The Scandal of Terminal Care in Japan
The following situation, in which I was involved, unfortunately happens all too often in Japan.
The Japanese wife of a western man developed stomach cancer and was treated in a University hospital in Tokyo. Her stomach was removed and for some months she was reasonably well. Then her condition worsened. She lost weight, could hardly eat, and her abdomen (tummy) swelled up from spread of the cancer. A local hospital looked after her at home, with a doctor visiting once a week. This treatment was not of the highest level, with the prescribing of multiple drugs some of which were inappropriate and caused side-effects, and drugs which were needed for effective relief of pain and discomfort not being used. The poor lady’s condition progressed to the point where re-admission was unavoidable.
But what happened then? Her care (if you can call it that) was shared between a team of doctors none of whom appeared to be in overall charge, and it seemed no one was prepared to explain to the patient and her husband what the situation was and what they were trying to do about it.
But the worst failing was reluctance to use a proper pain-relieving drug, that is, morphine. Was this difficult? Did it require specialised knowledge? No. It required basic knowledge of terminal care, easily accessible to any doctor. The husband in this case had to make a thorough nuisance of himself before the staff would bestir themselves to give her morphine. Fearful of what might happen if he wasn’t there, he would not leave her side. Although she was in a single room, would they provide a bed or futon for him? No. He had to make do with two chairs. Were the staff concerned enough to ensure he could leave to obtain some food for himself and then return to the hospital? No. The place was locked up at night.
The principles of pain relief in this situation are that morphine must be given in an adequate dose to relieve the pain and it must be given regularly in order to prevent return of pain. It can be given by mouth or injection. The common practice in Japanese hospitals of using a morphine-like drug by a skin patch is a waste of time. It is impossible to get an adequate and easily adjustable dose into the blood-stream using a skin patch.
The patient, or her husband, should not have had to beg for morphine. Were the hospital doctors afraid that a terminally ill patient may become addicted? Were they afraid that such a patient’s life may be shortened? Are there rules that limit the dose and frequency of the administration of this merciful drug? Were the doctors incapable of understanding that when someone is dying, treatment aimed at cure or prolonging life is futile, and the focus of treatment must change to assist the patient to achieve a good – that is – pain-free death? This is nothing whatever to do with euthanasia. In practice, with skilled administration of morphine, when a patient’s pain and distress are relieved, they may well live longer and die peacefully, no more wracked by pain.
Where is the decency and humanity of those who have, or should have, the ability and the means to relieve another human being’s suffering, but fail to act effectively?
How long will it take in Japan before high quality palliative and terminal care are routinely available to all who need it?
Note: This problem was highlighted by a Japanese doctor, Fumio Yamazaki, in a book, the English edition of which came out in 1996, called “Dying in a Japanese Hospital”, published by The Japan Times.
© Gabriel Symonds, December 2013