End-of-life care at A&E for the terminally ill

Hospitals implement procedures to ensure that needs and wishes of dying patients are quickly met
By Samantha Boh, The Sunday Times, 18 Oct 2015

Terminally ill patients are getting the care they need faster at several hospital emergency departments, thanks to new procedures there.

Doctors and nurses at the emergency departments are now trained in basic palliative care skills and a specialist team is activated once patients who need complex end-of- life care arrive there.

In the past, the directive was to go all-out to resuscitate a patient, regardless of his condition, causing some to die surrounded by machines instead of their families.

Now, the focus is to make the patient comfortable by, for instance, getting painkillers to him quickly.

A palliative care procedure - or protocol - was first introduced at the National University Hospital (NUH) in June last year and since then, four more hospitals have followed suit.

Tan Tock Seng Hospital (TTSH) started using such a protocol in January. A palliative care team is alerted when a patient with advanced stage cancer or organ failure arrives at the emergency department.

The team is also notified if a patient is suffering from extreme pain, breathlessness and other symptoms associated with dying.

The aim is to shorten the wait for medicine, such as morphine which, under previous rules, was given only after the patient was warded - which could take 12 hours.

"We want to bring palliative care to the fore so that patients who require such care get it on time," said Dr Mervyn Koh, head of the palliative medicine department at TTSH.

The new procedures also ensure that patients' end-of-life wishes are fulfilled. In some cases, this means taking the patients to an "end-of-life care room" to spend their last moments with their families. No attempts to resuscitate are made there.

At the Singapore General Hospital (SGH), the Comfort Care Protocol was started in December last year.

The goal is to provide maximum comfort for the patient, said Dr Puneet Seth, a consultant at SGH's department of emergency medicine. This includes providing a fresh set of clothes if the patient's are soiled.

"We might not be able to prolong life but we can, at least, accord them comfort and dignity in their final moments," said Dr Seth.

A medical social worker is also called in to the emergency room when families need help with last rites or paperwork.

At Khoo Teck Puat Hospital, acute and emergency care centre (A&E) nurses are trained by palliative care specialists to assess and manage symptoms associated with dying, in a programme which was formalised in September last year. One of its A&E doctors was sent for a postgraduate diploma in palliative care this year.

Changi General Hospital introduced its end-of-life protocol in June. The newly opened Ng Teng Fong Hospital implements it on an ad hoc basis but has not formalised a procedure.

NUH, which pioneered the procedure, has since incorporated a module on palliative care into its emergency medicine residency training programme.

It is also coming up with a booklet which will provide families with information on the grieving and dying process. This will be made available in the emergency ward.

Some families who have received care for their loved ones said they appreciated the new procedures. They said the wait for pain relief medication has been shortened and information on hospice care and homecare is readily available.

One woman, who wanted to be known only by her first name - Patricia - said she and her family were able to spend the last few moments with their 91-year-old mother in a quiet room as the transfer from the emergency room was done quickly at TTSH.

"It meant a lot to us," she said.