Friday, 2 December 2011

Palliative care - Doctors help patients say final farewell in comfort

Palliative care is an area growing in importance in S'pore, designated a sub-speciality
By Salma Khalik, The Straits Times, 1 Dec 2011

WHILE most doctors are trained to save lives, Dr James Low is also trained to help those who are dying to go gently into the good night.

As one of only 33 palliative care specialists here, he looks after not only the medical needs of seriously ill patients, but also their emotional, social, psychological and even spiritual needs - with a support team.

'When dealing with dying patients, one needs to focus on life, bearing in mind that the time left for the dying patient is short, and therefore is immensely precious,' said Dr Low, 46, who heads the geriatric medicine department at Khoo Teck Puat Hospital (KTPH).

'Palliative care is really about living life to the fullest, even though that life is truncated.'

Health Minister Gan Kim Yong recently described palliative care as 'that special human touch and compassion delivered to patients at the end of life... (it) involves listening to and respecting the patient's wishes on their care preferences'.

About 17,000 people die in Singapore each year, with one in four receiving palliative care in a hospice, at home or in a nursing home. Over half die in hospital.

In 2007, then health minister Khaw Boon Wan pointed out that Singapore lagged behind other countries in giving people 'a good death'. While most prefer to die at home, more than half actually do so in a hospital, he said.

He hoped that recognising palliative medicine as a speciality would encourage more doctors to train in it - and give the dying a better quality of life in their final days, weeks or months.

Palliative medicine has since become a newly designated sub-speciality in Singapore, with the first specialists officially recognised in February this year.

Since then, 20 doctors, including Dr Low, could call themselves specialists in that discipline.

Since then, another 13 have qualified. More are in training and expected to join their ranks in the coming years.

Among them, 10 were non-specialists now working at either the National Cancer Centre or a hospice. The rest were already specialists, primarily in the fields of geriatrics, internal medicine and cancer.

Most work at public hospitals.

Singapore also has 294 nurses trained in palliative care, up from 257 last year.

Dr Low said palliative care doctors lead a multidisciplinary team to manage a terminally ill patient. The team is made up of nurses, doctors from various disciplines depending on the illness, a social worker, a physiotherapist, an occupational therapist, a dietician and a pharmacist.

In some countries, spiritual leaders are part of the team.

Together, they try to deal with all the patient's concerns, such as pain, fears, the need for caregivers, financial difficulties and coming to terms with death.

Best places to die

A STUDY last year by the Economist Intelligence Unit, commissioned by the Lien Foundation here, ranked Singapore 18th out of 40 countries in its Quality of Death Index.

It looks at the end-of-life health-care environment, cost and availability, and quality of care to people who are dying. Things like public awareness, government policies and use of painkillers all contribute to good end-of-life care.

The best places to die, according to the study, are Britain, Australia and New Zealand.

All three have national, end-of-life health-care strategies, with Britain pipping the other two because of its long history of charity hospices.

Dr Low said there is a shortage of palliative care doctors and nurses in hospitals, nursing homes and hospices, and home palliative care services that allow patients to die at home while they are cared for.

Already, palliative care is increasingly sought by patients and their families. This is because 'being saved' can mean considerable pain and discomfort for a patient, and with little benefit.

Patients and their families are also opting for 'do not resuscitate' orders should their heart fail. A National University Hospital (NUH) study found that over half of dying patients have such orders.

Not a death sentence

DR ANGELINE Seah, 42, a palliative doctor at NUH, said that deciding not to be resuscitated and opting for palliative care is not a death sentence. Two out of three such patients actually get well enough to go home. Some continue to live good lives for months or even years.

This can happen when they recover from the problem that sent them to hospital, such as an infection. Although on palliative treatment, they would still be given antibiotics and other non-aggressive treatments.

In fact, a three-year study in the United States published last year found that patients with lung cancer on palliative care survived three months longer than those who were treated aggressively.

Doctors speculate that with palliative care, there is less trauma to the body, so it can fight the disease better.

Associate Professor Chan Mei Yoke, 48, of KK Women's and Children's Hospital, said her longest-surviving palliative care patient has been with her for six years. He has incurable brain cancer.

Prof Chan, who is an oncologist and palliative care specialist, said radiation and chemotherapy were just giving him side-effects, but no benefits.

Now, the 23-year-old is treated for his symptoms, such as vomiting and headaches, and also given hormones he lacks, like thyroid hormones and steroids.

'We don't know when he's going to die. It might be any time. He is relatively symptom-free now because of all the medicine we're giving him,' she said.

But not everyone lives that long after being diagnosed with a terminal illness. For Madam Margaret Chen, 68, it was two weeks from the diagnosis of her liver cancer to death. When doctors found she had the illness, it had spread to her lungs.

Her only child, Mr Derrick Wong, 48, was in a state of shock when he was told she would not survive long.

He recalls with gratitude the way the palliative doctors and nurses at NUH helped both of them in those two weeks.

They helped plan her discharge, asking if he had financial difficulties and if there would be someone to look after her if she went home. But her condition deteriorated so quickly that none of this took place.

When the end was obviously near, they allowed him to spend the night with her, even though it was in a C-class ward with other patients sharing the room.

'I brought a chair from the lounge and the ward nurse brought me a blanket,' he recalled. She died early the next morning.

Dr Seah said: 'Elderly patients usually feel their life is quite complete, and it's okay to go. But young people find it more difficult to accept.'

The final decision

DR JASON Phua, 39, a respiratory physician at NUH, said it was important to find out what the patient and his family wanted. Doctors will be honest about the prognosis, but the final decision is theirs.

'If everything that can be tried has been tried, we would suggest they consider comfort care instead,' he added.

Such family conferences can be as short as 10 minutes or take longer than an hour, but to Dr Phua, 'it's all part of doctoring'.

Not all palliative care is provided by specialists. Dr Ng Wai Chong, 42, assistant director of Hua Mei Mobile Clinic, a charity under the Tsao Foundation, looks after many frail elderly people with difficulties going to a doctor for treatment.

He and another doctor also provide 24-hour telephone support. Thanks to this care, 10 of 13 patients who died in the year ending September, did so at home.

Dr Ng feels that palliative care is something all doctors, including general practitioners, should be able to provide their patients.

KTPH's Dr Low said that being in palliative care can be painful at times, as the doctors and nurses would grieve with the family when a patient dies.

But he added: 'Journeying with our patients at the last stage of their life is a privilege; it transforms the doctor and the nurse in the most profound way.'

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