生·老·病·死 (Birth, Age, Sickness, Death): Nursing Home Infrastructure & Life Before Death in Singapore

Written in October 2019.

This work was awarded the honourable mention for Tembusu College's Best Essay: AY 2019/20 Semester 1.

"This essay lingers long after reading. It combines both a rational and lyrical contemplation of ageing, appealing to the reader both rationally in its argument for changes to care centres, and also emotionally through an evocation of the transience of life. The essay achieves its end not only through evidence, but also through drawing on relevant images and poetic quotes dotted throughout the coherent argument. The student voice is particularly clear and strong, and the representation of information is highly original.".

生 - Genesis

“He allowed himself to be swayed by his conviction that human beings are not born once and for all on the day their mothers give birth to them, but that life obliges them over and over again to give birth to themselves.”― Gabriel García Márquez

Nestled behind MRT tracks along a busy road in Ang Mo Kio is a modern building clad in brown, wood-like panels that juxtapose the concrete and tar of the nearby thoroughfare. Is it a condominium? A community center? Nothing on its facade reveals its identity except for the words “Ren Ci”. Only those familiar with the name would recognize this building as a nursing home. The brand’s Chinese name translates as ‘benevolence’, in accord with its vision of providing ‘Holistic care with loving kindness and compassion’.

With better healthcare and higher standards of living, we are living longer and healthier lives. As of 2019, there are almost 600,000 Singapore residents aged 65 and above (data.gov.sg, 2019), with this number projected to increase to 900,000 by 2030 (Teng, Hock, & Ser, 2011). Besides posing policy challenges, issues of ageing and death produce tensions in our social fabric. I argue that infrastructure (both physical and invisible) play a key role in shaping the social infrastructure with regards to the way our elderly age as well as how the Singapore society perceives ageing and death.

老 - Mellowing

“I spit into the face of Time That has transfigured me.”― William Butler Yeats

Ageing is more than skin deep. Enervated, our muscle tissues erode, our senses wane and memories dissipate. To promote wellness within an ageing population, the health of the aged should be of purview. Infrastructure needs to be in place to create spaces that encourages healthy ageing among the elderly.

The 2010 Population Census shows that Singapore’s older estates generally have a larger population of senior citizens. According to the Department of Statistics, in 2019, mature estates like Outram, Ang Mo Kio, and Toa Payoh had the highest proportions of residents aged 65 years and over. In these places, approximately one in five residents are aged 65 years and over. As the needs of the population change, spaces must change too to cater to the needs of older citizens. Earlier this year, Ang Mo Kio saw its first gym for seniors, set up by ActiveSG, a national movement for active living run by a statutory board under the Ministry of Community, Culture and Youth (Teo, 2019; Sport Singapore, n.d.). The gym features equipment catered to older users, designed to put less strain on the user’s joints. Approaches like this to promote wellness amongst the elderly reflects Singapore’s neoliberalist views and the government’s emphasis on self-care, where every individual is responsible for their well-being. However, further state-level intervention is still required to carve out spaces that would cater to the needs of our elderly citizens who cannot live independently or require medical attention.

The state emphasizes the responsibility of the family unit in the provision of care for its elders, evident in the Maintenance of Parents Act passed in 1995 (Singapore AttorneyGeneral's Chambers, n.d.). Guided by filial piety, Singaporeans generally commit to a sense of duty towards their elderly. Hence, in many cases, nursing homes are the last resort families turn to for the provision of care for their elderly, even if the family is unable to provide adequate care for their loved ones at home. The stigma towards nursing homes as “places of dread” informs this decision for most Singaporeans — a missed opportunity to provide a conducive space for the last juncture of life.

病- Debility

“Unbeing dead isn't being alive.”― E. E. Cummings

Devastating diseases make up scars in the timeline of humanity. Maladies such assmallpox and bubonic plagues once wiped out civilizations but are no longer a threat in our world-class city. However, our evolving lifestyles remain a prelude to novel diseases, biological and social alike.

As a secondary school student, I had the opportunity to volunteer at a nursing home in the area on multiple occasions. Though young at that time, my impression of it remained strong. For this essay, I returned to the nursing home, with the hope that time would have allowed for progress. I am appalled that the home remains true to my memory. I was greeted by the same drab, murky green facade and I walked right past the counter, with the staff not lifting their head to question my purpose. It was as if nothing in the building was worth protecting. Just beyond the counter, I could see residents on the ground floor, all dressed in identical loose gowns, pink for the ladies and blue for the men, all lined up along the walls, gazing upon an empty courtyard. Some watched me peculiarly and I managed a weak smile. The air smelled of disinfectant, and the disinfectant seemed to have void the area of not just bacteria life but life in general. Walking down the corridor, I observed the aged lying on their beds and, for the lucky ones, staring out the windows, waiting for the day to pass. Built to the Ministry of Health’s (MOH) minimum requirement of 6 square meters per patient (2002), the rooms are devoid of privacy and personality. Nothing speaks of home! I could not bear to be in that space.

A nursing home in Yishun. October 19, 2019. The elderly sit in the same spot for hours on end, confined within the four walls of this institution.

Traditionally, nursing homes are modelled after hospital wards (Basu, 2016). From their physical space down to the systems, the focus has been on the ‘nursing’ aspect these facilities are expected to provide, not so much the ‘home’ aspect. A ‘Not-In-My-Backyard’ syndrome highlights the resulting stigma that Singaporeans have towards these facilities, a response that manifests from the lackluster infrastructure that creates an image of the homes as dismal places people go only to die in. On one account, an HDB resident complained about leaves from a nearby nursing home blowing into their fish tank, raising concern that their fish may perish as a result. Elsewhere, HDB residents with a direct line of sight to an open terrace of a nursing home protested that they do not want to see the elderly constantly. The Ministry of Health stepped in to quell tensions by establishing a wall of plants to hide the terrace from the view of the residents (Basu, 2016).

Within nursing homes, the focus has always been placed on completing checklists — meeting Key Performance Indicators such as the number of fall incidents over the conviviality of the space. Under such a system, it is easy for residents to feel institutionalized. In the documentary “Anita’s Nursing Home Stay” (Chua, 2017), TV presenter Anita Kapoor experienced life in a Singapore nursing home for two weeks. The Habitat for Humanity Singapore ambassador candidly shared her reflections on the loss of autonomy and dignity she experienced when she was made to put on adult diapers, spoonfed and tied to her bed in a body jacket at night. In some cases, physically capable seniors can assume a “learned-helplessness”, becoming increasingly reliant on the nursing staff for things they can do themselves (Kiyota, 2018). She felt that death was a constant reminder for the residents and lamented the way the nursing home stripped purpose away from their lives. She acknowledged the incredibly hard work the staff there do but asserts that more must be done to go beyond meeting the “basic needs” and address the needs of the heart and soul.

A common sight in nursing homes taking the ‘medicalized’ approach to everyday aspects of life, including meal preparation seen here. The space appears much more like a mangy hospital than a ‘home’. October 19, 2019.

In a clear deviation from the traditional model, Ang Mo Kio’s Ren Ci Nursing Home provides new hope for much-needed reforms in our city’s nursing homes. Here, residents live in rooms with only 3 others for increased privacy and comfort. Four of such rooms will form a single “living cluster”, each with its living and dining area for the 16 residents. Staff will always be on hand within the living cluster to assist when required. Modelled after HDB blocks, there is a corridor on every floor, and this common area provides residents with a space for socializing between households and floors (Ren Ci, 2019). These steps taken make a visible difference to the vitality of the home.

These spaces should be one where agency lies with the elderly. The residents should not be ‘care-receivers’, but have their decisions respected. At Himawari Home in Japan, residents furnish their rooms with furniture they own. Residents and staff plan meals, shop for ingredients and prepare meals together. Outside the kitchen, residents are also included in house-keeping tasks whenever possible. Those receiving palliative care remain engaged with the household, such as hearing or smelling the meals being prepared, keeping them grounded in the rhythm of life (Anderzhon, Hughes, Judd, Kiyota, & Wijnties, 2012). Locally, the St Joseph’s Home emphasizes this treatment of its residents as ‘Person not Patient’. A unit can enable mobile residents with dementia to go about their daily lives, negating the treatment of them as patients.  Located within the nursing home is a childcare center, complete with an intergenerational playground, designed to engage both the young and old. Interaction between the young and old is encouraged to foster mutual understanding and shape the manner the young approach senescence (St Joseph's Home, n.d.).

死 - Quietus

“When the end and the beginning are both attended to, the service of a filial son is ended and the way of the sage is completed”― Hsun Tzu

Likely to the dismay of most, the likelihood of dying in an institution is high (data.gov.sg, 2019). At present, death sees the intervention of modern medicine which attempts to prolong a life that may not be worth living. We may fear the nearing of the moment we draw our final breath, but I believe that most of all, we fear the suffering that would precede our death. Even in our world class city, we do not claim to be able to rid all the pain death brings, but we can certainly try our best to reduce unnecessary suffering. The infrastructure must reassert the essence of medicine, one anchored about compassion and humanity, providing the means for a death with dignity.

There has been a rise in the number of nursing home facilities, from 63 in 2008 to 72 in 2018 (data.gov.sg, 2019). However, to ensure quality care, old habits must die. We must see to the end of infrastructure that is detrimental to the provision of better end-of-life care. Our city’s nursing homes are currently under the purview of the Private Hospitals and Medical Clinics Act (Singapore Attorney-General's Chambers, n.d.), which governs private hospitals, medical clinics, and clinical laboratories. However, nursing homes operate under a unique set of circumstances and constraints, and the law should allow nursing homes to function as such, to provide dignified, non-medicalized care for its residents.

We must also see to the death of the paternalistic approach to ageing many of these institutions adopt, which assumes that the aged require the organization’s care right from the get-go. Nursing homes must facilitate residents in finding their purpose and provide them with the resources required to fulfill that purpose. As our city strives to be self-sufficient in various aspects, we must not forget to provide the right care required for our aged, lest the aged must move far away from home such as to Johor for quality care (Basu, 2016; MoneySmart, 2019).

To enable constructive conversations about end-of-life care to take place, we must as a society, also dispel the taboo surrounding death. The Good Death Project began as a social work initiative under Montfort Care. Piloted in 2016, the project envisions a community that is open to holding conversations about living and dying well. Montfort Care also conducts Death Education workshops that allow participants to discuss death and works with community stakeholders to promote early end-of-life planning. Only when we are comfortable with discussing death can we speak-up about and improve the way we age and die (Arivalagan & Gee, 2019).

生 - A New Beginning

“When you learn how to die, you learn how to live.”– Morrie Schwartz

In this year’s National Day Rally, PM Lee Hsien Loong spoke about ageing and the importance of maintaining a proficient senior workforce (Prime Minister's Office Singapore, 2019). For this to happen, we must begin to recognize the elderly as assets, not liabilities, and empower them to lead their lives fully. For example, with regards to fall prevention, instead of restricting movement of the residents, Ren Ci empowers the elderly by teaching seniors to avoid fall hazards and the right recovery techniques to optimize post-fall outcomes. As nursing homes continue to be built to meet demands, they should not replicate traditional models but progress to become places that the elderly can call home. Moving forward, Singapore should continue to encourage fitness amongst its citizens for healthy aging. However, for those who require care, more needs to be done to ensure that the services provided address not only fundamental needs but ensure a quality life worth living. A paradigm shift in elder care would lead to a corresponding change in the physical infrastructure of nursing homes that will create a better space for all, regardless of age.


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