SINGAPORE: Many say they would die for their children, but throat cancer patient Ramamoorthy Rajeswari lived for them.
Hanging on to life by a thread, and in the midst of a global pandemic in June last year, she boarded a flight to India where her two children were. Her daughter and son – then 12 and nine years old – were sent there in January 2019 to be taken care of by family when Madam Rajeswari's cancer progressed.
Seeing them was her last wish.
The Singapore permanent resident had already defied her doctors’ assessment on how long she had to live. There was no guarantee she would even make it to India – cancer had wrecked her body and it was starting to fail.
“From a medical perspective, we didn't think that it was going to happen, said Dr Tricia Yung, one of Mdm Rajeswari’s palliative doctors from Tan Tock Seng Hospital (TTSH).
She suffered a few near-death episodes where she bled profusely, her oxygen level plummeted and she lost consciousness.
“She was holding on to her phone all the time. She was looking at the pictures of the children, family back home in India," said Dr Yung, an associate consultant.
An operation to treat her throat cancer had taken away her ability to speak. But it was obvious to the medical team Mdm Rajeswari "really, really missed home" and that going back to India was her last wish, the doctor said.
Her health was not the only obstacle. The COVID-19 pandemic had taken hold in India and tens of thousands of new cases were sweeping across the country. Flights from Singapore to India were few and far between.
With help from Air India and Singapore's Civil Aviation Authority and Ministry of Foreign Affairs, approval for Mdm Rajeswari to fly was granted just four hours before the flight departed.
"THE ONLY CHANCE"
Speaking to CNA at TTSH, Dr Yung recounted the journey to getting Mdm Rajeswari on a flight.
“It was really a 48-hour feat. From the moment we heard there is a flight going back to Trichy – the hometown – to the very last moment that we managed to send her on board,” she said.
“Though medically she was not fit yet, we felt that this was the best chance ... the only chance.”
Once they found a flight, the team sprung into action. The flight was fully booked, but other passengers gave up their seats to accommodate Mdm Rajeswari, her husband and her sister.
Higher-ups in the palliative care department personally went down to the airline’s office to explain Mdm Rajeswari’s situation and medical condition.
But 24 hours passed and they still did not receive clearance. They then turned to the Ministry of Foreign Affairs.
“The clearance and confirmations came only four hours before the actual flight, so it was such a challenging and adrenaline-rushed 48 hours,” said Dr Yung.
Beyond the logistical challenges, Mdm Rajeswari's medical condition was unstable. But doctors treated her in the hopes that she would be stable enough to survive the flight.
“We quickly gave her blood transfusion, topped up her oxygen and made sure that all her wounds were nicely packed,” Dr Yung said.
They taught Mdm Rajeswari’s caregivers – her husband and her sister – what to do if she had a medical emergency on the flight.
The final hurdle before they could leave: They didn't have enough oxygen cylinders for her on the flight, but managed to secure additional cylinders from an ambulance.
When they touched down in Trichy, Mdm Rajeswari and her family were met by a medical team that the TTSH team had reached out to through the Asia Pacific Palliative Care Network. Mdm Rajeswari was taken to a hospital so that her condition could be stabilised.
It was in the hospital that Mdm Rajeswari finally got to see her children.
Her husband Rajagopalan Kolanchimani – or Mr Mani – recounted her joy at seeing their daughter and son. She was unable to speak but communicated with them using an app.
"She wrote that she is okay, that she would be back and we could live together again," he said.
Mdm Rajeswari was discharged a few days later to make her final journey home about 50km away from Trichy.
On Jun 27, 2020, about two weeks after they arrived in India, Mdm Rajeswari died.
Mr Mani, who was described by his wife’s doctors as a “calm and devoted caregiver”, was by her side.
“Suddenly, she lost consciousness … When I checked, she had no pulse. The doctors had advised not to resuscitate her,” he said.
A neighbour who is a doctor confirmed her death. She was 44 years old.
In a tearful interview recounting his wife's journey home, Mr Mani spoke about her will to be with their children.
“She said if she doesn’t see her children, she won’t leave the world, she will stay,” he said. “She was so happy.”
He is still in disbelief that they were able to make the trip.
“I didn’t believe it would happen. They told us that we could go on Jun 10, a day before that, but we didn’t believe it at all. Because the COVID-19 situation was bad, and so was hers.
“Even in the ambulance on the way to the airport, I didn’t believe … Nobody believed that I could go. My company didn’t believe that I would be able to go.”
Even when they arrived in India, Mdm Rajeswari could not believe she was there, he said.
“It was so difficult, but I was also happy that I was with my wife (when she died). But when she was no more, that’s when it really got bad for me, when I knew she was not going to be around anymore.”
Mr Mani said he is grateful to donors and those who gave up their seats so they could be on the flight. Most of all, he is grateful to the doctors who worked tirelessly to make the trip possible.
Dr Yung said that the team felt “compelled” to fulfil Mdm Rajeswari's last wish because they were “touched by her determination and love”.
WHAT IS PALLIATIVE CARE?
The TTSH palliative care team tries its best to fulfil the wishes of all its patients, Dr Yung said.
The overarching theme and aim of palliative care – the care of patients with a limited life expectancy – is “adding life to days whether days can be added to lives”, she said.
It involves not just handling the patient's physical care, but also the psychological and social aspects of their lives.
Palliative patients are predominantly those with advanced cancers, who have a “high symptom burden”. The team also looks after patients with organ failure, who have equally high needs, she said. Patients typically have up to a year left to live.
When struck with illness and facing death, things like success and material things become less important. “It's about what gives them meaning and what's the focus and priority in life next,” she said.
“Number one is family, good symptom control or good death.”
Medical social worker Corinne Lee, who is with the palliative patient from the start of their journey, said her team helps patients with both emotional and practical issues like settling their CPF nominations.
“Some patients will not want to explore further about coping until all these (practical) things are sorted out, so we deal with whatever they present first,” Ms Lee said.
The hospital also has art therapy and music therapy options for palliative care patients, which have been shown to help their pain levels, reduce their anxiety and improve their mood.
How accepting patients are of death usually depends on the stage of life they are at, said Ms Lee.
The elderly who feel they have fulfilled their duties as parents are more accepting. Those who are younger, and especially those who kept to a healthy lifestyle, tend to be angry. They also worry about their families, she said.
Although death can be a taboo subject, Ms Lee said that when she broaches the topic with patients, they are “quite open to talk about it”.
“Sometimes they may be afraid to talk about it because they're trying to protect their family. Because sometimes it's the family members that are so openly grieving and telling them ‘I cannot live without you, don't leave me alone’,” she said.
Resident physician Dr Lynn Wiryasaputra, who is also from the palliative care team, said family members can be over-protective.
It’s “very common” in Singapore for family members to hide the diagnosis from their loved ones, she said.
“They feel that if the loved one who's sick is given the bad news … it will just make them lose all hope and everything will go downhill from there,” she said.
However, the team advocates sharing all information with the patient so that they can find out the patient's wishes and can make plans.
“It's a lot easier to talk about treatment options if the patient is aware of what disease they have,” she said.
For Mr Mani, who was there every step of the way for his wife, living without her has been a struggle.
"It’s been difficult to live a life without her, but there’s no choice. She took care of everything," he said.
"My wife was very brave. She would say 'Even I am brave, you have to be brave too'. I am managing with that courage."