It was Chinese New Year Eve in 2021 when a member of the Violet Programme (ViP) team received a call from St. Andrew’s Nursing Home (Henderson). “The blood pressure of Mr Tan*, a resident with gout and renal failure, has dropped. His godson insists that we send him back to the hospital but he is not keen.”
A video call was arranged between Mr Tan and his godson. With a promise that “we will bring the hospital to him and make him comfortable”, the godson finally gave his consent. The team set up a subcutaneous drip for Mr Tan and made some changes to his medication with his consent. By the following day, Mr Tan was sitting up in bed reading the newspaper when his godson visited. After that eventful Chinese New Year Eve, he did not make any further request for Mr Tan to be transferred to the hospital.
Mr Tan’s condition deteriorated again a week later. Under medication to control his symptoms, his demeanour was serene.
The closing report from the nursing home stated: “Mr Tan was attended by the doctor and palliative nurse. The pastor saw Mr Tan at 1pm and assured him that he was going to heaven, a peaceful and beautiful place with God, with no fear and pain. Mr Tan was assured, smiled and passed away within the day.”
Another ViP patient, Madam Sim’s* right foot was dusky and cold. She grimaced as the nurse opened the wound dressing. Restrained as a result of her repeated attempts to remove the nasogastric tube, her agitation and shouting caused much distress and discord among her family members. She had unceremoniously removed the tube again, just before the home visit. The visiting nurse gently coaxed her to take the “thickened water”, which she seemed to enjoy. Her pain medication was also adjusted.
A very independent lady who had paid special attention to her grooming and appearance in her younger days, recurrent strokes had left Madam Sim a shadow of her former self. Knowing their mother, it was clear to her children that an amputation to deal with worsening circulation in her leg would not be consistent with her wishes. They were less clear about the feeding tube; it did seem like her lifeline.
A family conference involving all four children was arranged the following day.
The two days of Madam Sim eating normally with less agitation set the stage for a consensus between the children and the clinical team as to the goal of care and how to handle the expected decline.
She passed away about a week later: calm, comfortable, with the family at peace.
Originally conceived in 2016 to address the rising end-of-life needs of patients with organ failure and dementia at home and extended to residents of nursing homes in 2019, ViP took off in the midst of the COVID-19 pandemic in 2020, as a partnership between St. Andrew’s Community Hospital (SACH), St. Andrew’s Nursing Homes (SANHs) and Changi General Hospital (CGH).
A service which adopts a specialist-on-generalist approach, it targets non-cancer patients and residents of nursing homes, whose prognoses are often uncertain. The programme aims to ensure continuity of care amid fluctuating demands with responses from the specialist palliative care teams or the generalist teams, as appropriate.
Patients are referred to the programme by staff of the home care programme, nursing homes, or CGH. Under the programme, the home nursing, home medical team or nursing home care teams provide general palliative care for these patients, while the ViP team steps in to manage patients’ symptoms when complexities arise. Under this new model of care, patients whose conditions stabilise will continue to be cared for by the home care and nursing home care teams and referred back to the palliative team if their condition deteriorates.
The programme aims to ensure continuity of care amid fluctuating demands with responses from the specialist palliative care teams or the generalist teams, as appropriate.
A system of rapid response with 24-hour coverage and support for patients with more complex needs provides a layer of support for the generalist teams. Training of home medical, home nursing and nursing home staff (the “generalists”) to build their palliative care capabilities and to identify palliative needs, manage common symptoms, facilitate goals of care discussions and guide families as well as caregivers through the patients’ last hours, is crucial. Close partnership between the ViP team and the other teams is key.
Mr Khairudin, son-in-law of ViP patient Madam Sumiah shared, “ViP, a SACH Home Palliative Care Programme, has equipped my wife and I with better awareness and understanding of my mother-in-law’s medical condition and well-being. We received guidance from the doctors and nurses through their close monitoring of her medical condition. This has allowed us to detect and recognise her symptoms early so that we can seek treatment for her medical condition. With support from ViP, my mother-in-law is able to receive treatment in our comfortable home environment. We are happy to be in this programme as we have gained more knowledge in taking care of the elderly. It has also enabled us to care for my mother-in-law while saving time and cost.”
From the inception of the programme in August 2020 until December 2021, the team had supported 181 patients at home. Of these, 97 of the 109 patients (or about 89%) who passed away did so at home. The team also supported 149 residents of nursing homes; 91% of them passed away in the homes.
By enhancing access to community palliative care, ViP helps to reduce admissions to hospitals, expands the reach of palliative care to more people with complexity-appropriate management by the different care teams and provides reprieve to patients’ families who are going through an emotionally challenging time. More importantly, the programme also helps home care and nursing home teams find closure on their journeys with their patients.
In recognition of the team’s work, the ViP team was awarded the Singapore Health Quality Service Awards 2022 (Best Team Award). *not their real names
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Words: Dr Karen Liaw, Senior Resident Physician, SACH; Dr Shaun Nathan, Resident Physician, SACH
Photos: St. Andrew’s Community Hospital, Singhealth
Original article source: The Hospice Link