Dr Beatrice Baiden shares her experiences of working in palliative care
“Isn’t palliative care simply a case of morphine and a good pillow?” asked a surgical SHO when I shared my interest in the specialty. Fortunately health professionals do not generally hold this view; palliative medicine is increasingly being recognised as a fascinating blend of patient-centred care, pharmacology and end-stage disease management. It is receiving increasing recognition, reflected by the well-defined career structure and increasing competition for training posts.
Recent developments have seen the realisation of Dame Cicely Saunders’ revolutionary vision, with end-of-life care pathways being integrated into most major clinical specialties.
"Isn’t palliative care simply a case of morphine and a good pillow?"
In my medical undergraduate curriculum this field was covered in a fleeting one-day slot in our three-year timetable. After the recognition that I could not base my career choice on eight hours’ worth of experience I arranged to spend time at St Joseph’s Hospice, a 100-year-old hospice in the heart of London’s East End.
9am – The day begins with a handover followed by a ward round. The first patient is hyponatraemic and mildly confused, which may be attributable to his malignancy. The consultant explains the importance of looking for and treating reversible causes of any new symptoms. We spend ample time with each patient; this is far removed from the “blink-and-it’s-over” surgical ward rounds I’m used to.
2pm – I clerk in a Buddhist HIV patient, who has been admitted for a blood transfusion. He has an extensive past medical history that includes sclerosing peritonitis, a side effect of his anti-retroviral medication that causes recurrent sub-acute bowel obstruction. I’m amazed at the number of pathologies he has and the strong stoical spirit in which he deals with them.
3pm – I attend an MDT meeting in the truest sense – the board includes a chaplain, social worker manager-come-counsellor, physiotherapist, occupational therapist, speech and language therapists, complementary medicine therapists, specialist nurses, staff nurses and doctors.
4pm – I tour the various departments, the beautiful chapel and an area called Finding Space, which is open for community events. This area serves as a welcoming space for activities, such as yoga, civil ceremonies and local charity group gatherings. This reflects the contemporary trajectory of the hospice and encourages the public to associate the hospice with tranquillity and social activity
10am – I meet with my supervising consultant. This is my chance to ask her a myriad of questions about training schemes and further educational opportunities. She offers extremely useful insights from her personal career progression.
"This is my chance to ask her a myriad of questions about training schemes and further educational opportunities"
11am – I attend an MDT with the Tower Hamlets Community team. Patients seen on specialist nurse home visits are discussed by the panel. This offers a chance to consider the complex medical and social needs of patients. The team have a thorough awareness of what is going on in their patients’ lives, not only from a medical perspective, but psychologically and, to some degree, emotionally. Attempts are made to broadly consider the wider aspects of their end-of-life experience and how it would affect the patients. One such case involves a gentleman estranged from his sister, who is known to the team, and how the two might be reconciled.
1pm – I undertake home visits with a specialist nurse. Some patients prefer their home environment and therefore decline hospice admission. One patient is keen to avoid the hospice as he feels it is overly inhabited by nuns. The specialist nurse explains that the St Joseph’s team often have to prevail against common misconceptions; he is admitted.
3pm – We assess another patient and bring her in for respite care. She has a UTI and her daughter needs rest from her demanding role as the full-time carer. Respite care has a dual purpose of giving palliative patients a change of environment and their full-time carers time to recuperate.
9am – A GP with a special interest in palliative medicine introduces local medical students to the hospice and gives a “how-to” guide on prescribing anti-emetics. A forum called “Gold-fish bowl” provides space for a man who is enduring end-stage emphysema to reflect on his experiences with the student audience. He enthusiastically shares intimate final realisations with the group of near-doctors. A palliative registrar then presents a retrospective cohort study on the controversial use of B-blockers in end-stage emphysema. A specialist nurse rounds off the day with a presentation on managing epilepsy in patients with brain tumours.
10am – I attend teaching by Parkinson’s UK, the research and support charity. The emphasis is on accurate diagnosis, medications to be given and avoided, and simple ways to help patients. After this session I visit the day hospice, which is reminiscent of creative clubs I attended at school. The patients here have access to alternative therapies and are encouraged to collectively exhaust their creative energies in music, pottery and painting.
"The patients here have access to alternative therapies and are encouraged to collectively exhaust their creative energies in music, pottery and painting"
2pm – I have an impromptu shadowing session of the ward doctors. We admit a gentleman with recurrent ascites secondary to hepatocellular carcinoma for therapeutic abdominal paracentesis. The palliative registrar demonstrates the technique and emphasises the importance of clamping every two hours and taking blood pressure readings, to exclude hypovolaemia secondary to huge fluid shifts, before continuing ascitic drainage. It is a very simple procedure that immediately reduces his pain and discomfort.
4pm – I had meetings with the chaplain and the social worker manager. Interestingly there was tremendous overlap between their respective roles. Both of them were very involved in counselling patients and their relatives.
10am – We see two new home referrals with the specialist nurse.
3pm – I spend my last afternoon shadowing the ward doctors. I observe them handle a patient during an acute episode of paranoid schizophrenia, which is complicating his terminal illness.
5pm – I end the placement on a high and mull over how fantastic it was, as it transported my clinical inclinations to definite career aspirations.
The highs and lows
- Friendly patients and staff
- Talking through practical career options in palliative medicine
- Seeing a different side to the patient experience by doing home visits
- Interesting teaching sessions.
- Shadowing ward doctors
- Unfamiliar environment.
When arranging a work placement:
- Schedule in time to discuss career options with your supervisor.
- Use your supervisor’s time efficiently by preparing questions beforehand.
- Arrange an on-call shift with your team.
- Find a unit with teaching sessions.
- Avoid packing your timetable full of activities. Some of the most interesting things you’ll see could be while you are roaming the wards during your placement.
Dr Baiden is an F2 at Broomfield Hospital, Chelmsford. Her email address is firstname.lastname@example.org Thanks to Dr Abigail Wright and Krishna for their help with this feature.
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