I received an urgent phone call for help – a young single lady, CK who was in her forties, had been battling with advance breast cancer, and she was allegedly crying in severe pain. The caller was the patient’s sister, not a healthcare worker. Even though palliative care had been around in Singapore for a few decades, there were still patients with far advance conditions who somehow did not receive adequate pain relief, not to mention a timely referral to palliative care services.
The given address brought me to a humble neighbourhood in an old public housing estate, where CK stayed with her mother. As I traversed the long corridor that led to her apartment, I was greeted by sights, sounds and smells of the 70’s or 80’s – the laundry, foot wear and potted plants that lined the walkway; the banners and altars, calligraphy, and garlands that fronted the apartments; the loud radio or TV blaring out of the front doors that were seldom closed; the smells of cooking (someone’s always frying fish!), stale cigarettes and incense.
Like many others, CK’s apartment front door was left opened. But in contrast to the laid-back placidity of the neighbourhood, there was a nervous buzz within. A motley crowd had gathered in CK’s apartment, that included several uncles and aunts, her siblings and their spouses and a few teenaged nieces and nephews. An extended family of this size was already exceptional in modern Singapore, and even more extraordinary was how they have congregated, not for some joyous festivity, but out of concern and care for an ailing member.
I was quickly escorted to her in the bedroom, only to be greeted by a terribly sorry sight – CK, emaciated and jaundiced, was crying and writhing in pain on her bed. This was a pain emergency! Any attempt to examine the exquisitely tender areas over the liver and bones only aggravated the pain. And even my explanation about how I intend to give her morphine felt like a callous delay in the face of her suffering. All this time, her family stood around the bed, helpless, anxious and now expectant.
Minutes after I gave her the morphine injection, she heaved and finally seemed to settle. I started to breathe again.
Then my worries began. When patients avoided morphine until they are so close to dying, death may be misperceived to be a consequence of morphine, just by reason of their temporal proximity. In such a big gathering of family members, it would be presumptuous to believe that all of them were ready for her death. I decided to first engage CK’s mother, who was the one most likely to feel the impact of her death.
We sat in the next room, together with CK’s sister. CK’s mother said she understood how ill CK was and only hoped that her pain may be relieved. We were still conversing when a commotion erupted from CK’s room. It began with a few excited voices, and rapidly escalated into a chorus of shouts and gasps. Some male voices could be heard shouting out short and curt instructions.
“I think we better see what’s going on,” I finally said to mother and sister, who were probably too polite to interrupt me – they come from a generation who still held a generous regard for the doctor.
As I re-entered CK’s room, I was horrified to catch a glimpse of a few of the guys struggling to lay CK down onto the bed!
One of the uncles must have spotted my alarmed and quizzical look. “CK wanted to pray to the spirits… they hoisted her up because she wanted to kneel and pray to them with joss sticks… There were two of them, over there.” He pointed towards the ceiling where the 2 apparitions supposedly appeared.
CK was quite awake now, though obviously exhausted by the exploit. It was amazing how she could have mustered that strength to even get up. And the pain? “It is less painful now. Thanks,” she replied.
Beyond the bewilderment over what just happened, I was actually relieved. I might have under-estimated the capacity of her body and perhaps even the prognosis. I decided to take my leave after giving some instructions on how to manage her pain with morphine, as well as prescribing medication if less congenial hallucinations appeared.
I tracked back the same corridor, still musing about the experience. But before I can get to the carpark, the phone rang again. It was CK’s sister.
“Can you please come again, doctor?” She was weeping between words: “CK just passed away.”
I rushed back to the apartment. My mind was already whirling with all the possible aftermaths of such a sudden death.
But while some of them were crying, most of the family grieved quietly. Some had started rearranging the altar as per the Taoist tradition. There was a sense of heaviness but also of completion or conclusion; not unlike how one might feel at the end of a tragic movie. A couple of the family members came over to thank me.
I had to meet CK’s mother again. Her eyes were puffed from crying; mine was trembling as I touched into her sorrow. I could not really come up with any words to comfort her. “The end happened so quickly and so abruptly”, was all I could finally say.
CK’s mother nodded. Then, in a rather deliberate manner, she said: “This is ‘good’ (death). I feel very relieved that the spirit guides have come. They will be fetching her to the right place.”
For a moment, everything seemed to come together perfectly – the cultural and traditional backdrop, the neighbourhood, the family, and even the visions. Death was never merely a medical event for an individual; sometimes, it can only make sense as a collective social and spiritual experience.
The modern narrative on the end of life is often crowded and even fore-grounded by a profusion of medical details — of distressing symptoms, unrelenting diseases, futility and hopelessness. But the end of life is never merely a medical event; it is a human experience that reaffirms the inescapable human condition and what it means to really live, if only we choose to turn towards it. “Ending Notes” is a series of anecdotes depicting these human experiences, from which may be aspects that moves, inspires or edifies us about life. While the stories are based on true events, the characters and background have been fictionalised, so that any resemblance to real person(s) is purely coincidental and perhaps reflect how we can as easily identify with the human conditions portrayed.
Taido is a Family Physician with an interest in end-of-life care.