Saturday 7 January 2012

Palliative Care

Uneasy are the last days for many
Palliative care report shows more than half who die will be afflicted by chronic illness
By Salma Khalik, The Straits Times, 6 Jan 2012

MOST people do not go easy into the night.

Last year, more than 17,600 people died in Singapore, with most suffering from worsening illness and disability in their final days.

According to the National Strategy for Palliative Care report, more than half the people who die will be afflicted by some form of chronic illness that 'may extend from days to months to years'.

Out of a group of 10 people, three would die of some form of cancer, another three from heart disease or stroke, and 1.5 from pneumonia.

The report projects that by 2020, more than 6,000 people a year would succumb to cancer and almost 2,500 to stroke.

The report produced three scenarios leading to death, based on the type of illness suffered. They are just broad trajectories to help policymakers understand the care needs of such patients and provide the appropriate health services.

Path One: Terminal cancer

Patients suffering from terminal cancer would find their physical ability gradually decline. For some, this lasts just a few weeks. For others, the decline drags on for years.

This is followed by a rapid drop 'during the final days or weeks before death when the disease overwhelms the patient's functional reserves'.

For such patients, the World Health Organisation has, since 1990, recommended that palliative care start at the point of diagnosis and should go hand-in-hand with cancer treatment.

Path Two: Chronic organ failure

Patients with chronic organ failure - especially with heart and lung failure - will also experience a gradual decline in physical abilities.

But this will be interspersed with 'episodes of exacerbation' marked by worsening of symptoms and often-times admission to hospital.

Said the report: 'Each episode may be severe and may result in death although the patient often survives many episodes. The timing of death is often unpredictable and sudden.'

It suggested empowering such patients and their families by teaching them to recognise symptoms and use medicines to prevent the situation from getting worse.

On top of that, home-care teams can give treatment at home to cut the need for hospitalisation.

But patients might need to be supported by a supply of oxygen and other home adaptations.

Path Three: Frail or suffering from dementia

This is the road taken by patients who are frail or suffering from dementia. The organs in frail patients are weaker and less able to fight additional infections or illnesses.

They may survive many years and die of a sudden illness such as pneumonia.

Such patients need caregivers at home, or have to be looked after in long-term care facilities such as a nursing home.

Working towards better palliative care

PALLIATIVE care aims to reduce suffering and give dying patients the best possible quality of life for their remaining days. It also provides support for their families.

In Singapore, such care and its quality is sporadic. The team tasked to look into the situation and recommend action, headed by Associate Professor Pang Weng Sun, came up with 10 goals to work towards.
- Identify all patients with terminal illnesses so that their need for palliative care can be assessed. All health-care institutions must set up a system to identify patients early.
- All such patients should be taken care of by trained professionals. If their needs are complex, they should have access to specialised palliative-care services in an appropriate setting, with multidisciplinary team support.
- Palliative care should be delivered in a coordinated manner that ensures continuity of care across settings and over time. Public and private sectors, as well as voluntary organisations, should coordinate efforts within a regional health system.
- It should be affordable, with quality care provided in a cost-effective manner.
- There should be adequate trained health-care professionals to meet the needs of dying patients. Include palliative-care training in all undergraduate and diploma courses for doctors, nurses and allied health professionals. 
- Increase inpatient hospice beds and improve nursing-home capabilities so they can provide palliative care to patients. 
- Set local standards to ensure the delivery of good-quality palliative care. 
Increase public awareness and acceptance of palliative-care services, advance care planning and bereavement services.
- Do research to improve the quality of palliative care and help in policy decisions. 
- There should be leadership and governance to guide the development of palliative care services and ensure oversight of services in Singapore.

This is a project on caring for the dying in Singapore done by NTU undergraduates from the Wee Kim Wee School of Communication and Information. 

Calls for more awareness of end-of-life care
Patients, families need to discuss dying and care options, say experts
By Melissa Pang, The Straits Times, 6 Jan 2012

THE report outlining what is to become Singapore's national strategy to develop palliative care has called for greater awareness and understanding of end-of-life health care.

Health-care professionals have identified the lack of open discussion on death, dying and palliative-care issues as a key challenge to overcome.

By not talking about these issues, patients and their families close off possible health-care options.

The report, titled National Strategy For Palliative Care, said: 'Patients or family members may carry the misconception that palliative care is meant only for patients at the end of their life and associate it with giving up hope and treatment, thereby refusing appropriate care.'

This is where advance care planning comes in. With this, a patient decides ahead of time how he would want to be cared for when he is no longer capable of making decisions.

The report suggested that a 'consistent set of messages' on advance care planning be developed and spread so it is not misconstrued as euthanasia, for example.

A steering committee should be set up with partners from hospitals to ensure health-care professionals have a basic understanding of advance care planning and tie-ups should also be forged with grassroots and religious leaders, who can spread the message of its benefits.

The seeds of this public education drive were sown with the launch of a community programme by the Singapore Hospice Council (SHC) last October. It will involve road shows, public talks and possibly a video or TV campaign.

SHC chairman R. Akhileswaran said death is such a deeply held taboo that, with Chinese New Year coming up, the families of many patients are declining home visits from palliative-care nurses or doctors for fear of attracting 'bad luck'.

He added: 'There's nothing wrong. It's our way of life. But how do we get over this fear so that those who need these services are not denied it?'

A survey the Lien Foundation did last September found that families and caregivers play a big role in looking after patients with life-limiting illnesses, so they are the ones who need information and training on how to provide care.

Caregivers also need emotional support, short breaks from the work of caring for a patient and bereavement support.

The report said bereavement support should be given to a family both before and after a patient's death - family members may even need counselling or psychiatric services.

Dr Jeremy Lim, the executive director of the Lien Centre for Palliative Care, which put together the report, identified greater public awareness as the most critical issue that the palliative-care scene here needs to look into.

Associate Professor Cynthia Goh, the vice-chairman of the workgroup that developed the report, agreed.

She said: 'If the public asks, 'Why isn't it that everyone who needs palliative care gets it?' I think that will galvanise the Government into doing something.'

Dr Lim added that action will beget a 'virtuous cycle' when the public becomes aware and starts to ask for more and better palliative-care services.


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