedside staff and among administrators.
Case summaries:
Mdm Kwok: This case concerns a retired seamstress who lives alone in a one-room HDB flat and has lived a relatively active life despite diabetes and hypertension. She is visited by Mr Chu, a case manager at a community-based organisation who is unclear what he should be doing for her. Should he be encouraging her to be healthier, or supporting her choices, even if they could lead to poorer health?
Mr Tsao: This case concerns a widower who lives alone in an HDB flat. He is visited by Mr Sengupta, a retiree and volunteer befriender, who is concerned about the older man’s lack of interest in conversation or socialising. What should a befriender do for Mr Tsao?
Mr Goh: This case concerns a man who spends all day at the food centre in an HDB block, observed by Mr Rasheed, a coffee stall hawker, who wonders if the older man is safe on his own but is reluctant to get involved in another family’s business. What should a bystander do?
Mrs Kumar: This case concerns an ageing caregiver who is undergoing dialysis and who worries about what will happen to her son who lives with chronic mental illness. Should she ask her daughter, Amrita, to take over her caregiving duties?
Mr Yap: This case concerns a man who has worsening pulmonary disease and who cares for his wife, who has mild dementia. How should his son, Alex, respond to the needs of his parents?
Mr Tan: This case concerns a man with moderate dementia who lives with his daughter Leila and her family, and is cared for by Nabila, a foreign domestic worker. When Mr Tan’s behaviour at an adult day centre jeopardises his placement there, how should his extended family respond to his changing care needs?
Mr Ali: This case concerns a man with neurological and physical impairments in the aftermath of a stroke, who is cared for by his wife Mdm Siti, and Enziroh, a foreign domestic worker. When Mr Ali’s home care plan falls apart repeatedly, what should hospital staff do differently?
Mdm Cho: This case concerns a woman with advanced dementia who is cared for by Smita, a foreigner domestic worker, under the supervision of Serena, Mdm Cho’s daughter. When Mdm Cho begins to choke and spit during Smita attempts to feed her, how should Smita handle Serena’s expectation that she will be able to cope with the problem?
Ms Yeo: This case concerns the director of nursing at a nursing home, who convenes a staff meeting to talk about a common problem. What should staff do, and refrain from doing, when a resident with dementia hits another person?
Mrs Kulkarni: This case concerns the director of a nursing home, who meets her director of nursing and other senior staff to talk about shortcuts. Is it appropriate to use diapers to save time even if a resident does not need them, or is the practice ethically problematic?
I thank the project team, authors of the Casebook’s Practice Perspectives, and our contributors from healthcare and social care institutions across the country for creating a ‘living’ work to support a community of professionals, caregivers, and volunteers, in fruitful discussions of challenging ethical issues in their everyday teaching and learning activities.
Seeing the ways that this work might be used in Singapore and beyond local settings is an exciting prospect for the project team. We are indebted to the Lien Foundation and the Yong Loo Lin School of Medicine for their support of this project.
Dr Jacqueline Chin
Editor-in-Chief, A Singapore Bioethics Casebook
Centre for Biomedical Ethics, Yong Loo Lin School of Medicine, National University of Singapore
May 2017
