Friday 20 June 2014

Docs, nurses struggling with palliative care

Many find basic training insufficient for handling dying patients: Survey
By Feng Zengkun, The Straits Times, 19 Jun 2014

MANY Singapore doctors and nurses believe their basic training does not prepare them enough to handle patients with life-threatening illnesses.

Furthermore, some of them think there are too few specially trained medical professionals and even hospices and beds for the dying and terminally ill.

This was the worrying picture health professionals painted in a survey commissioned by the philanthropic Lien Foundation group.

"Doctors and nurses are frequently the guardians of care at the end of life, guiding patients and their families through a challenging time," said Lien Foundation chief executive Lee Poh Wah yesterday at an event to share the survey findings.

He said the results underlined the need " to make palliative care part of our health-care system's DNA".

Palliative care refers to the holistic caring for patients going through the last stages of their lives, by meeting their emotional, physical and other needs to minimise their suffering and maximise their quality of life.

The Ministry of Health estimated that by 2020, more than 10,000 people a year would need such care, up from 8,000 in 2009.

About 200 doctors and 425 nurses from across the health-care spectrum were surveyed between February and April.

About six in 10 doctors and four in 10 nurses said their basic training did not prepare them to handle patients with life-threatening diseases.

"The focus during my time in medical school was all about management options first, and palliation was taught or considered as the last resort," said an unnamed doctor in the survey. "The preparation of our doctors is sorely lacking in end-of-life issues... We are taught to avoid and not embrace it, and then we see that death is more the norm than the exception when we enter the workforce."

The National University of Singapore's Yong Loo Lin School of Medicine, for example, devotes only four days of a student's entire medical course to palliative care.

Its dean Yeoh Khay Guan said however that this was time spent in the hospice, and other aspects of the students' curriculum - such as how to communicate with patients - were relevant as well. More training in palliative care is in the works, he added.

"We plan to expand and enhance the training... from the third to the fifth year of studies, in a variety of practice settings, including hospices, home care and in hospitals," he said.

There are 46 palliative care medicine specialists in Singapore. As of August last year, there were about 600 palliative care-trained nurses.

There were 35,829 registered and enrolled nurses at the end of last year.

The Lien Foundation recommended several measures to improve "the quality of death" in Singapore. These included making sure doctors and nurses have the skills to talk about death and dying with patients despite the stigma, superstition and discomfort surrounding the issue.

Meanwhile, new national guidelines on end-of-life care are expected to be unveiled at the end of this month. These will ensure that doctors identify in advance patients who need such care, as well as caregivers who are at risk of severe grief.

The guidelines come after the Health Ministry accepted recommendations from a broader report called the National Strategy for Palliative Care in 2012, which looked at how to deliver such care in a more coordinated manner.

Some findings

ABOUT 200 doctors and 425 nurses were surveyed earlier this year about their thoughts on death and dying in Singapore.

These are some of the results:
- 98 per cent of doctors and 95 per cent of nurses feel that hospice palliative care should be made readily available.
- 62 per cent of doctors and 38 per cent of nurses feel that their basic medical or nursing training was not enough to prepare them to handle patients with life-threatening illnesses.
- 74 per cent of doctors and 46 per cent of nurses felt that medical professionals do not know enough about palliative care.
- 85 per cent of doctors and 76 per cent of nurses felt that there should be national conversations about death and dying.

More being done to develop palliative care services: MOH
Channel NewsAsia, 19 Jun 2014

The Ministry of Health (MOH) on Thursday (June 19) responded to the Lien Foundation survey findings on palliative care in Singapore, saying it recognises the need to further develop such services and raise awareness of end-of-life issues.

The survey findings reported by the Lien Foundation on Wednesday showed that almost all doctors and nurses consider hospice palliative care important for those with life-threatening illnesses, but there is insufficient training for healthcare professionals and trained staff to offer such care.

In response, MOH said manpower training and development is key to further developing palliative care services in Singapore and that it has "made some progress in this area in recent years".

The number of nurses trained in palliative care, for example, has been increasing from 23 in 2009 to 594 at the end of 2013, it said. For doctors, the National University of Singapore's Yong Loo Lin School of Medicine launched its Graduate Diploma in Palliative Medicine for the 2014-2015 academic year, which was fully subscribed, it said.

The course aims to train doctors, especially family physicians, to be competent and confident in managing patients with palliative care issues, both in the clinic and home settings, the ministry added.

"Nevertheless, we are aware that we need to do more as we raise the awareness of end-of-life issues and palliative care services," a MOH spokesperson said.

In addition, MOH said it is working through the Regional Health Systems framework to build the capabilities of primary and community care providers.

It cited the Project Care initiative by Tan Tock Seng Hospital as an example, which has been running with MOH funding since 2009. Through the programme, Tan Tock Seng Hospital provides end-of-life care support to six nursing homes in the central area, as well as provides training in geriatric and palliative care and advanced care planning to nursing home staff.

The MOH spokesperson added the ministry will provide more details of its plans for the palliative sector later this month at the Singapore Palliative Care Conference.

Insufficient training, manpower to care for terminally-ill, survey finds
About 74 per cent of doctors and 46 per cent of nurses say medical professionals do not know enough about how to provide care for such patients, according to a survey commissioned by the Lien Foundation.
By Tan Qiuyi, Channel NewsAsia, 18 Jun 2014

While almost all doctors and nurses consider hospice palliative care important for those with life-threatening illnesses, a number of them feel that medical professionals do not know enough about this approach to care-giving, a survey commissioned by the Lien Foundation revealed.

The report on the findings of the survey, released on Wednesday (June 18), showed that 95 per cent of doctors and 94 per cent of nurses surveyed considered hospice palliative care important for the terminally-ill, while 98 per cent of doctors and 95 per cent of nurses want such care to be made readily available.

Hospice palliative care is a holistic approach to caring for patients going through the last stages of their lives, by meeting their needs - physical, emotional, psychosocial and social - to alleviate suffering and maximise the quality of life for patients and their loved ones.

The report suggested the following areas of action for the local healthcare community and policy-makers to consider:
- Enhancing basic medical and nursing education as well as continuing professional training to increase the skills and knowledge of hospice palliative care of doctors and nurses
- Equipping all doctors and nurses with the skills of how to talk about death and dying with their supports
- Incorporating palliative care principles in all healthcare settings, and fostering a culture and environment that supports better end-of-life care
The Lien Foundation commissioned Blackbox Research to conduct the survey, polling more than 200 doctors and 400 nurses on their views on death and dying. The survey was conducted from February to April this year.


The survey found that 74 per cent of doctors and 46 per cent of nurses felt medical professionals do not know enough about hospice palliative care. Among those with frequent contact with terminally-ill patients, about half - 44 per cent of doctors and 59 per cent of nurses - said they were familiar with hospice palliative care.

"This suggests a gap in the knowledge needed to support patients in end-of-life matters," the Lien Foundation said in the report.

One possible reason could be the lack of education in palliative care. According to the survey, 62 per cent of doctors and 38 per cent of nurses said basic medical or nursing education was not enough to prepare them to support patients with life-threatening illnesses.

Lee Poh Wah, CEO of Lien Foundation, said: "It's a reality check. Doctors and nurses are insiders, they have seen death, dealt with death up close, they know the limits of medicine"

"It is important that patients can have informed choices, they can clarify their care preferences, but at the end of the day, the supply side must also meet their needs. The supply side meaning the health care institutional capacity, the skills of the clinicians, must match up to the demands of the public," Lee added.

Medical students at the Yong Loo Lin School of Medicine at National University of Singapore (NUS) receive about four days of training in palliative care in their entire medical course.

For those at the Lee Kong Chian Medical School at Nanyang Technological University (NTU), it's one week.

Palliative care is an elective component for enrolled nurses here, while nursing degree and diploma holders receive four to six hours of lectures on the subject in their entire course.

In contrast, nurses in degree courses in the UK, like Manchester University, get two weeks of classroom teaching and one week of hospice attachment.

Doctors and nurses say the system's weaknesses in supporting the dying, are insufficient training and expertise, lack of information on palliative care, not enough hospice facilities or bed shortage, affordability and discomfort talking about it.

The subject of palliative care is delicate for doctors to raise because patients or their family members may think they are giving up on treatment.

Associate Professor Pang Weng Sun, Vice-Dean Clinical Affairs, Lee Kong Chian School of Medicine at NTU, said: "The line between responding to treatment and no longer responding to treatment is not always clear. Sometimes we know there are more we can do to help a patient, to continue treating the patient but it may only help to a certain extent, it may not really cure the patient. But when do we throw in the towel and say let's stop all treatment becomes a very difficult decision even for the clinicians sometimes."

There's also a shortage of trained personnel. There are only 46 palliative care medicine specialists, that's equal to 0.4 per cent of Singapore's close to 11,000 doctors.

The situation for nurses is also dismal -- 1.9 per cent of the 36,000 nurses here are trained in palliative care.

How medical professionals are trained also plays a part, said Dr Noreen Chan, Senior Consultant of Palliative Medicine at National University Health System.

Dr Chan said: "We are very good at telling people how the body works, what happens when the body breaks down, and how to fix that problem. This is what I call the disease-oriented approach, and that has worked well for a very, very long time.

"But I think the downside to such an approach is when we can't fix the problem, when the disease runs beyond our control, then the natural reaction is for all of us to feel like failures but now we're beginning to realise that not being able to cure a disease or even to stop its ravages or its progression is not a failure, because there's always a person who has that disease and if you move away from the disease-focused approach to a person-focused approach. There's always something we can do for people and their families. That is really the underlying philosophy of palliative care."

Patients, too can opt to make the shift to palliative care.

The findings echo an earlier survey of Singaporeans, which found that many saw the need for more awareness and dialogue about death and dying. Medical experts say national conversations are crucial in helping people understand their role as patients.


There are plans afoot to enhance the training of healthcare professionals in this area of care. The Yong Loo Lin School of Medicine at NUS, for instance, will expand its training in palliative medicine.

Associate Professor Yeo Khay Guan, Dean of Yong Loo Lin School of Medicine at NUS, said: "Currently, undergraduate students at the NUS School of Medicine receive training in palliative care from the third year of studies. We plan to expand and enhance the training in palliative medicine from the third to the fifth year of studies, in a variety of practice settings including hospices, home care and in hospitals."

At NTU's Lee Kong Chian School of Medicine, medical students will receive hospice palliative care training in their fourth year of studies, while Duke-NUS Graduate Medical School provides one-day exposure and training in hospice palliative care for students, according to the report.

Doctors' moment of truth, despair
By Lim Yi Han, My Papaer, 19 Jun 2014

WHEN a disease starts winning the battle, it is time to make a critical decision: Should one stop fighting death and focus, instead, on a comfortable and dignified final phase of life?

Patients and their family members look to doctors and nurses for guidance.

But here's the bad news. In Singapore, most of these health-care professionals feel ill-equipped to answer this question. They simply do not know enough about palliative care, which would reduce a patient's suffering and make the remaining days of his life better.

The result: Patients continue their futile fight against death, going for chemotherapy sessions and putting up with the pain, even when there is no hope left.

Even when doctors know that the fight is pointless, they don't know quite how to gently tell the family that it may be time to accept the inevitable.

A survey commissioned by philanthropic group Lien Foundation showed that three in four doctors and nearly half the nurses here feel that they do not know enough about palliative care.

Currently, there are only 46 palliative-care specialists among some 11,000 doctors here.

This survey polled 207 doctors and 425 nurses. Only 17 per cent of these doctors and 26 per cent of nurses felt they had enough training to care for the dying.

Take the example of a cancer patient who had to choose between continuing chemotherapy sessions or going on a Haj pilgrimage. An honest assessment of his condition could help him make the most important decision of his life.

"If people know they don't have long to live, goals do change," said palliative-care specialist Noreen Chan, a senior consultant at the National University Cancer Institute, Singapore.

Pang Weng Sun, vice-dean of clinical affairs at Nanyang Technological University's Lee Kong Chian School of Medicine, said: "Very often, you are used to treating a patient with the view of curing the patient...At which point do you say, I should take a step back and maybe change my approach now, because the patient is no longer improving? It's not always a clear area and, actually, not an easy decision.

"The first thing we need to get our doctors to start working on more is, how do you start conversations about what's important to the patient...And that itself is a difficult conversation to initiate."

Medical schools here plan to expand and enhance training in end-of-life care. Currently, the amount of training in palliative care given to students in their entire medical course is about four days to a week.

The Yong Loo Lin School of Medicine at the National University of Singapore (NUS) plans to introduce simulation sessions in which students talk to "dying" patients.

It would help to have a framework to deal with the situation, said Joshua Lee, 23, a final-year medical student at NUS. "But translating that to the bedside, when you have to explain to a patient that he has a few months to's not something you can pick up from the textbooks," he said.

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