Category Archives: Clinical

Palace of Care – COVID Symptom Trading Cards

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New day, new symptoms. The whole body aches and pains subsided today which was a relief. Just as I was lulled into a sense of lessening unwellness, something else arrived to knock that idea out. A sore throat the likes of which I had not experienced since I had my tonsils taken out as an adult came to say hello. I would describe it as swallowing rusty liquid razor wire. It was such a lovely greeting that with each swallow I was overwhelmed with emotions and tears came to my eyes. I threw all the medications I had at it, and then some, but nothing worked apart from lying down in the foetal position, but that didn’t bring any relief. Or was I lying down in the recovery position? Probably not as I do not feel recovered as of yet.

I was hungry and had to eat through each painful mouthful. The dry crusty parts of the bread were like sandpaper on my disease-ravaged throat. I winced and grimaced through each gulp of food. My appetite had returned but had to contend with the pain barrier. I persisted and after a few minutes, the pain started to abate. If the drugs don’t work make your own. As a response to the pain, my body produced endogenous opioids, bringing relief to my agonised throat. The second half of the meal was swallowed with relative ease.

Both of my Latissimus dorsi, those big wing-like muscles on the sides of our backs, were aching today as if I’d had a huge workout yesterday, which I hadn’t. My pectorals on the opposite side of the lats also felt similar. I had not done any heavy lifting at all but had done some coughing yesterday. Curious symptoms continue to be collected. What will happen tomorrow?

Palace of Care – Omicron BA.5 variant Top 10 lessons

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Photo by Rodrigo Curi on Unsplash
  1. Writing is difficult when you have brain fog.
  2. Pain does override everything else going on.
  3. End-of-dose pain return is a thing.
  4. Oral medications take a while to kick in.
  5. Nerve-related pain sucks.
  6. I am not alone, many others are going through the same symptoms as me.
  7. Friends have been kind and have offered to drop stuff off.
  8. Being sick for even two days feels awful, I can’t imagine what it feels like for my patients.
  9. It is demoralising when you’ve taken all your medications and you are still in bad pain.
  10. Writing is difficult when you have brain fog.

I think therefore I am? – Culture Clash

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Each place has its way of doing things and when people from different cultures intersect there may be clashes and discord. Some cultures will under-treat, and others will over-treat. Where will Goldilocks feel most comfortable? Too much of a good thing isn’t always a good thing. The most expensive treatments aren’t always the most effective.

Inequity pervades the world. NZ-trained doctors who have traveled back to Asia may be shocked that people with non-survivable strokes are kept on life support for weeks or even months as standard practice. Their relatives with end-stage dementia are fed via tubes and the quantity of life may be prolonged for lengthy periods, of up to years. This does not always come with any discernible quality of life benefits.

People may be from healthcare cultures in which the patient and family can have whatever they desire if they can pay for it. This can include experimental therapies with or without scientific bases. Desperation can lead to high sales figures but is there any care in those types of healthcare? People search all points of the compass but do they find any compassion? Expectations are set but people do not become settled. When time is of the essence is it correct to waste it without people’s informed assent?

Palace of Care – Heart Follows Mind

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Her brain had no trouble accepting what was happening but her emotional heart took longer. The love of her life for over 45 years of marriage was dying. The doctors had warned that he might become confused and agitated as his condition deteriorated. He was comfortable and the pain relief had taken a few days to optimise. He was more relaxed and then deteriorated. He became less lucid as we neared the end of the week.

A clash of cultures became evident thanks to some of the visiting friends of the family. “You have to ask your doctors if they will give infusions to your husband. In China, he would be having lots of intravenous fluids, and other treatments such as tube feeding.”

We had to explain that artificial hydration would be too much for the dying person to handle, and would worsen skin swelling and likely worsen his breathing. We did not want to add to his already heavy burden of symptoms. His wife indicated she understood our rationale. We explained he could die at any time.

Intellectually his family could accept the ongoing bad news, but when it came to emotions it would take much more time. Their loved one was dying and all they wanted to do was to help but didn’t know how to. Mouth care was a task that we delegated to them. Our counsellor was asked to talk to the family.

Their brains understood the words we shared, but their emotional hearts couldn’t understand the language and operated on feelings instead.

Palace of Care – A Reluctant Patient

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I first met our reluctant patient in the outpatient clinic with his girlfriend. It had taken a number of phone calls before he would come in for assessment. He was scared of hospice and had resisted his Oncologist referring him to us. He didn’t know what we were about and what he didn’t know frightened him.

He had been unwell with cancer for over a year with severe pain making him unable to sit or lie down for more than an hour at a time. Sleep was difficult for him and he was woken up several times a night by burning pain that spread down his right leg. He wasn’t keen on any changes in medication, and it took much negotiation for him to allow us to increase the doses of the pain relief agents he was already taking. He didn’t want to consider anything new, just yet. As his pain was so severe I offered to admit him into the inpatient unit but he wanted to stay at home.

Over the next month, his pain did improve but any relief would only last for a few days at best. We again offered to admit him for pain control but he still wasn’t ready. Some weeks later the pain had worsened bringing tears to his eyes. His mother and girlfriend were exhausted and felt helpless as they couldn’t help reduce hisWith encouragement from his mother and girlfriend he agreed to be admitted.

We started him on a different opioid that afternoon. The next morning he was full of smiles. He told us he was pain-free for the first time in two years. He stayed a few more days as we helped him with other issues, and then he went home. As well as good pain control we had built a trusting relationship that would help during his next admissions.

Palace of Care – Maturity Crash Course

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She was still a child when we admitted her to our inpatient unit. 21 years old but she acted more like a teenager. She had been unwell for five years with bone cancer and had undergone many treatments. She had spent a lot of time in hospitals and had moved from her hometown to be closer to live in the same city as the treatment centre. In her last hospital admission, she had been troubled by a racing heartbeat and had been reviewed by heart specialists.

She was nervous on arrival at the hospice, and she wanted us to discuss any changes with her Oncologist. She had been under his care since her first treatment and she wanted him involved in any treatment decisions. We were happy to involve him and discussed our proposed changes with him. He said that he would defer to us when it came to palliative care issues as he felt we had more experience. Over the next week we built up trust with our young patient, and we were able to control her pain well enough that she could go home.

After two weeks she had become unwell with worsened breathing and ended up in the hospital. They scanned her and found cancer in her lungs had worsened. She asked if she could be readmitted to hospice and a transfer was arranged for the same evening. Medications to ease her breathing was started.

She was reviewed on the ward round the following day and was started on high-dose corticosteroids which initially helped her breathing. A few days later she asked to speak to the doctors. She said that she understood that her lungs were in bad condition, and without medication, she would die. She asked if she could stop her medications. She had discussed this with her family and they wanted to support her decisions.

She chose to stop her treatments and wanted nature to take its course. We provided symptom control medications to keep her comfortable. She died a week later.

Between the first and second admissions, she had grown up a lot. A young girl had grown up into a young woman over a few weeks. A brave young woman who took control of her situation and chose to stop active treatments, opting for comfort care only. She went out on her terms and did it her way.

Palace of Care – Upgrade to a Combo Deal

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Almost a year ago I visited a local Rongoā Clinic as I was interested in learning more about traditional Māori medicine which is comprised of diverse practices with an emphasis on the spiritual dimension of health. Rongoā includes herbal remedies, physical therapies such as massage and manipulation, and spiritual healing.

During my visit, I met a Rongoā clinic patient who had recently become one of my hospice patients. She was well at the time but over the course of the past 11 months her condition worsened. Pain developed and initially had been controlled by the herbal remedies applied. In recent months the pain had become intolerable and she had become bed-bound. Too sore to leave her bed let alone leave the house. Everyone involved in her care were worried and wanted to ease her suffering. She initially refused to take the strong pain relief agents that we had suggested, and preferred to continue with only her Rongoā treatments.

I asked for a joint assessment to be arranged with myself and the Rongoā practitioner both seeing the patient at the same time. I went to the clinic this morning and was joined by the nurse assigned to our shared patient. We were ready to show our patient that we were happy to work together in a fusion of traditional Māori medicine and modern Palliative Medicine. We were hoping that together we could convince our patient to have both traditional treatments and strong pain relief agents. We wanted her to have the best of both worlds of care.

That was the plan, but someone had already beaten us to it. The patient had recently been seen by her new general practitioner and he had already convinced her to take pain relief along with her traditional treatments. The combination worked and at the clinic this morning a smiling patient greeted us. Her beaming smile told us exactly how she felt. Her husband was happy that his wife had improved with the combination of treatments. She felt better and was now able to check up on his housework, to make sure that he was meeting her high standards. She was back, after having felt trapped in a dark place. Both of our organisations made plans to follow her up in the near future, and we pledged to each other that we would like to work together more in the future. In the meantime, the formerly bed-bound patient was being taken into town to have lunch with her husband.

Palace of Care – Palliative Plumbing

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Our patient was dying of end-stage cancer, it had spread throughout his body causing significant pain. He had been having trouble passing urine, over the last two days. This had worsened and our ultrasound bladder scan showed urinary retention with a collection of 1.5L. One of the more painful conditions that people can have. The bladder’s walls are elastic but are not meant to stretch that far. Many nerve endings were firing off pain signals, our patient writhed in his bed. His wife and daughter were distressed seeing their lovely man in such discomfort.

The doctor on call was called in at 1 am after the nurse had tried twice to catheterise our patient without success. The urinary catheter could not pass through a blockage despite the nurse trying all the usual tricks. The doctor attempted catheterisation three times before calling me in. I arrived just after 2 am and decided that I would have to perform a more invasive procedure. The patient was too distressed, he was too unwell to be transferred to the hospital. I would have to drain his bladder using a needle, something I had never done before in my 20 years of medical practice.

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Palace of Care – A Self-Sufficient Family

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One of the cruellest consequences of COVID lockdowns was the restriction that we had to place on visitor numbers. We were generous in that we would allow each of our patients up to four named visitors, but this still fell short when it came to families with more than four members. We acted with humanity and compassion, thinking to ourselves how would we feel if it was us in their situation? But what do you do when someone has 15 children? It is difficult for a family to choose who gets to come in, and who has to stay out. Video chat technology allowed for virtual visits but they were no replacement for in-person visits.

Our patient was a man in his 50s who had six children, the two eldest lived out of town. The four younger children were keen to spend time with their Dad, and their Mum struggled to choose who would be the nominated ones for any given day. The family had always been close and the parents had home-schooled their children. They had always done things in their way. Having Dad critically unwell and away from home added to the overall disruption of their family life. Our team’s opinion was that our patient only had limited time left to live. Given the circumstances, we flexed our approach and allowed the four younger children to visit alongside their mother.

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Palace of Care – Nerve Block

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Photo by Manuel Chinchilla on Unsplash

I don’t think of myself as a proceduralist. I don’t like performing invasive procedures as I don’t like to cause pain if I can avoid it. I will do them when they are necessary but it is not a natural fit for me.

The patient was a 39-year-old mother of a 7-year-old son. She was admitted for pain control and I thought she would not have much time left to live. She had known this herself for the past six months. In preparation, she had purposefully reconnected with her ex-husband the father of her child. She wanted to make sure that they would have a loving relationship after she had died. She had been reluctant to come into hospice as she had wanted to spend as much time as possible with her son and other family members at home.

We wanted to sort out her pain as quickly as possible to get her back home. We managed to sort it out within the first three days. This was good as she had met with our social worker and the final adjustments to her will were being made. Her lawyer had been engaged and would be arriving in three days for her to sign the final papers. It was important to have this sorted out as she wanted her house to be transferred to her ex-husband for him to have a house to raise their son in. She had worked hard to buy her house, it was her pride and joy. She wanted her son to have a stable home environment.

Overnight she went to the toilet but on the way back to her room she heard a loud crack from her right hip, followed by overwhelming pain. She could no longer support her weight and managed to call out for help. The nurses needed to use the lifting hoist to get her back in bed, which made her scream.

I reviewed her the following morning and I recognised a familiar pattern. Shortened leg, twisted at a non-anatomical angle, tender to touch and excruciating pain with the slightest of movements. Fractured hip, likely broken through a metastatic deposit. We talked about going to the hospital but she did not want to go anywhere. She said that she had already been to the hospital too many times in the past. She thought her time was limited and she wanted to spend it in hospice.

We gave her stronger pain relief which relieved her pain but because of her poor overall condition, it made her sleepier. She didn’t want to be sleepy, as she still needed to sign her new will. Her son’s future welfare needed to be sorted out before she died.

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