Palace of Care – Dehumidifier

Photo by Laårk Boshoff on Unsplash

We didn’t know what was keeping him going. He hadn’t eaten anything for ten days. No drinks for days. Somehow he was still producing urine. Where did it come from? His son speculated that he was drawing the water out of the room’s atmosphere. “Dad’s become a dehumidifier.”

He had outlived many doctors’ prognostication attempts, including my own. “Anyone else would’ve died a week ago. He’s not anyone else he’s stronger than most people.” Somehow he had stayed alive with his metastatic cancer for four years. He had received multiple treatments over the years. They had kept him alive, but the last three months had been a struggle. He had lost 20kg over the years of illness. 10kg had been lost in the past three months because of severe nausea.

The cancer was cruel as it melted his body away it took away his appetite. His once mighty frame was reduced to skin and bone. He still wasn’t used to his reflection, it had continued to change. Despite all of the weight loss, one thing he never lost was his sense of humour.

In life he had always done things in his way, at his own pace and it was no different in his death. The family maintained their long vigil, and he remained mostly asleep but responsive when he was awake. If our staff found evidence of his imminent death we would inform them. We also warned them that sometimes people don’t want anyone to be around at the point of death and that he might slip away when an opportunity presented itself.

He was kept calm and comfortable. His family were supported and our patient died three days later.

Palliative care for patients with Parkinson’s disease

I often work in a palliative consultation service, and we are seeing more patients with chronic neurological conditions like Parkinson’s Disease. Parkinson’s disease is a progressive neurological disease that causes tremors (shaking), slowness of movement and stiffness. It can cause changes in facial expression so that people look expressionless. and changes in handwriting and speech too. We have to be careful not to prescribe medications that can make things worse, like for example, we currently give Metoclopramide (maxolon or pramin) for nausea but we need to avoid this medication in a person with Parkinson’s Disease.

Tanja Bahro and the team from the Southern Metropolitan Palliative Care Consortium in Melbourne Australia conducted a survey and found that palliative care clinicians wanted to know more about caring for patients with PD. Not being able to find a guide, they wrote their own! Please email Tanja for a copy tanja.bahro@smrpcc.org.au. They’ve had great feedback from users.

Tanja, tell us about your resource:

“Parkinson’s Disease – Issues for the Palliative Care Team” is a practical resource for people working in specialist palliative care, who are caring for people who are dying both with and from Parkinson’s Disease (PD). It was developed by our project officer Lee-Anne Henley with the great help of Dr Jim Howe, a very experienced neurologist in the area of progressive neurological conditions and palliative care, as well as Robert Wojnar, a pharmacist at Cabrini with a special interest in PD. The resource explains the main issues for people with PD at end-of-life and describes considerations and solutions. It also includes a practical care plan on which we have received some excellent feedback.

What gap did you see that lead you to develop it?

Because of the long trajectory, it is difficult for a health care team to know when people with PD should be referred to palliative care. A lot of PD patients also enter a nursing home and then at times lose contact with their neurologist. This can result in people not being referred to palliative care when appropriate and missing out on a multidisciplinary approach to care when the neurologist is no longer involved. Medication management can be difficult with PD patients, as some medications need to be continued to keep the patient comfortable but might also interact with medications commonly used for palliative care. We undertook a survey of palliative care staff and found that people wanted to know more, so we tried to find clinical guidelines or similar resources. When we couldn’t find anything we thought we’d better develop something ourselves!

How will it help patients and clinicians?

We hope to achieve greater awareness of appropriate referral to palliative care and we’re working on that. With the resource, we anticipate that palliative care clinicians will liaise more with the neurologist— they now have a simple and comprehensive guide to the main issues for people with PD and can therefore act quicker and prevent some of the pitfalls. Our next project is to adapt the resource for the residential aged care sector, but that’s more complex because we must take into account that the clinicians there might not have specialist palliative care knowledge.

How can people get the resource?

We want to make sure that we distribute the resource only to clinicians with experience in palliative care, so we haven’t put it on our website, but pc clinicians can just contact me on tanja.bahro@smrpcc.org.au and I’ll email it to them very quickly.

I think therefore I am? – On Death and Dying

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I virtually attended a Palliative Medicine conference over the past three days and have heard talks from a wide range of speakers. Included were a gastroenterologist and a haematologist both from specialties who are still unsure about which patients to refer to palliative care, and when to refer them.

It becomes a self-fulfilling prophecy if all the referrals we get are very late then we cannot do as much for the patients and their families. If the referral only arrives 72 hours before death or two weeks before death, does that mean palliative care is synonymous with end-of-life care? But that is not what we are trying to do in reality. Our services are happy to work alongside other specialties. A patient can be on the liver transplant waiting list and also receive palliative care from the local hospice. This is different to the USA where admission to the hospice programme means you cannot have ‘active’ treatments anymore. We have many patients who are still on their palliative chemotherapy/radiotherapy/immunotherapy and many other active treatments including haemodialysis. Even as the patient undergoes various treatments we are keen to help reduce suffering in its many forms, both physical and emotional, spiritual, and social.

How can we get this important message across? A patient referred to palliative care/hospice doesn’t mean that you have given up on them. One of my mentors Dr David Perez who worked in Medical Oncology would talk to his patients about coming to the point where there were no more active Oncology treatments available and the time had come for Active Palliative Care.

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I think therefore I am? – Colours

Photo by Sharon Pittaway on Unsplash

Most people have a favourite. Something caught your eye when you were a kid. It might be the colour of your favourite toy. Or your favourite food. It might be the colours of your nation’s flag. Colours are abundant in our world, the different shades make the world more interesting.

People are of different skin colours too. Some of us are white. Some of us are Brown. Black. Yellow, Olive-skinned. Grey. Different but the same in many aspects. Various empires sent their colonists out into the bigger world. The locals were impacted and the trauma that was experienced can be passed down through the generations. A deep lack of trust was ingrained by the actions of colonists toward the natives. This distrust can be passed down the bloodline, leading to intergenerational trauma.

When you are in good health you can tolerate a lot more than when you are unwell. Your baseline fears and needs come to the surface under stress. The uncertainty of their situation can leave a person terrified. The fears from the past can come back, no matter how strong a person had been in suppressing them.

Past traumas can be triggered unintentionally and people may want to avoid situations when they feel at their most vulnerable. People try to remain as independent as possible, and they may struggle in their non-acceptance of help. When you are weak and tired you may try to show your strength by pushing people away. Not being able to toilet or shower oneself may be one such situation. Requiring assistance means the loss of privacy and dignity. Having to be naked in the presence of others is a huge line to cross. Having to admit, “I need help. I am vulnerable.” A nightmare situation for anyone, having to be fully exposed. Add to that the inter-generational fear triggered by someone who resembles your ancestors’ oppressors and pre-existing suffering can be amplified.

Colours can affect us in many ways. Red light means Stop. Green for Go. What does amber/orange mean? Speed up or slow down? Everything becomes a blur of colour. The centre cannot hold, as a human being accelerates towards the finish line. The colour in their eyes faded down to a sparkless stare into space. The light of the person dims as they prepare to leave this plane of existence. Off they go to parts unknown, never to return again.

I think therefore I am? – Only Human

Photo by Isabella and Zsa Fischer on Unsplash

Last week was a heavy one in terms of clinical need. I was completing the latter half of a 12 day stretch and looking back at last week I realised I didn’t do enough self care. I missed my Brazilian Jiu Jitsu (BJJ) session last Monday as I was still feeling the effects of something dodgy I had eaten for lunch on Sunday. The instant weight loss was accompanied by instant energy loss from 36 hours of food poisoning.

My supervisor has been away for over a month and I am overdue for a professional supervision session, which I usually attend at least monthly. There are some months which are harder going in which I may need two sessions a month, and at times when it is especially severe even weekly sessions. The sessions allow me to reflect on my practice and how it affects me. I learn a lot from the sessions and have been attending regular sessions for the past 12 years. They have helped me become a better practitioner and are an important self-care practice.

Seasonal Affective Disorder isn’t usually a problem for me, but after the wettest Auckland July in many, many years I think I developed Rain Affected Despair. No it’s raining again, and again, and again. The down-pouring clouds have clouded my cognition. The constant humidity has led to this human feeling ‘mid’, as the young folks say. The real issue is I didn’t want my carefully styled hair to get wet after spending hours preparing it each morning. Also less opportunities for sunlight exposure.

I participated in many emotionally heavy conversations with patients and their family members last week. Many tears were shed. There were some tragic cases requiring my skills and some of them were challenging and pushed me to work at the top of my scope of practice. Professionally satisfying but the emotional labour was tiring.

I went without my usual Wednesday BJJ session due to a work commitment. I chose to attend a peer support network session as it only occurs once a quarter. It was good but took out another two hours from my day. I missed the physical aspect of BJJ but also the social aspect of catching up with club-mates.

By Friday, day 12, I was worse for wear and in need of a rest. The perfect storm had blown into my town and reminded me of my mere humanity. I have limits and am not a tireless robot. I will work on my self-care more this week, as I really need to.

Palace of Care – A Change of Plans

Photo by Adam Borkowski on Unsplash

We knew he would die soon and we asked him if he wanted us to contact anyone. He told us he would like his son to know, but he didn’t have his phone number. By this time he was too unwell and needed help with communication via social media. Our nurses helped him to send a message via his accounts. He died before he received any replies.

As per his wishes, we had arranged for a funeral director to uplift his body as he had wanted a simple cremation. He had limited savings and arrangements had been made with social welfare for a funeral grant to pay for his cremation. Our nurses again checked his social media accounts and found a reply from his son, including a phone number. A phone call was made overseas and was answered by the young man’s foster mother. She was told of our patient’s death, and said that his son wanted to come over to see him, and would arrive in town in three days’ time.

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Palace of Care – RIP Technoblade

Photo by 卡晨 on Unsplash

Today tragedy leaked from the internet and into my home and many millions of homes all over the world. 23-year-old Minecraft YouTuber Technoblade has died. He had written the last message to his fans only eight hours before he died. He had asked his dad to read out his message on this video. If you watch the video make sure you have some tissues at hand.

Technoblade was diagnosed with cancer in August 2021 and continued to post his popular videos even whilst undergoing various cancer treatments. With his usual generosity, he continued to share his entertaining insights with his 10 million followers.

Millions of ‘kids’ all over the world have learnt about the reality of life with cancer. Today they have experienced the death of someone who they may have gotten to know over many years of watching his videos. Grief has appeared on their drop-down menus, and they may not know how to deal with these unknown feelings. A huge reality check has occurred and the stark difference in real life is there is no respawning.

An online companion can no longer keep them company. Loss of life has led to a loss of childhood innocence. Please take care of your kids as they mourn during this sad day on the internet.

Palace of Care – Calm Personified

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My patient arrived in 1970s New Zealand (NZ) a refugee. One of the millions of innocent victims of a proxy war. She and her husband had worked hard, and raised their family well. Their children had grown up and had made good lives for themselves and their own families. She was the proud grandmother of six, with ages ranging between 2 to 18 years old. She was admitted for end of life care and had been comfortable. Her family attributed this to her Buddhist beliefs. She had always been the calm one in their family. “Dad was the fiery one, and he had died about seven years ago.” She had carried on with life, taking even the death of her partner with calm. She her family that she would see him in the next life. She wasn’t sure in what form he would be reincarnated, but she was sure they would meet him again.

She had lived a calm life and her family were not surprised that her dying process was also calm. She didn’t need much in the way of medications as she was mostly comfortable. She lost consciousness and we warned the family that death was likely imminent, that she would be dying soon. Two weeks passed and she was still alive. She remained comatose and non-responsive. She had not been alert enough to have any oral intake. The family made sure her mouth was kept moist.

Her family asked us how long she had left to live. We explained that from our experience that other patients in similar situation likely would have died two weeks ago. Our science could not explain why she was still alive. We asked if she had any unfinished business, was there anyone that she had not seen yet? The family gave us a puzzled look, she had seen everyone that she needed to see. Or so they thought. As clinicians we all wondered, what she was waiting for?

We found our answer a few days later. As I was heading upstairs for lunch, three men walked into the hospice. One of them walked ahead, followed by two others. The two men wore green uniforms and looked as if they could handle themselves. The man in front was a short, Asian man in his forties. His hands were cuffed together. He was led to his mother’s room and spent some time saying goodbye to her. He cried as he had not seen her for two years he had served in prison.

She may have been comatose and thought to be insensate, but she knew her son had come to say goodbye.

She died two hours after her son’s visit.

Palace of Care – A Father’s Grief

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I went to see the new patient who had just arrived by ambulance. A Chinese man in his 30s who was drowsy and confused. He wasn’t able to move out of bed, and needed full assistance with all cares. He was accompanied by his wife and his father. Our patient’s English was reported as good but he wasn’t alert enough to answer many questions.

“Where are you sore?”

Hands pointed to his abdomen as he grimaced.

His father said, “He’s always considered other people before himself. That’s how he’s been since he was a young boy.”

I made some adjustments to the patient’s medication to try to ease the suffering.

His father came to speak to me, and I ushered him into a small meeting room.

He was angry and devastated. He spoke to me in Cantonese which I have some understanding of, thanks to a childhood of watching Hong Kong TV series on VHS video tapes. My usual slow process with Cantonese, is to convert it into Mandarin and then into English. I have trouble when trying to go back the other way, so don’t speak Cantonese.

He recounted the clinic appointment they had attended yesterday. They had driven from home to the Oncology Centre. His son required a wheelchair as he could not walk the long distances. The Oncology registrar that met them was Chinese and spoke Cantonese. He asked if his son could lie on the bed as he was tired from sitting up for hours to get to clinic. The registrar answered no, that the clinic was too busy today. This surprised the father who said, “Couldn’t they see how unwell he was? Then they told us bluntly, there was nothing they could do for my son. That he was dying. I was so angry that I wanted to complain, but my son wouldn’t let me, he told me to leave it, and that he wanted to go home.” I listened to him for 45 minutes and talked to him in Mandarin which was our shared second language. He had calmed down and was able to head back into his son’s room.

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Assistance for Australians with administrative tasks after someone has died

Honestly, the very last thing you want to do when you are grieving is wade through the piles of administrative work that’s needed after someone you love has died.


I remember after my mum died, doing to the Post Office to request that her mail be diverted to me. Are you the Power of Attorney? Queried a the young Post Office worker. Well, yes I am, but as the person has died, the Powers of Attorney have ended So you need to ask me if I am the Executor of the Estate.
Her: …..

Me:….

Her: Are you the Executor of the Estate?

Me: Why yes, yes I am.

Or CItylink. Would not tell me why my mum’s owing balance was cos of privacy. But I wanted to pay it off and close it. Can we have a certified copy of the death certificate. OMG. If I paid you $50 would that cover it? $100? No, can’t say., privacy. Gah!

I have fortunately not had the need to use this new service https://deathnotification.gov.au/ but it is a fantastic idea and I look forward to hearing how it goes. The Australian Death Notification Service (sorry to our cousins over the ditch) takes on much of the administrative burden after someone dies for you, and it’s free. What a fantastic idea! It’s supported by all the States and various organisations.

Let us know if you use it or hear of anyone who’s used it.

https://deathnotification.gov.au/