The Need for a Supportive Environment for Good_dato Seri Dr Devaraj

7/31/2019 The Need for a Supportive Environment for Good_dato Seri Dr Devaraj

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Dato Seri Dr T DevarajPenang Hospice Society


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Taking a macroscopic view of care P C is whole person or holistic care

Holistic care best addresses suffering

All who are ill suffer, not only the dying

Good medical care is

foundation of medicine

holistic

responsibility of all in clinical care should begin with diagnosis


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Generally good health, alongside long-term disabilities and diseases will

characterize modern societies apartfrom occasional epidemics


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DEPARTMENT OF STATISTICS, MALAYSIA

Table 1: Past, present and future trends of senior citizens,

Malaysia, 1960-2020

Year Number of Percent of Growth rate of:

senior citizens total populations Elderly Total

(000) population population

1960 386.6 4.8 - -1980 745.2 5.7 3.1 2.3

2000 1,398.5 6.3 3.4 2.6

2020 3,439.6 9.9 4.8 1.9


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UN Conference - September 2011

Focus

CVD, CRD, DM, Cancer 2008 deaths: 57 million / 36 m NCD

Epidemiologic transition & LD

countriesWEF costs NCD $47 trillion by 2030


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Origin when young, decades get established Ageing population

Illness trajectory varies with disease and alsoindividual + / - progressive

- cancer, organ failure, dementia

Adv. Medical knowledge / technology will

* more to live with disease / disability

* postpone death Identifying dying uncertainty in individual


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care expectations public, doctors

costs of care

ethical dilemmas

who will be the carers?

sites of care?


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Are increasing and will continue to do so Kinds of care will be determined-by

morbidity and response to treatment

Acute

Intermittent

long term care

All societies and health care systems will be

challenged health care recognized as a human right

costs of care rising


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Whole person care for all who are sickirrespective of diagnosis or stage of theillness,

Addressing appropriately all his or herproblems

Competent care

Compassionate care

suffering, QOL, fulfill expectations


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compassion

andmodern medicine

suffering terminally ill

die with dignity

place to die peacefully

Dame C Saunders

1918 - 2005


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Approach - holistic (whole person)

involving family

Aims - decrease suffering

provide comfort

not shorten life

not prolong lifesupport family


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WHEN ONE IS ILL

PT

HOSP.

CLINICS

TAKING CARE TO THE HOME

HHP

1992 PT


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PC service provision 1998 as PCU / PCTs PCU (> 6 beds, dedicated staff, ward)

200 beds in 2002

2005 Pall.Medicine medical sub-specialty

2007 Fellowship PM / 2 completed in 2010 Diploma in P Nursing being developed

MOH and Hospice groups

referrals for community care

medications grants


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CANCER Prevalence 90.000 / mod to severe pain 15,000

Annual cancer deaths 12,000

Incidence 2009 40,000 (2/3 at stage 3 / 4)

PC need 26,000 (new per year)

Coverage HHP > 17 % (4489 / 09) PC beds > 10 % (1000)

PENANG (2009)

PC need - 1000 new a year

Coverage 626 (2 HHP)

Think point:

estimated need for Malaysia is

80% of all deaths


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TAKING CARE TO THE HOME NEW

MODELS

PT

HHP

HOSPITAL SUPPORT

TEAM

HEALTH SUPPORT TEAM


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PALLIATIVE CARE

ANAPPROPTIATE MODEL

TO ADDRESS SUFFERING


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Dame Cicely Saunders suffering of terminally ill

WHO (1990)

active total care of patients whose disease notresponsive to curative treatment

WHO (2002)

an approach that improves QOL of patientswithlife threatening illness

what is a L T I ?

WHO (2002) childrenactive total carebegins with diagnosis


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Death

Death

Death

Saunders

suffering

WHO 1990

WHO 2002

Not responsiveto curative Rx

Quality of life inLTI

Dying


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IS HOSPICE CARE

SYNONYMOUS WITH ENDOF LIFE CARE?


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Palliative care is basically just good medical care, and itcan be delivered by any care provider who has theapproach and skills in an environment of support

All specialists, family doctors and nurses should accept

responsibility for the delivery of good care, relying onspecialized palliative care staff and programs only forthe most difficult or unusual problems

Ian Maddocks

Emeritus Professor of P C


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Patient centered care

Care involves all health professionals

Problems addressed appropriately from diagnosis

Will minimize suffering regardless of disease outcome What patients want get well (cure), feel better

(control), care and comfort

MAJOR ILLNESS Death

Control

Cure


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But we tell everyone that the principles of

palliative care are applicable, whatever the

illness, whether simple or complex, early oradvanced, curable or life-threatening, at

home or hospital.

true but very confusing!Derek Doyle 2003


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We are all born to die. At present 50million die yearly. We

ought to give those who are to leave life the same care and

attention that we give to those who enter life, the newborns.

By enabling the vast amount of knowledge available in the

field of palliative care, the quality of life of the terminally illcan be significantly improved

Oxford Textbook of P Medicine 1992

Think Point:

message is babies matter, dying matter but what about

those in between who are ill ?


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In many ways I think this is the most exciting way forward,helping to move support and symptom control to an earlierstage of the disease. It emphasizes that hospice treatment isnot merely a last resort but can be practiced in the general and

teaching hospitalIt is only when such care is spread through the National HealthService in general, in both hospitals and the community, as wellas in hospices, that these people will have the help they need

Dame Cicely Saunders

Parthenon Publishing Group 1988 & Free Inquiry

1991/92 Vol 12 No.1


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Get well (cure)

Feel better (control)

Care and Comfort

?

must I be dying to get good care


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WHAT WOULD YOU

WANT

WHEN ILL ?


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Study of PC intervention in 151 newly diagnosed non-small-cell lung cancer by Temel et al. Results: as cf standard care group, the intervention

group had better quality of life, lower rates ofdepression and a 2.7 month survival benefit

Editorial: The study by Temel et al. represents animportant step in confirming the beneficial outcomes ofa simultaneous care model that provides both palliativecare and disease-specific therapies at the time ofdiagnosis.

Think Point:why not advocate good medical care by clinicians

from diagnosis?


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HOLISTIC CARE IS GOOD APPROACH

FOCUS ON END OF LIFE CARE

up to 80 % of all who die

DOES NOT ADDRESS ALL SUFFERING

hence not appropriate


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No moral impulse seems more deeply embedded than the

need to relieve sufferingit has become the foundationstone for the practice of medicine, and it is at the core of thesocial and welfare programs of all civilized nations

Callahan D. The Troubled Dream of Life: In Search of a Peaceful Death.1993

A Physician is obligated to consider more than the diseasedorgan, more even than the whole man he must view theman in his world.

Harvey Cushing (1869 -1939)

* A doctor must be a compassionate and caring person first,and if he/ she knows something of medicine it will be his /her additional qualification

Anonymous


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Public

Government

Health

Professionals

SupportGroup

Friends

Family

Patient/Individual


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Promotion of health

Prevention

disease

premature death Cure or control disease

Care and comfort

all who are ill

chronic ill

incurable


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universal coverage

equal access

efficient use of resources

equity in financing

consumer choice

control of expenditure

clinical freedom for providers

Long healthy life, short ending

meeting needs and curbing costs

?????????????

HOW DO YOU DO IT


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No country can call itself civilized if an ill

person is denied care because of lack of

means

Aneurin Bevan

1947


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Palliative care = holistic care

Good medical care is also holistic care

Why continue perception that they are different?

Commonality is holistic care

Best if all clinical care is holistic care

Thus all clinicians have a duty of holistic care

Holistic care from diagnosis by primary doctor

P C specialist accessed for problems

Way forward - advocacy by P C practitioners

our constituency all with a major illness

* This approach will be welcomed by public


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Enormous as it should be for all ill

Current P C approach does not address all who suffer

Even if environment of support improves the need will

not be addressed Mainstream medicine must be involved

GMC is the duty of all clinicians


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NEEDS

SUPPORTIVE

ENVIRONMENT


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Patient centered Health system

- levels of care, primary care led, seamless care

Resources adequate trained staff, $

Professional carers

- caring attitude

- competent

- compassionateThink point:

Can we attain developed status in health care if mind

sets do not change?


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Philosophy of care - primary care led andcommunity based

Continuity of care between practice settings

and levels of care Applies to many chronic conditions and

chronic illnesses

Main thrust of care home / community care

In patient care as back up


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Specialist

Doctor

GP/ResidentialPrimary

Secondary Care

Tertiary Care

Self, family, friendHome

Think Point: elements of above already ongoing but not in anenvironment of support


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Public maintain healthy lifestyle, manage minor illness,

have a family doctor, access hospitals only for A &

E or via family doctor, and not abuse system

Providers (health professionals & hospitals) be ethical & professional, not abuse system

Government

critical role

ensure equitable access, resources provide services

regulate health care


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reestablish

whole person care

as good medical practice

involving all clinicians


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you can start

tomorrow

Dr Mary BainesNational Palliative Care Conference,

November 1993


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LIFE IS UNCERTAIN

DEATH IS CERTAIN

If as physicians we believe that advances in medical

technology can indefinitely postpone death then it is a

delusion - D Callahan (1993)

Patients / families

keep pushing doctors to go on trying till the end

are ready to let go disturbed or fear being kept alive with unacceptable

technology


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Healthy

Financially secure

???Short final morbidity


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Free from avoidable distress, suffering

In accord with ones wishes, culture

Consistent with clinical and ethical standards

Company of loved ones

Opportunity for farewells and fulfillment

Achieve meaning of life

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The Need for a Supportive Environment for Good_dato Seri Dr Devaraj