I spent 3 short weeks on elective at Hayward House Hospice, Nottingham, and here is a snapshot of what I learnt there:

Lesson no.1 – The hospice tree

To be completely honest, a few months ago I didn’t understand what a hospice was.

There is a ward for inpatients, yes, and people do go there to die – but that’s just one branch. As a whole, the tree looks after patients and families of patients with incurable diseases, and looks after them in every way it can.
There is day care – a lively social club of sorts with a clinic running alongside it, full of volunteers, newspapers and food. There’s a complementary therapy block – similar to a spa with its pine wood walls and aromatherapy oils. The ward is where patients go either for a few days to get their symptoms under control, or for end of life care. There are hospital and community teams for helping out and advising on the care of patients elsewhere. And finally there is a host of teaching and research activities which the team is enthusiastically involved with, from co-writing the Palliative Care Formulary to teaching expert communication skills.

Lesson no.2 – Hospices are rule breakers

It’s in the little things they do. Real flowers are allowed on the ward, and more than 2 visitors can come, and they could stay all night if they needed. Dogs come to visit, and patients can have a sneaky bit of chocolate or a drink here and there.

The ward is more like a home which happens to have doctors and nurses in it, rather than a hospital ward with rules. They focus on the individual and what would make them feel happier.

Lesson no. 3 – hospices tell the truth

“Just tell me Doctor, how long have I got left?”
For the first time I saw patients being given a straight answer, the doctor’s best guess. This was invariably followed by a sincere discussion about what they wanted to do in this time, what they needed doing for them, and gratitude.
I was able to learn communication skills from people who have sad and difficult discussions every day, and learnt to properly explore the patient’s anxieties first, and how to involve fully everyone in the room. It was invaluable to learn in this way.

Lesson no.4 – hospices aren’t depressing

That’s not to say bad things don’t happen there, because clearly they do. But the focus is always today – how are you feeling today? How can we help you today? – as well as making the experience of disease and end of life as positive as possible. As physicians, the doctors are experts are uncovering the source of patient’s pain and prescribing the most targeted pain relief.

In working at the hospice I learnt to deal with my own emotions and reactions to patients’ deaths, and found that talking it out with the team was helpful for everyone.

Will it make me a better doctor?

I am certain that this is true. In addition to the above, I learnt about symptom control at the end of life, including use of strong opioids and syringe drivers. I got to grips with some of the issues surrounding end of life such as symptoms of advanced disease, knowing when to start certain treatments and when to stop others. Also I am more confident in treating patients with incurable diseases and knowing how a referral to palliative care services may help them.
Practicalities of the elective

My elective was very easy to arrange by email. It would be good to check how many students are going to be there at the same time – more than 2 would be a little crowded.

I was warmly welcomed and felt part of the team from day one. Each day started with a ward meeting so I learnt people’s names quickly and I found out what was happening that day. The main activities included ward rounds, clerking new admissions, hospital team visits, and day care clinics. It was easy to get involved and I was able to actively help with care, not just stand and watch.

My top tip would be to ask everyone lots of questions about what they do, and to hear lots of interesting stories in return!
Jessica Richmond

Living Every Moment – my experience of Palliative Medicine in New Zealand
Working abroad – how I did it

Ever since starting work as a doctor, I had always wanted to work abroad. It was just a question of when. I felt that it would be useful to experience healthcare outside the NHS and that this would help me become a more resourceful and adaptable physician.
I decided to wait until completing Core Medical Training and MRCP, so that I would feel sufficiently experienced to make the most of the opportunity. During my CT2 year I sent my CV to hospices throughout New Zealand. I got a reply back from Hospice Southland in Invercargill, at the bottom of the South Island. Within a few weeks I had a Skype interview and soon after that followed a job offer. Deciding to accept the job and withdraw my application for ST3 training was a tough decision, but it ended up being one of the best
decisions I ever made.

Palliative Medicine in New Zealand

There are some differences in general between the healthcare systems in New Zealand and the UK, but the hospice system is part funded by government and part funded by charity, as is the case in the UK. Each hospice organisation covers a specific geographical area and the team will help support people in their own home, in care homes or as an inpatient at the hospice. At Hospice Southland we covered a large geographical area which incorporated the
region of Southland and the Queenstown area. There are many rural areas in Southland, which posed challenges in terms of supporting patients in their own homes. We worked closely with GPs and local district nurses, and often family members provided a lot of care support for patients.

A typical day at Hospice Southland

The day would start with an interdisciplinary team meeting, where we would discuss overnight calls, high risk community patients, and current inpatients. The hospice cat Meg would often join us for these meetings! As I was the designated community doctor I would often have a morning of home visits with one of the community nurses. I enjoyed being out on the road and travelling to different parts of the region to visit patients in their own
homes. Together with the nurse I would devise a management plan which included appropriate medication regimens for symptom management and future planning discussions. We would sometimes have lunch on the road, which was often a good excuse to sample some of the region’s best cafes!

Post of the Month: October 2017

Written by: Jennifer Short

REFLECTIONS

I am a core medical trainee who has wanted to pursue a career in palliative medicine since medical school. I have found many opportunities to gain valuable experience in the specialty, but recently I have very sadly gained a greater insight than I would have wished: my best friend passed away. She was diagnosed with a rare, aggressive cancer 18 months earlier and underwent several treatments and procedures, but unfortunately none were able to get rid of the disease. It is cruel and unfair (probably a daft thing to say: it often is I guess). She was a doctor too. Throughout this devastating time, we have seen healthcare through different eyes, from the inside, and I have noticed things, good and bad, often just the little things, but things that make a big difference, and I thought it would be good to reflect and to share, to learn lessons that might make a small difference to us, our patients and their loved ones.

Doctor as patient

Firstly, some thoughts regarding looking after a patient who happens to be a doctor.

Don’t be intimidated when treating patients who are doctors. We are all ‘normal’ people and in that situation, many of us will feel vulnerable, scared and out of control. We may just want to be treated like everyone else, to have things explained simply and thoroughly, and for no knowledge to be assumed. We will still want to be cared for and guided, and for someone else to be our ‘responsible clinician’ – that should not have to fall to the patient, they have enough to deal with. This of course will be different for each individual – as it is for every other patient. The rules still stand: treat each patient as an individual, be guided by them.

When breaking bad news to a patient who happens to be a doctor (or to a relative who is a doctor) good communication skills may become even more important. That person should, as much as possible, be protected from having to relay that information. It is not fair, nor appropriate, so make sure you take time to ensure that loved ones also understand. This may mean multiple conversations aimed at different levels but it is invaluable.

In addition to this, always bear in mind that what you are not saying is also important. Often we use ‘signposts’ when breaking bad news, give vague, brief information until we have a more definitive diagnosis and plan. However, this can be difficult with those who have some knowledge. They may be told that ‘the bloods and ultrasound show that the kidneys are bigger than they should be and are not working as well as they should be and this needs further investigation.’ A patient with medical knowledge may read into this what was not said, ‘it is very likely that the cancer has spread’. If not handled appropriately, this then puts them in a terrible position – do they break this potential bad news to their relatives, or do they quietly go along with it, silently distraught?

Doctor as loved one

Going from the role as doctor to the role as a ‘loved one’ if one of your friends or family is unwell is hard. Really hard.

The job we do is often tough at the best of times, but when you are dealing with a patient with a similar condition to that of your loved one, or when you are breaking bad news very similar to the news that has just been broken to your loved one, it can be unbearable. I have found that there is a ‘put on a brave face and get on with it’ attitude within our profession. This is not helpful, to us or our patients. We need to find a way to look after ourselves: peer support, senior support, friends and family, and time off work if necessary. You need to be able to be focussed on your job and your patients when you are there, so if that means taking some time out to focus on you and your loved ones then so be it. You need to be safe.

As I’ve already said, knowledge is hard. Equipping yourself with knowledge by researching the condition, treatment and prognosis can be beneficial and may help you to cope and also allow you to guide your loved one. However, it can also be dangerous. Firstly, you may not know the full details of your loved one’s case, so any research you do is unlikely to be specific to them. Secondly, you are putting yourself in a difficult situation if you know more than your loved one. If they chose to not know about their prognosis, for example, it is unlikely to be a good thing for you to know. Your job now is to support them, in the way they want to be supported. Don’t try and be their doctor, they will have enough of those.

The insight gained as a loved one in this situation can also have some positives and you may find new ways to help your patients: point them in the direction of a support group you may have heard your friend talk about; anticipate some of the issues they may face; understand just a little bit more how they, and their loved ones, might be feeling. But always remember that every person is different and never assume that just because you and your loved one coped in a certain way and wanted a certain amount of information, your patient and their loved ones will be the same. Keep a distance and keep perspective. The support and understanding of colleagues will play a big part in this.

Doctor of a patient at end of life

As I said at the beginning, I have wanted to work in palliative medicine for a long time. Throughout this journey with my friend I have at times questioned this desire and whether I have the strength to cope in such an emotional specialty. But these doubts have only ever been brief and ultimately I have been inspired by the palliative teams I have seen care for my friend. Seeing the palliative specialist teams from this point of view has also highlighted some important points to me which I think we can all learn from as doctors looking after patients at the end of life, whether in the palliative specialty or otherwise.

My experience as an ‘insider’ has made me realise just how difficult good, effective communication is, especially with end of life issues. Palliative consultants discussed difficult issues with us and they were amazing, explaining things clearly to us all and giving opportunity for us to ask questions. I would view these consultations as ‘successful’ and ones for me personally, to learn from. However, when non-medical loved ones later asked me certain questions, I realised that what you think people have understood from a conversation may be very different to what they actually have, especially when the topics being discussed are conceptually hard, as well as being emotional. As much as you can, go back, discuss again, ask them questions, as well as answering theirs. This may just help clear any simple misunderstandings, which may make a big difference.

You can have a big impact, not only for a patient but for those around them. How loved ones experience that death will make a huge difference to how they feel about and approach deaths they will have to face in the future, including their own. Simple things like staff using our names and showing genuine care by listening to our concerns and thoughts and making suggestions as to how we could care for her and spend those final days with her, guiding us through that part of the journey, made us all feel supported and cared about and empowered us to be there in the best way we could be at such a sad time. The memory of that compassion will stay with me for such a long time to come. As I said, much of this is simple and comes with just having basic empathy. But it also easy for it to get caught up and lost when you’re dealing with the day to day struggles of being swamped by the never ending tasks that need to be completed at work and the constant plate spinning that is involved in trying to maintain a healthy work life balance. We all know how hard it is and that frequently plates are dropped, but the next day we can pick them up and start frantically spinning again! But for that patient and their loved ones in that moment, this is the only thing that matters and there isn’t another chance to get it right. They need the support now. They need to be able to ask those questions now and not to feel rushed. Of course this is hard if you have to leave to do the school run and I don’t have any magic answer as to how to achieve this balance. I guess it is just about having these things in mind, trying to keep perspective and doing the best we can do at that particular time. Hospice staff seem to be amazing at this and I would encourage hospital healthcare professionals to spend more time at hospices, which are specifically set out for this purpose and where there is, in general, more expertise and time to focus on these aspects of care, and take back with them the skills learnt and experiences gained to the busy, less than ideal, hospital environment.

Practical points

Lastly, I would like to highlight a few general, practical points. These are things which seem like common sense and I’m sure we would all like to think that we do them, but I see on a day to day basis people not doing them, myself included.

Ask the patient. Remember that patients will often know a lot more about their condition and medications than many of those around them, including healthcare professionals, especially in complex cases. Listen to them and ask them questions, where appropriate of course. You may need to confirm things with healthcare professionals, but it can be much more time effective and accurate to walk to a patient’s room to check the drugs they are on for example, than trying to get hold of GPs, pharmacists, specialist nurses etc. It is also respectful to acknowledge that they have been competently managing their condition prior to coming into hospital.

Keep patients informed. It is all too easy for us to take on the role of the person in charge of the patient’s condition and by doing so remove their control and involvement when they are hospitalised. Put yourself in their shoes. They lie in bed all day and have things done to them, and often we don’t even inform them why or the results. The big procedures we are of course much better at, but how many times do you explain to a patient why a phlebotomist will be coming round to take blood from them in the morning, and later that afternoon when we sit and look at the blood results on a computer, how often do we go and inform the patients of the results, even when they are normal? Often it would only take a few extra minutes, but it is very important to the patient.

Complete death certificates as soon as you can. I completely understand that it is often one of a very long list of jobs to do and that we often have too many sick patients to look after, but I feel it is often not given enough of a priority by junior doctors. For that patient’s family, getting the death certificate means that they can get on with making arrangements, and having to wait even one more day for it, can make a devastating time even more distressing.

Conclusion

This is of course, just my reflection and my opinion, not based on any research in any way, but my thoughts on my experience. It focuses on issues that occur when the patient and/or relative is a doctor, but the points are relevant to all patients and our day to day work in general. I hope that it gives a slightly different perspective on some issues, that we can all learn from and reflect on in our roles, whatever they may be.

Post of the Month – August 2017

Written by: Alice Gray

After my FY2 year, I had decided that I wanted to take some time out of formal training to experience Palliative Care outside of the fantastic system we have in the UK. I was given the opportunity, with the support of Cairdeas International Palliative Care Trust, to spend six months as a volunteer doctor in Uganda with the Palliative Care Unit (PCU) at a large hospital. During this time, I was able to get involved in various aspects of the life of this busy department, from a clinical role, to teaching, to research and even supporting the set-up of a project to rear and sell pigs, aimed at improving the financial sustainability of the team.

Shortly after arriving, some members of the team were due to travel to Rwanda to conduct a palliative care needs assessment in Rwanda and I was given the opportunity to join them. It was a great chance to not only put my research skills into practice, but to see how palliative care can develop and become established in a resource poor setting. It did cause me to realise how much of my GCSE French I’d forgotten! We were able to visit District Hospitals that were more rural as well as large Referral Hospitals in Rwanda, collecting data and conducting some ‘basics in palliative care’ teaching sessions with various health professionals. Although oral morphine is slowly being introduced in Rwanda, access is still limited and it was humbling to see doctors trying their best to keep their patients comfortable with the limited resources they had. When faced with a patient who, following a stroke leaving her bedbound, began to develop pressure sores on her legs, they filled hospital gloves with water and placed them under her heels to replicate a pressure mattress. Their creativity did not cease to amaze me. It was encouraging to see the Rwandan Ministry of Health and clinical staff not only recognising the need for palliative care, but actively seeking support to develop their services from their Ugandan colleagues. The need for sustainability and a cohesive service is not easy and there’s no ‘quick fix’. But when I went back to Rwanda at the end of my six months, I was amazed at how things had developed, supported by the expertise, education and mentoring given by the PCU team.

During my time with the PCU team, I was able to learn from a variety activities. There were daily clinical duties, with ward rounds and tumour board meetings, teaching opportunities with medical students, pharmacists and other healthcare staff through lectures, mini-rounds and journal clubs. One day I found myself teaching a group of mental health nurses after they found that they were caring for a lot of terminally ill patients. It was an honour to be part of their first introduction to palliative care!

Clinical duties were for me the highlight. I would regularly elicit signs that I had only ever read about as patients presented with advanced disease for a number of different reasons. One such patient was a 27 year old woman from the north of Uganda who presented with a fungating breast tumour. She had presented so late as she had been afraid of coming to the ‘Western hospital’ and had tried to go to a local healer first. It was only when her pain became unmanageable such that she could hardly stand and the wound began to smell that she sought medical treatment. Unfortunately, she spoke a more rare tribal language that none of the team knew. However, they worked hard to overcome the language barrier to ensure that she understood what was going on and what treatment she was being offered. We decided to start oral liquid morphine for her pain and continued seeing her regularly. There were some difficult decisions to be made about treatment as chemotherapy supply had been unreliable and it was discovered on admission that she was also pregnant. The PCU continued to support the patient, her family and the ward team through these difficult decisions and the remainder of her admission. A month after her discharge, we bumped into her when she returned for an outpatient appointment and we almost didn’t recognise this smiling, chatty, walking young woman.

Being able to listen to patients’ stories and be a part of their journey is always such a privilege, but I have been truly humbled by what I have seen here. Seeing the high standard of research, persistent advocacy and compassionate clinical care being offered by the PCU team has been inspirational. Palliative care is a human right and should be available to all who need it, no matter where they are in the world. It is teams like PCU who are really making that not only a dream, but a reality.

Post of the Month: July 2017

Written by: Yuk Chun Lam

I spent six weeks at Mae Tao clinic (MTC) in Mae sot, a North-western town near the Thai-Burmese border in Thailand during my elective. Patients who visited the MTC were Burmese migrants who lived near Thai-Burmese Border or Burmese refugees who were displaced to Thailand because of civil war. I was placed in the medical in-patient departments where I looked after patients with various medical conditions and palliative care needs. I had the privilege to walk with a lot of patients along their end of life’s journey during my past experience working as an oncology nurse and medical student in the UK. It was such an inspiring experience to see how palliative care differed in the UK and Myanmar.

Demographic of patients

Comparing with the aging population in the UK, the life expectancy in Myanmar is much younger (around sixty years old). Lack of antenatal screening, poor nutrition and sanitation as well as low vaccination uptake were some of the contributing factors of childhood mortality in Myanmar. I was surprised by the number of middle-aged patients with end stage liver failure due to chronic alcohol misuse. Their poor diet and sedentary lifestyles also predisposed them to cardiovascular or cerebrovascular diseases which contributed to premature death. Undiagnosed heart failure was also commonly seen during consultation because congenital heart defects were not picked up earlier in life, or as a complication of rheumatic fever.

Symptom management

Only a small proportion of patients are entitled to Thai health insurance scheme or free health care even though they worked and based in Thailand. Patients were mostly with low socio-economical class and did not have access to health service. I have met a lady in her sixty who presented with chronic abdominal pain, decreased appetite and weight loss with a background of bowel cancer. Since the patient could not afford any curative treatment in Thai or Burmese hospital, she was admitted to the clinic for symptom control. Sadly, given with limited resource in the clinic, only simple analgesia and intravenous fluid could have offered for symptom control. Parental route of analgesia and other symptom management medications were not available. A nasogastric tube could be placed sometimes if oral medications were not tolerated. Besides western medicine, traditional herbal medicine was commonly used among Burmese patients. They might apply the medication as a form of paste for pain relief, or take it as herbal tea to manage symptom such as pain, dizziness, nausea or general unwell.

Spirituality

A large proportion of patients in the clinic are Buddhist. When talking to them, they may attribute to their conditions or physical suffering to the “sin” that they have committed in the past, or in previous lives. In order to “rectify their sins”, patients or their family members need to “gain mercy” which can be done in various ways: praying, mercy release of animals into their natural habitat, or doing kind act through donation/helping people in need. When someone died, family sometimes invite monks to chant prayer during funerals to free the spirit of the death. Occasionally, a male family member may become monks in Buddhist monetary for a short period of time to gain mercy for the deceased.

Caring for the dying patients

Healthcare is self-funded in Myanmar. To people who cannot afford, it means they often need to travel days to get to the clinics that are run by charity. For people who wish to die at home, they might found themselves too ill or too poor to travel back to their hometown. Equally changeling is that the clinic carried such a good reputation that patients who often travel days to visit the clinic to hope for treatment. It is often tremendously disappointing to find out their conditions are incurable. The lack of resource also meant that care provided in the clinic could be inadequate to meet the complex care needs of the dying patients.

Family members are often the primary carer for the dying patients, usually in a form of personal and nursing care. For patients without any relatives, their personal care might not been cared for. For those who are lucky enough to have their family members by their side, their carers often bear significant physical, psychological and financial stress.

Giving the lack of resource and infrastructure in the healthcare system in Myanmar, palliative medicine and hospice is still a relative new concept to patients, relatives and healthcare workers. Visiting a palliative medicine specific institution in developing countries like Myanmar did not appear to be a feasible option. My experience demonstrated how palliative medicine exists as an integral part of medicine, regardless what speciality you are exposed to, or which part of the world you are going. It was such an eye opener to witness how people in different culture think about terminal conditions, end of life care and death.