seamless care_dr sh leung

7/31/2019 Seamless Care_Dr SH Leung

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Dr. Leung Suk Hing, Dr. Joseph Ninan

Palliative Care Association of Kota Kinabalu

Dr. Chitra R.

Palliative Care Unit, QEH, KK


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(Spehar et al., 2005).


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6 full time nurse coordinators (NC)

1 part time doctor


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Liaison Enables:

1. Regular Friday afternoon meeting between PCAand PCU

2. Communication

3. Accessibility

4. Joint Family Conference

5. Medication

PCA

Community Setting

Home visits

PCU

Hospital

Setting


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Case 1:


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53-year-old, married muslim Bajau lady.

Squamous Cell Ca Cervix, Stage 2 B, Dx 2008.

August 2008 completed concurrent chemo-

radiotherapy


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October 2009 discovered to have pseudomyxoma

peritionei from mucinous borderline tumour of

the appendix.

December 2010 CT TAP showed that the

peritoneal cavity was filled with mucin.


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Exploratory laparotomy showed that the

disease was very extensive involving all loops

of the bowel and the peritoneum

June 2011, a rectovaginal fistula wasdetected, with faeces coming out from the

vagina when the stool was soft

She was able to manage her rectovaginal

fistula effectively and left the house onlyafter her bowel had opened.

continued to live an active life, going out

and visiting friends daily


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She had five children whose age ranged from

24 years to 35 years

Her husband lived with his second wife andshe lived with her children

She commuted between Kota Kinabalu and

Kota Belud, a rural town


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November 2011, She had a bulging mass

palpable per abdomen in the umbilical

region, which started to discharge clear fluid

and the abdomen was also distended withascites

A colostomy bag was used to catch the

discharge.


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One night at 7:30pm, her son in Kota Belud

called NC with great concern because the

patient vomited in the morning, refused to

eat and stayed in bed most of the time.

The patient was in Kota Kinabalu at the time.

NC called up the patient and found that thepatient was scared and in great distress

because there was a large amount of black

color discharge from the abdominal mass


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The patients condition was worsening and

the family was unable to cope

NC tried to arrange for the patient to be

admitted to PCUUnfortunately the medical officer could not

be contacted

Finally NC was able to discuss the case with

the staff nurse and arranged direct admissionfor the patient


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Case II:


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49 year old male, Chinese, married with

three children aged 9 to 15 years

October 2011, Dx Stage IV, squamous cellcarcinoma of the lung


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He worked as a lorry driver and his wife is a

home maker.

The mortgage for the single story terracehouse which they lived in had been paid off.

In the event of patients death, the wife

planned to move in with her family memberand rent the house out as a source of

income.


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Mr. Wong had expressed his wish to die at

home.

However, during his final hours with deathrattle, his parents discussed with his wife the

taboo of having a death in the house, which

would make it difficult to rent out or get

good rent.

Mr. Wong was unable to respond verbally


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The wife explained to him that in PCU he

would be able to receive professional care

from doctors and nurses around the clock,

which was not possible at home.

From the changes in Mr. Wongs facial

expression, the family members felt relieved

that he understood and was agreeable to beadmitted to the hospital .


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NC immediately liaised with PCU and

arranged for ambulance and direct admission

to PCU.

Mr. Wong died the next day peacefully with

all the family members with him.


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Case III:


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58 years old housewife with three children.

November 2011, at the time of presentation,

she had metastasis to liver, spine, andcervical and mediastinal lymph nodes.

the primary source of malignancy remained

undetermined despite extensive investigationincluding immunohistology, MRI, CT scans,

mammogram, tumor markers, and EGFR

mutation analysis in Sime Darby


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She initially presented with mid thoracic pain

and lower limb weakness of two weeks

duration.

MRI of spine showed multiple bone

metastasis. She received one fraction of

radiotherapy to the spine in Kota Kinabalu.

radiotherapy machine broke down after one

fraction.


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was referred to Sime Darby Medical Centre to

complete the palliative radiotherapy and

further investigation.

Subsequently she returned home for

chemotherapy.

She had undergone major investigation andtreatment in the private sector.


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After receiving one cycle of chemotherapy,

patients friend, who is a PCA volunteer,

referred her to PCA.

After spending about two hundred thousand

dollars on all the expenses, she was having

financial difficulties in paying further

medical bills.

She requested to be referred to a public

hospital.


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Her case was discussed on the regular Friday

meeting.

Admission to PCU was arranged in thefollowing week for her to be assessed by the

oncology team promptly whether it was to

her benefit to continue with chemotherapy.


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Case IV:


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21 year old male, medical student .

2009, Dx osteosarcoma of right distal femur.

He suffered repeated recurrence withmetastasis to both lungs and mediastinallymph nodes despite surgery, radiotherapyand multiple lines of chemotherapy.

March 2011, Above knee amputation wasperformed.


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His major physical symptoms of chest pain

and dyspnoea were difficult to control

Pain relief from palliative radiotherapy to

the chest was short lived Various combination of analgesics had been

tried with varying degree of relief

Before the last admission he was on:

- Fentanyl Patch 25mcg

- Oxycodone 100mg BD

- Amitriptyline 25mg nocte


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During the day of the last admission before

he died, his chest pain and dyspnoea

progressively got worst.

He steadfastly refused hospitalization.

NC promised him that direct admission to the

ward would be quickly arranged and anambulance could be dispatched to send him

there anytime he was ready to accept

admission.


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Late in the evening he called NC and agreed

to be admitted to PCU.

His admission was facilitated smoothly andefficiently.


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Case V:


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Mr. Teh was a 62 year old divorced retiredwelder.

2010, diagnosed with Squamous Cellcarcinoma of the larynx.

Underwent chemotherapy, radiotherapy, andtracheostomy.

July 2011, laryngoscopy showed that thetumor was eroding the base of the tongueand the epiglottis.


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Mr. Teh came to Kota Kinabalu from West

Malaysia when he was a young man.

His wife divorced him and probably returnedto Indonesia with their three children in 1997

They had never been in contact with him

since then.


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He had eight siblings whom he had lost touch

with over the years.

He lived alone in an isolated renteddilapidated wooden house with no cooking

facility.

He got around by driving his old car.


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On the day of a routine visit late in themorning, he was found to be weak and tiredwith body odor

There was redness and colored discharge

from the tracheostomyHe had not been taking care of the

trachaeostomy tube regularly.

In view of the fact that Mr. Wong was

exhausted trying to take care of his ownneeds such as food and personal hygiene,PCU agreed to admit him for respite careimmediately


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1. Timely admission to PCU as a preferredplace to die.

2. Expedite consultation to explore thefeasibility of further palliative treatment

for patients.3. Prompt direct admission to PCU for

symptom control.

4. PCA NC can arrange for direct admission of

patient to PCU after consultation with PCUmedical officer or staff nurse when thesituation warrants it.

5. Respite care for patients and their family.


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