Wednesday, April 11, 2012

Persistent Vegetative State (PVS) in Taiwan

A few posts down from this one I posted part of a conversation I had with a young nurses in the health system here. She had spoken of the lawsuit from the family of an accident victim against a team of neurosurgeons. Sure enough, today the Taipei Times hosted a piece  on the Increasing Cost of Saving Lives:
Seven years ago, surgeons at Tung’s Taichung MetroHarbor Hospital operated on a man who had suffered a head injury in a traffic accident, but the outcome was that the man ended up totally paralyzed and blind. At the end of last month, the -Taichung branch of the Taiwan High Court ruled that the hospital and the three doctors who performed the operation must pay the man’s family more than NT$33 million (US$1.1 million) in compensation.

One of the doctors is neurosurgeon Lee Ming-chung (李明鍾), who is famous for his valiant, though ultimately unsuccessfu, efforts to save the life of another brain trauma patient, a little girl surnamed named Chiu (邱), who had been turned away by several other hospitals.
The Chiu case was quite sad. Readers probably recall it. The girl had been beaten unconscious by her father and then refused at hospitals all over Taiwan claiming they had their quota of neurosurgical cases. She finally wound up at a hospital in Taichung, where she died.

Tung's is the big building with the rotating restaurant easily visible from almost anywhere between the slopes of Tatu Mountain and Taichung Harbor west of Taichung city. Despite its unusual name it is a first-rate and extremely well run hospital, where foreigners from ships in the harbor are taken for medical help. The sons of the founder ran for legislator posts in the recent election, some Blue, some Green.

The Taipei Times piece observes that one reason health care is cheap in Taiwan is because doctors are often not insured. Because litigation is so common -- it is not even more common because of the undersupply of lawyers -- doctors are becoming shy about entering professional specialties where the likelihood of lawsuits increases. The writer goes on:
Taiwan has the highest rate of PVS [persistent vegetative state] in the world. The number of PVS patients in the US is estimated to be somewhere between 15,000 and 40,000. According to available information, Taiwan had a total of 4,792 PVS patients as of 2008, and 6,000 PVS patients are now registered for care with the Genesis Social Welfare Foundation, a charity that specializes in this field. These figures suggest that not only does Taiwan have a very high rate of PVS, but the number of cases is increasing very fast. As to why people end up in this condition, the most common cause is scooter accidents, followed by overmedication.
I found this paragraph astonishing, since I'd never heard this distressing claim. The author notes that rates of PVS in Taiwan are 60% higher than in the US. In Taiwan PVS patients cannot be taken off life support at the request of the family; who must also help pay for the upkeep. This probably increases the number of  PVS cases. Another cause is likely the enormous number of scooters in Taiwan. Maintaining such patients is presented by the MOI as a "pro-life" position. Taiwan Panorama had an article on the local hospice system a while back, with some comparisons to similar systems in Japan:
The costs, in terms both of money and manpower, of the Japanese model are huge-monthly care for the average patient costs roughly NT$380,000, a world apart from the NT$50,000 spent by CSWF. As the majority of PVS patients in Japan entered their states through automobile accidents, much of the funding for their care comes from fees levied on vehicles for that very purpose. CSWF, on the other hand, receives only 10% of its funding from the government, with the remaining 90% coming from public donations.

After starting initial work on the hospice in 1980, Cao was finally able to open the hospice six years later, taking on patients from poorer families free of charge. To date, CSWF has cared for nearly 500 such patients.

Patients in vegetative states are cared for by professional caregivers at CSWF, with nurses providing care 24 hours a day over three shifts. Every two hours the patients are rolled over, patted on the back to help clear their airways, and have their linen changed, and they are fed once every four hours. They are washed every two days, to help maintain their cleanliness and hygiene, as well as their dignity.

Over the past 18 years, CSWF has opened branch hospices around the country. The goal is to have 23 locations in cities and counties throughout Taiwan, Cao says. Thus far they have completed 13, with another four in the planning stage, and the organization hopes to meet its goal within the next five years.
The GSWF home page is here.

UPDATE: A nursing professor explained to me that in cases of terminal disease, if the entire immediate family and the succeeding generation signs a DNR and the hospital ethics committee approves, then the tubes can be removed by doctor. This change was made last year. But for a coma patient whose prognosis is uncertain, that is still not possible.
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8 comments:

Anonymous said...

Fascinating!

I have known several Taiwanese who have been caring for a relative (parent) in a PVS. They refuse to pull the plug for reasons of filial piety. They can't bring themselves to take actions that may "kill" mom or dad.

Anonymous said...

If the families can not "pull the plug" can the victim have a living will that would have a do not resuscitate clause or do not care clause that could override the restrictions made in your article? Failing that could there be a clause REQUIRING removal to our home countries where a DNR could be executed (pardon the pun)?

Anonymous said...

When a culture of entitlement intertwines with misinformed notions of medical care, what you have is a society that will place undue blame upon healthcare providers for NOT CURING illness and death. In modern, technologically-advanced medicine and medical care, viewing death and illness through strictly emotional states or traditional i.e. filial way of thinking, prove to be problematic indeed.

I have encountered many traditional Latino and Asian families who put their loved ones through torture during last days of their loved ones' lives. On the surface they do this because of filial love and such, but in reality it also stems from selfishness.

I remember one glaring incidence with a Chinese family whose patriarch, a 94 year-old man, was kept alive on life support simply due to the family's selfishness and ignorance of medical care. The poor man was in last stages of liver disease, which meant his cardiovascular system was also affected. He "coded" meaning stopped breathing/ no heartbeat many times. Yet the family kept insisting that we resuscitate him using "full code" i.e. chest compressions, intubation, meds, etc...

The poor man had ribs broken from chest compressions during one such code. The family blamed the medical and Nursing team for that, and couldn't see past the fact that it was time to let go and make this 94 year-old, frail, sick man a DNR instead of Full Code. We kept educating the family that were it not for modern medicine, dad/ grandpa would have died a long time ago. They could see for themselves how much pain the man was in, regardless of how much meds and sedatives we were pumping into him. Nevertheless no one in the family wanted to "kill" him because they loved and honored him so much. The poor man suffered for many more weeks until he finally died from DIC, which is an awful way to die. The family made him suffer needlessly and die in such awful manner....it was cruel.

To me, this is filial love twisted into sick, macabre, version of filial love. It is in essence selfish in nature, not filial. Keeping a dying person alive simply for the gratification of "filial duty" is sick and twisted. Filial love is a good trait, but all good traits when taken to extreme can become paradoxically bad, is it not true?

Jenny

Anonymous said...

When my late mother was sick with NHL, I became her caretaker and was involved in her medical care plan. Her diagnosis wasn't good for the start, it was Stage IV so I knew intellectually that her chances for full recovery was low. However, emotionally I wanted for her to beat the cancer and live so badly, I did everything to ensure that her medical, dietary, and supportive regimen was up to latest, most efficacious standards. My point is that there is a way to reconcile both intellectual and emotional aspects of caring for loved ones who are critically ill.

After 7 months of fighting her NHL, my mother died at Stanford where she was being treated. She was only 63. I was with her and was updated on her condition right up until the end. I made sure she was not in pain and did not suffer. Our family held vigil at her bedside, and we even held a Buddhist ritual at bedside right after she passed. My mother had fought her cancer so bravely and I wanted her to live so so badly as well, but it wasn't meant to be. When her condition took a drastic turn for the dire and death became imminent, plus her pain/ suffering unbearable, I knew it was time to do the kind and most loving thing. I let her go. Losing my mother was the hardest thing to hit me ever, as we were best friends as well. I took sabbatical from work for a period of 7 months after she died because I couldn't handle being in a hospital environment.

Illness and death under modern medicine can prove to be tricky for traditional societies to reconcile. Add to this the issue of managed care/ government-provided healthcare, and you have a problem that needs much educating and addressing.

Jenny

ALX said...

They might have DNR or living wills that state they want to have no treatment, but in reality if even one relative says "No you shouldn't pull the plug." the hospital goes with their wishes. This way they keep the relatives happy but also don't have to foot the bill (the NHI does that).

Tom said...

Good article, Michael. Hospice care seems to be getting a bit more press coverage over the past year. The idea of "Do not resuscitate" has come a long way, but from what I have seen there are still many cultural hurdles to get over. Making an actual written will itself is still a step many of my relatives feel is just asking for death.

vin said...

Deciding not to tell a terminal patient that he or she is dying -- and families have the right in Taiwan to decide whether a doctor can tell a patient this -- is selfish beyond measure. Taiwanese culture is glaringly deficient in humanity until the "moral" prinicple of filial piety is no longer entitled to enact this crime against what it means to be mortal -- to be human.


May traditional culture in all its pathetic, disfigured, and fear-ridden precepts against straight expression of feeling and its sabotage of personal autonomy not sink one of the better universal health-care systems in the world.

Feiren said...

I'm not sure about how many doctors are insured, but it is true that medical malpractice claims are increasing in number and amounts awarded much to the chagrin of doctors.

However, I don't think the lack of lawyers holding down the numbers. In fact, doctors who kill or injure their patients are routinely indicted for criminal professional negligence. If convicted, the civil suit for damages just piggy backs on the criminal case. So prosecutors, not private lawyers, end up doing most of the heavy lifting.

Doctors in Taiwan are angry about being convicted in criminal cases for negligence, and I believe rightly so. Doctors make mistakes. If it is serious enough, they should pay for it, but not be convicted of a crime.

However, of course what doctors really don't like is being held accountable and judged by non-medical professionals. That's natural, but not justified.