Category Archives: Clinical

Palace of Care – True Flies

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Photo by Dieter Pelz on Unsplash

Every summer the hospice is visited by thousands of flies.

We are situated next to a big park and flies are a constant presence in the warmer months.

They can be really annoying for our patients who may be too weak and tired to fend them off. Their family members may also have troubled keeping the flies away.

Every summer I have said that I would bring in an electric bug-zapping racquet to deal with the flies.

This summer I finally brought one in.

In recent weeks as well as doing a medical round I also do a fly-catching ward round at least once a day.

I made myself available 24/7 on-call for the purpose of catching pesky flies. I can be called in any time of the day or night.

This has led to great amusement for patients, family and staff members.

Yes, I am probably the most highly qualified pest control worker in the country.

As well as catching flies I practise some medicine as well.

I clear each room of flies and then I head outside to the balcony area and get rid of the ones that are out there as well.

It’s one man against thousands of flies but if it makes my patients’ time slightly more bearable it is worth it.

It is also a good way to add to my daily step counts.

I will continue to catch flies and expand my repertoire of work roles.

This is especially important each and every Flyday.

Palace of Care – Second Languages

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Photo by Tim Mossholder on Unsplash

They had lived in New Zealand for many years and could speak English as their third language. Their English was pretty good but they did not feel confident when discussing medical issues with healthcare staff. Their children had grown up here but were busy with work. One child worked in NZ, the other child was overseas. Thanks to time zone differences, their overseas child would sometimes be available to help with translation during our patient’s clinic appointments. The patient and their spouse didn’t want to risk any misunderstandings when it came to discussing medications and treatment plans.

We had offered them a virtual appointment but they wanted to come in person. Face to face it was easier to communicate even with masks on. I greeted them in our shared second language, Mandarin Chinese. This made them feel at ease right away. They felt they would be able to communicate better with me. They had come for a pain review and I was able to quickly assess our patient. Our patient would be seeing their Oncologist the next day. I provided them with written instructions and also wrote a note to the Oncologist asking them for advice about another problem they had mentioned to me.

The communication was by no means perfect as my Mandarin is not 100% fluent, especially when talking about medical issues. I had to use occasional English words interspersed between paragraphs of Mandarin but we were able to understand each other well in terms of language and also cultural expectations. They were pleased to meet our pharmacist who could also speak Mandarin.

It felt good that our diversity and inclusion recruitment programme was making a difference. Our effort to reflect our demographic continues to be beneficial and is another patient-centric point of difference in the services we provide. We are doing better than before and will continue to keep trying to make our ability to connect better.

I think therefore I am? – On Adaptation

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Photo by Yuriy Chemerys on Unsplash

Humans can adapt to many different situations. It may take a few days to acclimate to the weather at your trip’s destination, but you get used to the new situation. Physiological adaptation occurs with the senses. If you hear a repeated sound your brain will adapt to it and will start to filter it out. You will start to notice it less and that allows you to notice other sounds. The same occurs when you encounter pungent aromas, after a short period of time the smell will be less noticeable. Something similar occurs when you expose yourself to differences in temperature, e.g. sauna or ice bath.

This adaptation process will work to a certain extent and depends on your body’s coping ability. If your body is compromised in any way then your ability to adapt will be affected. Serious illnesses can lead to an inability to handle these situations. There is a limit to what you can cope with. This might be changed with training. Repeated exposure to the stimulus will lead to changes in the body and mind.

Adaptation and coping are not purely physical and the mind has a big part to play. I have looked after many people who have survived for much longer than I thought would be possible. I have often remarked that they are kept alive by sheer force of willpower. A strong mind will sustain a physical body much longer than expected. People with strong beliefs or reasons to stay alive may also outlive their prognoses.

This inner strength lies somewhere deep inside the individual and their determination may have resulted in many successes in the past. These people might be described as stubborn, and like most personality traits people will stay true to themselves right until the end. Sometimes people have to actively let go before they can finish their current life. One person said, “There’s too much love around me, I can’t leave when there is so much love.” That’s why some people will wait until there is no one around before they can die. They didn’t want anyone to witness their very end.

We all make choices. Survival is not mandatory. It is an active choice that many of us make. Adapt or die. It’s not that simple. Even coping with a change in time zone can be a challenge as I am finding out today. Yawn.

Palace of Care – Q+A

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Photo by Ilja Nedilko on Unsplash

The reason your legs and tummy are swollen is because of your illness. When you are really unwell the body is under great strain and isn’t able to produce the protein that your body needs. Amongst other roles protein keeps water in your blood supply. When you don’t have enough protein in your blood the water will leak out into your tissues. That’s why your legs and abdomen are so swollen. This is not the kind of swelling which will respond to medications that make you lose water. They would make you lose water from your blood supply leading to dehydration but the fluid in your legs and abdomen would not decrease. Massage can help shift the excess fluid if the problem was blocked lymph glands, but it is unlikely to help the kind of swellings that you have. That being said it can be soothing and can make you more comfortable so I would encourage you to have gentle massages.

We try to be flexible when it comes to visiting hours here. We know that your energy levels are low and that you feel like you need to be at your best whenever your visitors are around. This can be exhausting. I would recommend that unless it is the people closest to you visiting that other visits be limited to ten minutes. You can blame this on me, “that nasty doctor has limited visiting times.” Your energy is a precious and scarce resource. We’re keen to help you save your energy for whatever you feel like doing. Please let us help you. We’re keen to try to make life easier for you if possible.

Palace of Care – First Do No Harm

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Photo by Liza Pooor on Unsplash

It’s not like what you see on TV. In real life, resuscitation doesn’t work so well. I’ve worked on many cardiac arrest calls in the past and almost 100% were not successful. In those few successful resuscitations, the person was left physically and mentally damaged. With your burden of disease, the chances of a successful resuscitation would be close to zero. The first thing they teach us in medical school is, “first do no harm.” If something that we are considering doing has questionable benefits but likely harm, we really need to think about it carefully. You have so much going on already, and the last thing we want to do is to make your situation worse. Some of our treatments could worsen things with little chance of benefit. If your heart or lungs were to stop working, we would not be able to bring you back. We would not perform CPR as it would cause you harm with no benefit at all. I don’t think you are at risk of having your heart or lungs stop just yet, but I have to be clear with you as to what to expect. I don’t want there to be any surprises between us. It’s not over yet. So let’s focus on making the most of your time. Let’s concentrate on something that will help you, treatments that can decrease your suffering, and make you more comfortable. Is there something that you have always wanted to do that you haven’t done yet? Is there something nice that we could help organise?

I think therefore I am? – Masks

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Photo by Khashayar Kouchpeydeh on Unsplash

Medical masks have become part of daily life in hospice and palliative care units all over the world over the past three years. We have had to get used to having important conversations with most of our faces covered. Compassionate expressions have had to be conveyed with the aid of eyebrows and hands. Smiles have been with eyes only rather than with the full face.

There are a number of workmates I have worked with for two years or more, with which we have never seen each other’s faces. I removed my mask in order to be heard more clearly during a family meeting the other day and my patient who had known me for eight months saw my whole face for the first time. There are young children who have only known people outside of their own families to wear masks most of the time. Things are changing with the easing of COVID restrictions but for the healthcare workforce, it will be a while yet until we can take off our masks for good.

A barrier to viruses can also serve as a barrier to communication. People who have hearing impairments cannot lip-read if other people’s mouths are completely covered. There has been less transmission of yawns. Apparently, if you are more empathetic and you see someone else yawn, it can trigger a yawn of your own.

On the other side of the mask is that there are many choices of masks that people can choose to wear. Maybe it has allowed people to show more clearly what fashions they want to show off. People can show their membership in groups with the type of mask they wear. They don’t just have to be the same old boring surgical light blue but can be any colour of the rainbow.

Has it become easier for people to mask their intentions? What else is being hidden? What else is being left unshared? Kisses are left unblown. We are now more familiar with the smell of our own breath than ever before. What else has been lost since we have been wearing masks? Will we ever get those things back?

Palace of Care – Team

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Photo by Vlad Hilitanu on Unsplash

They had been a team for many years. It all started when they married. They raised their children well, and eventually became grandparents. That’s when everything started to change. He started to lose his memory to Alzheimer’s Dementia, his body was still in good working order. She started to lose control of her body to Multiple Sclerosis, her mind was still in good working order. They managed to cope well, making up for the other’s disabilities. She was the brains of the team and he was the brawn. They did well for the first three years and then their illnesses took away the last of their independence.

His cognitive impairment worsened and one day he decided to leave the house by himself. He drove off leaving her and the children to search for him. They called the police to help, but he could not be found until two days later. He was befuddled and unkempt when they found him. His main job before retirement was as a taxi driver. Despite his various impairments, he could still drive safely.

Her physical ailments worsened. She had become doubly incontinent and now needed full assistance with her activities of daily living. She suffered from recurrent urine and chest infections, which required hospital admissions. She had needed to be admitted three times in the past six months. The hospital team had asked her to complete an Advance Care Plan – ACP on the previous admission. This had been a difficult exercise but an important one. She was able to make it clear what she wanted and didn’t want. She had decided that if she developed another life-threatening infection, she would not want anything apart from comfort treatments.

I met her during the current admission. She had become unwell over the past week with aspiration pneumonia due to her poor swallowing. Fevers and shortness of breath were the main symptoms. Though the ACP had been completed and loaded onto the hospital system it was still ignored. IV antibiotics were given as well as fluids. When she woke up she was angry that her treatment wishes had been ignored. She had spent a lot of time preparing her ACP and it gutted her that it seemed to have been a futile exercise. She made it clear what she wanted and did not want. She asked for all treatments to be stopped, she had had enough.

I think therefore I am? – Sales Pitch

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Photo by Artem Beliaikin on Unsplash

Different healthcare cultures lead to different healthcare and expectations. If you have the money you can buy almost any treatment it depends on what people are willing to sell, and the cost that is being charged. There is a large market that caters to desperation. Nothing else has worked, come and see us, and we will keep you alive. If it doesn’t work it isn’t our fault, you probably didn’t follow the strict protocol correctly. You didn’t try hard enough. Sorry our treatments is so good but we can’t offer a money back guarantee. It’s so good that you won’t need your money back. It also cures…whatever else you have. No what I’m selling is not too good to be true, it is truly good. Those other doctors haven’t had as much training as I have. They were just trained in traditional Western or Eastern medicine. I am an advanced practitioner and I will be able to help you. Join our subscription model and start saving your life now. Just one easy monthly payment via direct debit. Don’t worry about the billing we will just collect the money ourselves as customer satisfaction is our top priority. It’s a real bargain my cold-pressed extra-virgin snake oil…

Drink this potion, apply this lotion, move your body in this motion.

Use this poultice, made without artifice, I have 40 years of practice.

It looks bigger on the scan, that’s just a scam, your disease our treatment will slam.

What else can we do, what do you mean you can’t poo, none of our happy patients would ever sue.

Why would you want a treatment pause, didn’t you read the last clause, it’s all ours now what was yours.

You did it all wrong, you didn’t follow along, our medication is strong.

The price has to increase, the supply of this rare element is about to cease, yes we extract it from fleas.

You can’t get out of bed, that’s all in your head, why don’t you try harder instead.

We will now have to intercede, our service you will always need, otherwise your cancer will grow at speed.

Sorry we can’t answer right now, our attention we cannot allow, we are too busy saving lives to take a bow.

It worked for everyone else, it even cleared up that guy’s welts, it’s your attitude that smells.

What you’ve run out of funds, you can’t afford the frankfurters just the buns, well sorry we have to runs.

Palace of Care – Surprise!

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Photo by Tyler Nix on Unsplash

“Where is your pain?”

He grimaced as he pointed towards the left side of his neck.

“How would you score it out of 10, with zero being no pain and 10 the worst you’ve ever felt?”

Jaw clenched tightly he opened his gritted teeth to tell me, “7 out of 10.”

It looked more like 17.

The pillow seemed to swallow up his head. Loose skin covered his arms and torso, signs of significant weight loss.

“I’m not sure if I’ll make it.”

He was scheduled to be heading home at the end of the month, but I was unsure if he’d still be alive at the end of the week. “I don’t know either, but we’ll take it one day at a time.”

Over the next three days, he worsened each day, heading back home was not going to be an option. The family would have to bring home to him instead. They made urgent plans to travel to visit him. The clock was ticking away his life. Would they make it in time?

Yes.

Their arrival had a surprising effect.

His face brightened when they came to see him. He became more alert and he was able to recognise each of his family members.

The next day he was able to eat more food.

Two days later he walked to the bathroom without assistance.

Five days later he wanted to go to the home of one of his local children.

His family’s arrival from afar had improved his condition in ways that medications could not.

The power of love had provided him and his family with bonus time. It might not last long but they would make the most of it at home together.

He died twenty days later surrounded by his family.

Palace of Care – No Matter What

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Photo by Priscilla Du Preez on Unsplash

Do you understand what is going on with your gut?

Yes, the cancer has caused a blockage.

That’s right, anything that you swallow will probably come back up again. It’s a mechanical obstruction and our medications won’t be able to keep it unblocked.

There’s no other treatments?

We could try steroids to see if it could lessen the cancer swelling, to see if it would loosen up the blockage. It may not work, and even if it does work it will only work for a short time. And there can be side effects. Some people become more agitated, it would worsen your immune system so it would be easier for you to get infections.

Hmmm. I need to think about it

That’s fine, I wasn’t expecting an answer right now. We will keep checking in with you, we want to make sure we do right by you. When you are very unwell the body had difficulty keeping things in balance. For example physical balance can be affected and it mean you are at greater risk of falling. That’s why we’ve been nagging you about not walking by yourself.

Nod.

I know you want to stay as independent as possible but we need to keep you safe. I don’t want you breaking a bone, you’ve got enough going on already.

Sigh.

The illness can also affect your mind balance too, you’ve probably had some trouble remembering things.

My memory has been bad for months.

And overnight you were a bit confused.

Yeah, I wasn’t sure where I was.

The strain and drain on your body from the cancer is causing it all. I know you’re trying your best to be yourself, but it’s becoming harder and harder. Things are becoming a struggle for you.

Nod.

I don’t want you to struggle. Please let us help you with some things. To try and free up some energy for you. So you can spend time with your friends and family.

They keep encouraging me to do stuff, but I’m not sure I feel up to it.

Listen to your body, if you feel up to it, go for it. If you don’t it’s okay to have a rest.

Nod.

Okay we’re going to work on your nausea today, and we’ll check in with you again tomorrow morning about the steroids. I just want you to know that no matter what happens we’ll keep on trying to make you more comfortable. There might come a point where you aren’t able to speak for yourself and I just want you to know that we will act in your best interests. We will always try to make you more comfortable.

Thanks Doctor.

You’re welcome. We’ll see you later. Please let us know if you need anything else.