Category Archives: Practice

Palace of Care – Welcome to Hospice – Part 1

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Photo by Belinda Fewings on Unsplash

When the hospice nurse had suggested an admission into hospice she really had to think about it. Did this mean that she was about to die? Was that why she had suggested I go in, because they thought that I was about to die? They denied it, and said that they wanted me to go in to help control my breathing and distress. I asked my family and they were scared as well, but knew that I needed help. We decided to give them a go, but man we were still nervous about it.

Turns out we didn’t have to worry, the people were friendly and nothing seemed too difficult. The doctors and nurses started working on my breathlessness, and by the next morning I started to feel better. I met a number of the team members before I headed home a few days later. We had been worried that when you’re admitted into hospice that there is only one way out, being wheeled out by the undertaker. When it was time for me to go home, I walked out the front door.

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Bedside Lessons – 20 – Crossing the Line – Part 1

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Photo by Max Böhme on Unsplash

I was working on the liaison psychiatry team in my final year of medical school. I went to meet a patient that had self-referred, which was unusual. Psych liaison provides psychiatric input for patients who also have medical issues that have brought them into hospital. I went with the nurse specialist to see the patient, an Englishman in his mid-thirties.

Work had brought him and his Latin American wife across the world. He was a nature documentary maker and had been based in the lower South Island filming the local wildlife. Just before Christmas he became unwell with a severe nosebleed, which required hospital intervention. Simple blood tests revealed grossly abnormal results. Acute Myelocytic Leukaemia (AM bloody helL) was the shocking diagnosis which destroyed their plans for Christmas and life in general. An urgent admission was arranged to our hospital’s Haematology department, which served the entire region. Harsh chemotherapy needed to be started otherwise our patient would’ve only had days left to live.

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Palace of Care – Like father, like son.

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Photo by laze.life on Unsplash

The little old Chinese man, looked so pale, he didn’t know what to do with himself. His short-term memory had been impaired for some years but had worsened in recent months as he deteriorated.

We both used our second language to communicate with each other, Mandarin. Both speaking with thick accents, but able to understand each other. His supportive daughter had come over from China to look after her parents. They had lived in New Zealand for over twenty years.

He had always been terrible at reporting his discomfort. His daughter talked about when he had appendicitis and had not told anyone until he almost died of an intra-abdominal infection after his appendix had burst. His stock answer would be to say, “I am fine,” but his body language was a give away for his wife and daughter. He didn’t let anyone know that he had painful shingles until he was found writhing in bed, crying because of pain, telling his family that the pain was so bad that he wanted to die.

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Palace of Care – What’s in a name?

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Photo by Tim Mossholder on Unsplash

She was transferred from hospital into hospice at the end of her life and only had days left to live. End-stage cancer had taken complete control of her body. We were handed over that it was important that we respect her wishes especially when it came to calling her by her proper name. It was a name that she had to fight for, that she had won for herself, but at great cost.

Not everyone understood her wishes. When her relatives came to see her they brought old family photos, and called her by a different name. She looked different in the photos, much younger, and dressed in different clothes. We were all young once. She was becoming less responsive as each day passed and her family talked about someone who sounded different to the patient that we had only a short time to get to know.

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Palace of Care – Saying No – Part 3

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Photo by Christina Deravedisian on Unsplash

He was admitted because of uncontrolled nausea and vomiting. We thought it might be a malignant bowel obstruction but his bowel sounds were normal. He would vomit at least three times a day. Strangely the vomiting didn’t seem to bother him, in fact at times he and his wife seemed happy after he vomited. We weren’t sure of what was causing his nausea and vomiting, his blood tests showed evidence of dehydration, but there was nothing obviously reversible going on to explain his symptoms. He looked unwell and after a few days on our ward he appeared more gaunt. Our attempts at controlling his symptoms were not working, we hadn’t solved the mystery yet, until we noticed the half-filled blue glass bottle on his table. “Keep out of direct sunlight.”

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Palace of Care – Saying No – Part 2

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Photo by Timothy Eberly on Unsplash

My usual approach to complementary or alternative therapies is to try to keep an open mind. A lot of treatments do not have much evidence-backing but can be important to the people wanting to try them. A lot of the patients I see have exhausted all that Western medicine has to offer, thus they seek alternatives. Some of these treatments may be expensive in financial and other costs. I am supportive of a patient’s right to choose whatever treatment they want. If it makes them feel better, who am I to judge?

I do draw the line if an alternative treatment is causing harm. First do no harm is the first concept they taught us in medical school, but it is not a concept taught in all therapy schools. Rarely have I directly intervened when it comes to my patients receiving complementary or alternative treatments, but that does not mean that I would not do so.

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Palace of Care – Saying No – Part 1

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Photo by Debby Urken on Unsplash

In his professional life he was used to taking charge, of taking control and at times this bled into his personal life as well. His wife’s mother was unwell with widely spread cancer, she had been admitted into the hospice for symptom control of pain, breathlessness, and nausea. He had always been close to her right from their first meeting, he was probably closer to her than he was to his own parents, and even called her Mum. She had always been there for her children and their partners, and he really wanted to be there for her. He wanted to make sure that she was treated right, and he had a small inkling that his manner might come across as intimidating, but that was useful in police work. He just wanted to make sure that Mum was being well looked after, it was what she deserved.

She was a Pasifika lady in her early 60s, with end-stage cancer to her liver, lungs, and many bones. She was the frailest patient in our inpatient unit and I was worried that she might be dying. She was well cared for by her family who were always with her. Her husband of similar age, two daughters and a son-in-law, who I found out was a police officer. He had already caused a bit of a disturbance in the unit as he had spoken in an aggressive manner to some of our nurses, and was impatient. The family were all tired, worried about our patient, and stress levels were high. The family members all seemed to defer to the policeman who had taken on the role of family spokesman. The patient was fatigued but had not slept much in the past days because of uncontrolled pain. The first time I saw her I thought to myself that I wouldn’t be surprised if she crashes quickly.

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Palace of Care – There’s no place like home

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Photo by Andrew Umansky on Unsplash

It had taken some convincing for her to be admitted into the hospice inpatient unit, after two rough weeks in hospital. COVID lockdown restrictions had meant that she had not been allowed visitors for most of the time. She hadn’t been locked up but she had felt like a prisoner in her hospital room. For safety reasons not windows could be opened. Things kept changing, and the doctor with the sad face kept on bringing bad news. It seemed like nothing ever went right. The treatments were not working. Her calcium had risen to dangerous levels which required repeated treatments.

When she arrived at hospice her COVID swab result had not come back yet, so for the first day she still had to be under restrictions. She had a room to herself, and she could open the window and door to the balcony. The fresh air was a nice change after being cooped up inside the hospital. The food was delivered in takeaway containers and they only provided plastic cutlery. A small thing but just something else to add to the list. The people were all nice and really tried to make her feel at ease, but deep inside she felt uneasy.

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Palace of Care – How did you first meet each other?

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Photo by Leonardo Sanches on Unsplash

Taking the social history is an important part of our assessments in palliative care, as we need to know the people that we are dealing with in order to be able to help them to the best of our abilities.

One of my favourite questions to ask couples is, how did you first meet each other?

The replies are always interesting and take people back to exciting times. Transporting them to when they first fell in love.

Examples of answers include:

“I was working in the islands and she was the beautiful girl on the bicycle who caught my eye. I just had to find out who she was. We’ve now been married for 52 years and have four children, 15 grandchildren and four great-grandchildren.”

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Palace of Care – The Art of Prognostication

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Photo by Arthur Ogleznev on Unsplash

End-stage COPD (chronic obstructive pulmonary disease) due to lung damage from smoking had been his problem for the past decade. Lung tissue destroyed by toxic exposure leading to severe shortness of breath. He needed oxygen at all times, and could only at best mobilise short distances. Life had become a struggle, and just when he thought things couldn’t worsen, they did.

He was in really bad shape when he came in on Friday, he was only semi-conscious and could not respond to my questions. His wife and son, who were his main caregivers at home, looked exhausted. He looked terrible, blue lips and tongue, breathing rapidly, short, shallow breaths, with only a small amount of chest movement. I had not seen him so unwell before, which really concerned me.

Using all my clinical skills and experience, I really thought that he was dying, that he would die within the next hours. That he might last only days, and might never fully wake up again. I gently conveyed this news to the family. That I thought this might be the end of his life. They took it well, he had been unwell a long time, and had been close to death many times in the past.

I prepared his medication chart for end of life care. I wanted to cover the five common symptoms that occur at the end of life; pain, breathlessness, nausea, agitation/confusion, respiratory secretions. Anticipatory prescribing for a dying person is done, in order to cover the things that occur commonly during their last hours to days of life. Aiming for comfort more than anything else, we started him on syringe driver medications. This would mean a continuous infusion of symptom control medications to keep him calm and comfortable for whatever time was left. I left that Friday afternoon truly thinking that I would not see my patient alive when I returned after the weekend.

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