Booster shot for palliative care in Singapore

Ms Hazel Chua, a nurse from the hospice care department of the Singapore Cancer Society, makes things comfortable for 72-year-old former carpenter Lau Ee Chai in his home.
PHOTO: Booster shot for palliative care in Singapore

SINGAPORE - Before a patient stricken with a life-limiting illness draws his last breath, chances are, he would have been cared for by a nurse trained in palliative or end-of-life care.

The number of such specialised nurses have been on the upswing in recent years, in tandem with an ageing population that would be more vulnerable to chronic diseases.

Today, there are 697 nurses trained in palliative care, said a Ministry of Health (MOH) spokesman.

This is about 17 per cent higher than last year's figure of 594 and more than double the 337 such nurses in 2012.

Just five years ago, there were only 23 palliative care nurses in the country.

The ministry spokesman said most of these nurses work in inpatient hospices and for home palliative-care providers.

Others take care of patients in public hospitals, community hospitals, speciality centres and nursing homes.

Today, between 5,000 and 6,000 people receive either one of three types of palliative care in the community - inpatient service, day-care activities and home-care assistance. This includes any form of medical care which focuses on reducing the severity of symptoms and improving the quality of life for terminally ill patients.

By 2020, more than 10,000 people are projected to require palliative care, according to MOH.

Easing patients' pain

Staff nurse Pamela Koh from Dover Park Hospice said the top two complaints from her patients in the 50-bed hospice are breathlessness and pain. More than 90 per cent of them are cancer patients.

Generally, Ms Koh will first offer these patients interventions which do not involve medicine, such as making sure the ward is well-ventilated, as well as helping to soothe their anxieties. Only after these measures are taken will medicine be used to make them comfortable.

More than half her patients also suffer from restlessness, delirium and confusion, especially as their condition worsens. She keeps a close watch on them by placing them in beds which are nearer to the nurses' station.

Ms Koh, who has a nursing degree from Curtin University in Australia, two certificates in palliative nursing and one certificate in pharmacology, is one of 35 nurses trained in palliative care at Dover Park Hospice.

She is also only one of seven nurses at the hospice who are trained in advance care planning (ACP). This is a process of ongoing communication between the patient, family members or substitute decision-maker and health-care professionals about future medical care, should the patient be unable to make his own decisions.

More than 1,000 inpatients at Dover Park Hospice have completed the ACP process from March 2012 to March this year.

Caring for them at home

Other nurses, such as Khoo Teck Puat Hospital's nurse clinician Sim Lai Kiow, conducts such discussions with patients and their substitute decision-makers regularly in the hospital's ACP clinic, which was set up last October.

Ms Sim has helped housewife Sherling Lau, 41, to complete her father's ACP plan. Former carpenter Lau Ee Chai, 72, was diagnosed with a malignant brain tumour earlier this year, which has immobilised the right side of his body.

His family has declined cardiopulmonary resuscitation in the event that he suffers a cardiac arrest. They have also opted for limited medical intervention.

Ms Lau, the eldest of his three children, said her father can no longer talk, but had nodded his head to show that he liked being at home.

He is now being cared for at home by Ms Lau and her mother, assisted by regular visits from staff nurse Hazel Chua from the hospice care department of the Singapore Cancer Society.

Ms Chua has taught Ms Lau and her mother how to massage his abdomen to promote regular bowel movements. They were also taught how to check that his feeding tube is correctly positioned in his stomach before giving him liquid feeds.

Ms Chua said she also flags medical emergencies which would warrant a trip to the hospital, such as bleeding and bad infections.

Dr Irwin Chung, director of the care integration division of the Agency for Integrated Care, which oversees the long-term care sector, said nurses make up 30 per cent of the 1,000-plus health-care professionals who have undergone ACP training.

The ACP service is now offered by more health-care institutions and to a bigger pool of patients, as reported in Mind Your Body last week.

Studies have shown that patients who went through ACP were more likely to have their final wishes met, compared with those who did not.

Their relatives also experienced less stress, anxiety and depression.

A local study published in the journal Nephrology in 2011 found that 90 per cent of 461 renal nurses occasionally or never discussed ACP with their patients, compared with 67 per cent of physicians and 54 per cent of medical social workers.

Of those who discussed ACP with their patients, only 19 per cent of the nurses initiated the discussion. It was usually the patients or their family members who raised the topic.

The authors noted that nurses seemed to fear upsetting patients or their families the most, noting that "this is a pity as renal nurses often have the most contact time with dialysis patients compared with the other disciplines and, therefore, have a closer relationship, as well as more opportunities to initiate and follow up on ACP discussions".

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