Palliative Care : Before you go... Straits Times 2022-07-19

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The Ministry of Health is raising awareness about end-of-life care. But there are issues such as improving the skills of trained staff, community back-up and help for caregivers that need to be addressed.

Timothy Liu For The Straits Times

Published

2022-07-19

Singaporeans have worked hard to enjoy the good life they have today. They must also make sure they have a "good death", one not burdened by financial costs and unnecessary medical interventions.

The issue is in the spotlight after Health Minister Ong Ye Kung said last month his ministry will work to raise awareness of palliative care, and make the hospital discharge process smoother.

Palliative care is aimed at helping someone live with a serious, complex illness in the best way possible, improving the quality of life for the patient and his loved ones.

One key point the minister made at the annual Ministry of Health (MOH) workplan seminar was boosting end-of-life care by providing adequate support for caregivers to look after their loved ones at home. This is an important issue for Singaporeans - indeed, Mr Ong cited a 2014 Lien Foundation survey which found that 77 per cent of Singaporeans hope to die at home, but only 26 per cent manage to do so.

The future of end-of-life care should be a collaborative effort between healthcare institutions at all levels, including patients and their families. Patients must receive appropriate care at the right time, place and cost at different stages of their illness.

What are the obstacles to achieving this and how can they be addressed?

MEDICAL ASPECTS OF SUCH CARE

One reality of people nearing the end of their lives is that there can be a lot of to-ing and fro-ing between home and whatever medical care they might need.

It is critical to ensure a smooth discharge process from hospital to home, or other healthcare institutions such as inpatient hospice or day care.

An efficient discharge process also helps in ensuring the patient is referred to the right specialist. Many people think that end of life care is for cancer patients, but it is also needed for patients with end-stage organ failure, advanced dementia and severe frailty.

Importantly, plugging the gaps in discharge planning also improves the quality of life for patients and prepares caregivers physically and psychologically for caring for their loved ones at home.

One aspect of this is prognostication - how long a terminally ill patient has left to live. Obviously, such a prognosis involves sensitive discussions between doctors, the loved one and his or her family. There's also the pragmatic aspect of funding that end of life, and how a prognosis puts limits on that. Many in the palliative field have been advocating referral, not by prognostication but based on patients' symptoms and care goals.

This situation would be ideal if there was more skilled, trained manpower in home palliative care to support patients being discharged. Effective use of technology, such as tele-consultation and tele-monitoring, can also supplement manpower shortages and allow more end-of-life patients at home to get the medical attention they need.

Another aspect of end-of-life care is that patients' needs get more complex when they have more than one illness. So it is essential to build capability in upskilling palliative care doctors and nurses to carry out tasks such as peritoneal dialysis, blood transfusions and use of ventilating machines, to name just a few. In the past, hospices typically did not handle such procedures and would send the patients to the hospital instead when necessary. As more complex cases arise, training hospice healthcare staff on such procedures will help minimise the need to have patients being sent to hospital.

This need for upskilling may seem surprising. However, one of the findings of a 2021 survey by the Singapore Hospice Council showed that awareness about palliative and hospice care was low among healthcare professionals. About half of the doctors, nurses and other healthcare professionals said they had little to no knowledge of what is palliative or end-of-life care.

CARING FOR CAREGIVERS

Beyond the medical needs of patients, caring for them at home involves costs and poses challenges to caregivers.

Their stress levels increase as the condition of their patients declines. A financial consideration of the healthcare system should therefore include the cost to the patients and their families.

After all, in his speech last month, Mr Ong also noted that 50 per cent of the hospitalisation costs that people incur in their lifetime are racked up during their last three months of life.

The mental wellness of caregivers is often overlooked. They may be overcome by emotional and psychological pressures, and unsure where to seek help in the community. Getting a respite from their caring duties or having the flexibility to move patients temporarily to a day care or an inpatient hospice can relieve caregivers' stress.

Caregivers need to be equipped with the correct knowledge and skills in home personal care for their patients, and how to access community-based services to undertake tasks such as feeding and showering patients.

Local community and grassroots organisations can also step up to provide help, such as providing meals or minding the patient, to give caregivers time to run errands with peace of mind.

A positive step is that medical and nursing schools have added palliative care to their programmes as part of the curriculum, including the option to be attached to a hospice.

Having medical and nursing students "exposed" to the daily practices of a hospice or palliative care setting will not only raise awareness of palliative care but also allow them to gain invaluable experience working with end-of-life patients.

This, and the MOH's recent moves, will help raise awareness to help more people die at home in the comfort of familiar surroundings, rather than in a hospital. And this will also raise awareness that end-of-life care, while a difficult and sensitive subject, is an essential part of life - and death.

• Timothy Liu is chief executive of Dover Park Hospice.