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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