【April 2019】2- Calm Approach to the Last Station of Life

Written by Wen-qin Liang and translated by HFT Secretariat

For people living in rural and remote districts, going to hospitals can be difficult, especially for matters of life and death when the need of palliative care is desperate and the scarce resources make it even worse. Puli Christian Hospital (“PCH”) was established to serve people in remote districts, and it started providing palliative and hospice care services twenty years ago with its palliative team. In 2017, PCH set up its palliative and hospice ward to provide more comprehensive care for Nantou area residents.

“When I started to serve in Puli Christian Hospital in 1993, palliative care was an unfamiliar concept not only to the public but also to medic professionals,” recalled Dr. Cheng-Sheng Zhang, who was asked how palliative and hospice care was being set up and promoted.

It all begun with a call in 1994, when an old lady with advanced cancer wished to move back to Puli from the United States and die peacefully in her hometown. Her family members inquired Puli Christian Hospital for home care resources, and this call somehow was transferred to Dr. Zhang’s phone extension. At that time, PCH still had insufficient manpower issues and had no precedent of house calls and no idea how to charge for house-call service. Dr. Zhang said to himself that patient’s needs should be prioritized above everything else, and so he drove his car to pay personal visits and provide constant care until she passed away.

That happened to be the time when Hospice Foundation of Taiwan (“HFT”) started promoting palliative care and providing classes for professionals. It was not until Dr. Zhang read about HFT that he understood what he did for the old lady was called palliative care. He registered for HFT’s training class and was determined to provide more palliative services to people who need it.

It was not long after that the government started to promote the palliative care pilot project. HFT also sent a team to visit PCH and encouraged it to set up a palliative team and provide palliative care to the neighboring area. In 1995, PCH appointed Dr. Zhang as the physician to lead its palliative team to start providing home care services.

With insufficient manpower, PCH insists on serving people and providing palliative care service. The covered areas expand from Puli to remote districts like Guoxing, Yuchi, Shuili, Xinyi, Rea’ia and more. PCH is the first to start providing palliative care in the Nantou area, and has been doing so for more than 20 years.

“Though the shortage of manpower hasn’t been solved, our nursing staff pays home visits constantly, and has exceedingly surpassed the NHI cap of 45 visits per month. As long as patients need us, we shall continue to visit them,” said Dr. Zhang with affirmation.

From Palliative Home Care to Ward Care

Since PCH started providing palliative home care service, the palliative demand in the area has been noticed. The setup of a palliative ward seems to be inevitable. All the relevant assessments have also been carried out to evaluate the possibility. However, “manpower resources and cost of the facility and place are all realistic concerns. Compared to regular medical care, palliative care requires higher quality with higher management cost and higher demand for staff power. This is why the setting up of a palliative ward has been under constant evaluation,” Dr. Zhang spoke openly.

As palliative care matures over the years, palliative home care cases have also increased by nearly 100 per year; demand for palliative shared care has also increased. Of note, the nursing home ran by PCH has made efforts in combining palliative care and long-term care into its services and those efforts have been awarded with the National Biotechnology and Medical Care Quality Awards, and also the SNQ Symbol of National Quality – Safety and Quality. “Setting up a hospice ward felt necessary and right, so we started working on it. The hospice ward was established in 2017,” said Dr. Zhang, who has been asked by the hospital administration whether he is willing to take over the palliative care department again and lead.

The shortage of nurses has remained a tough challenge when it comes to providing medical services in remote districts. “The original goal was to open 12 beds, but as the staff turnover rate is high in rural and remote districts, qualified candidates are rare and unable to meet the nurse/bed ratio of 1:1; thus the number of beds has reduced to 5 beds,” said Bao-chu Lai, the Nursing Supervisor of PCH. Once PCH recruits enough nursing staff, the ultimate goal is still to offer 12 beds.

Once Stabilized, Patients Return Home

While most people assume that the palliative and hospice ward is a place of no return, more than half of the patients who check in at PCH actually return home once they are stabilized.

“This is one of the purposes of patients to choose to stay in the hospice ward. When patients check in, we ease their acute symptoms and refer them to the home care team to take over once they are stabilized,” said Nursing Supervisor Lai.

Dr. Zhang added, “What we hope to provide is comfort. When we go to the communities to promote palliative care, we always explain palliative care to the public in a very direct manner. We tell them palliative care does not mean giving up, but means to ease your pain and symptoms, and maybe even to help you live longer.”

For most patients living in the cities, once they check in to the hospice ward, they would prefer to approach their end in the hospitals. However, for people living in rural districts, they prefer to revert to their origins and go back to their familiar houses, with their family members and in their neighborhood. This is why the palliative team of PCH will endeavor to support patients’ condition in the shortest time possible to reduce hospitalized time. Patients’ family members will also be taught how to care for advanced patients, especially what should be expected and cared for at the end of life stage, so that both can feel ready and focus on that moment rather than panicking.

Comfort of Mind and Soul in the Fullness of Life

When patients are at the end of their lives, family members are often emotional and find it hard to accept. Some even relate the hospice ward as a place of dying. The palliative team will typically explain the purpose and aim of the hospice ward and introduce its facilities to help family members understand and be consoled. Hui-chen Chiang, the nurse head of PCH hospice ward further explains, “We pay full attention to assist and care for mental consolation; we also remain connected with regular visits to provide grief and bereavement care, and to help during the family’s grieving period.”

Chih-kai Yang, director of PCH social service department, added they prefer to talk to patients and their family members to offer counseling and spiritual care. “It is probably because of the rural/city differences, patients here are mostly local elderly, who are not comfortable at expressing their feelings. We help them focus more on how much they are being loved and to love themselves. They are not burdens just because they are sick, but they are loved dearly. This helps patients feel calm and fulfilled. Additionally, family members who care for patients have also a share in the distress and pressure. As a result, the palliative team not only cares for the patients but also for their family members.

Director Yang also shared a case story with us. When Director Yang was communicating with an old lady who suffered from liver and renal dysfunction, he discovered this old lady had been referred from many hospitals and hadn’t been home for quite some time. Though her husband accompanied her to the hospice ward, deep down in his mind, he was still looking for other medical services to revive her. The lady showed distress and was not willing to cooperate. Noticing her discomfort, the PCH palliative team members started to communicate with her husband for her longing to go home. Finally, the husband agreed to take her home.

Later Yang heard from the family that once the old lady returned home, she felt safe and relaxed, and enjoyed a long sleep. A few days later, she passed away peacefully.

PCH palliative team’s heartfelt care has touched many hearts. “Many things we use to care for patients have been donated by patients’ families, such as the essential oils for patients’ massages, the piano played for them, and the car driven on visits. Some family members have even signed up for volunteering,” said Nursing Supervisor Lai. These stories of helping patients’ lives have all become the driving force and motivation to the hearts of the PCH palliative team members, who are encouraged to continue serving fervently.

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