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Thursday, January 7, 2010

On palliative care - by Dr Jessica Otte

Excerpt from Dr Jessica Otte’s amazing blog writings
(Rose Charities Cambodia was privilaged  that Jessica elective’d there in 2009)

"I am not an expert in palliative care, but hopefully by the end of my rotation, I will have deeper insight. In my present understanding, palliation involves treating all aspects of a person’s ‘unrest’; physical, mental, emotional, spiritual, financial, relationship, and other concerns are what we can help the terminally ill work through. Our focus is not on curing the disease. A team involving doctors, nurses, pharmacists, social workers, spiritual leaders, family, friends, counsellors, and outreach/community care aides, has the patient at its centre; together, we work to come up with a plan. There are some common aspects to these plans:
·    Worldly: getting affairs in order (i.e. making amends, assigning power of attorney etc.); filling out the Palliative Drug Benefits plan
·    Spiritual: reconnecting or gaining strength from faith, perhaps by speaking on a regular basis with a minister, rabbi, or the hospital chaplain
·    Symptoms: being free from pain or uncomfortable symptoms; bone pain, nausea, trouble breathing due to fluid on the lungs (pulmonary edema) are some pretty common issues with many terminal illnesses, like metastatic cancer; care may also involve consulting appropriate specialists to see if they can be of service (eg. would the patient benefit from a surgical debulking of their tumour
·    Living Will: deciding what to do if things get worse: exploring whether the patient could benefit from an attempt at resuscitation or whether a Do Not Resuscitate (DNR) order should be signed; drawing the line for other interventions (eg. refusing a ventilator for ALS/Lou-Gerig’s disease); figuring out who will serve as a proxy decision maker should the ill patient be unable to do this herself
·    Dying: making a plan around dying – would they prefer to be cared for at home or in hospital?; exploring how much intervention would be desired (eg. if a cancer patients happens to contract an infection in hospital, should we treat the infection or not, with the possibility being that they succumb to the infection before the cancer)
·    After death: making a plan for after death – funeral arrangements, finalizing a will, etc. which is an important way of sparing the surviving family from decision-making in the most difficult of times
End-of-life planning and sorting out these issues may be a practical and necessary part of the job, however,  much of our efforts are centred around helping someone enjoy their remaining time with their loved ones, and to aid them in the process of confronting death. I have never been terminally ill, so I do not know exactly what it would be like. I cannot sympathize, but I can empathize. I can imagine how it could be difficult and frightening for some, and welcome or calming for others. I understand the manifestations of grief, how different they are from person-to-person, and can help someone to recognize that their feelings are normal. I cannot take away their feelings but maybe I can help them be more comfortable with having them. There is no pill for uncertainty or regret, but re-framing thoughts can offer a way to cope.
I can sympathize with those losing a loved one, as I have already been in those shoes. This is one time in medicine where sharing my personal experience may benefit my patients (or their families). I remember the first time I had to tell someone they were dying – she handled it better than I did! Since my preceptor made me do this on my own, I tried using some ideas from the SPIKES mnemonic to deliver the bad news. They may be a great start, but one can never go wrong “doing onto others as you would have them do unto you” in those circumstances. If they really don’t like something you are doing or saying, they’ll tell you to stop!
Let’s see in a month, after formally experiencing the field of Palliative Care, how different my ideas are about it. It feels wrong to say that I’m looking forward to it, but there is great capacity for helping people in a tangible way, and much learning for me to do."                                         Dr Jessica Otte


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