Before I had my home visit rotation, I was secretly afraid of going "alone" on HV, because of debridement. I had done a lot of these things during clerkship and when I had spent about 6 months in surgery pseudo residency . I am not the "yucky" person type, too. I think, I must have gotten used to referring patients to the friendly surgeon in the last three years prior to this fellowship training while in a private hospital.
On my second home visit Wednesday, along with a junior resident (Aimee), 3 nurses and the ambulance driver, I attended to an 87-year-old with breast cancer and is a bedridden Lola with history of multiple strokes and uncontrolled diabetes, somewhere in Tondo, Manila. The last medical assessment was Breast Cancer Stage IV but the family does not have a record of any diagnostic exam results. Instead, they gave me copies of their latest medical bills. She has a very big sacral ulcer that made me miss Dr.RSN and his meticulous wound care that he has always given to patients. It was a challenge - I even had a hard time fitting the surgical blade to the holder =p ;
But I did it and HAPPY! I still know how to do decubitus ulcer debridement. =)
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When it comes to being patient, I am a work in progress.
Testing The Waters:
On with the same patient, I noticed during the course of our assessment that:
a.) Lola is occupying only a very small space in this 3-storey house. The room is like Harry Potter's (but in fairness, it has a sliding glass door and window).
b.) There are so many family members in the house today but they all deny living in it except for Carmen, the primary caregiver (the only caregiver!) and the house help.
c.) A daughter owns a caregiver facility in the US of A and she seemed to be ignorant about how her mother is doing. She kept on mentioning that she has all these dressing materials back in the US of A that she could have brought home with her but nobody had told her about the bedsores her mother is having.
It frustrated me and I let them know it. (As an afterthought, I was not able to use my ALS: Bracket)
I assessed Lola to need an IV antibiotic treatment and further surgical management and thus, I advised hospital admission. The family could not afford anymore a private hospital after Lola stayed for almost a month in the nearest private hospital in the area. I could not admit her in the Hospice Unit for the three beds that we have is occupied; and the waiting in the PayWards is LOonnggggg.
I talked to two of my co-fellows and asked them about OM to ask about some details. I advised the family to bring patient to this government hospital. During the last hospital admission, the family had decided for a DNR/DNI. I talked with the family more so as to get their perceptions and understanding.
I instructed Aimee to prepare the referral form. I wanted it done properly because I know how it feels to be on the receiving end of a "poor quality, bordering on useless" referral form. As a palliative care physician-in-training, I thought it was best to let OM know about the advance directive and so it was written on the referral.
It was about 3 hours since we left Lola's house when I received a phone call from her daughter. She was telling me that the hospital will not be admitting Lola since "wala na silang gagawin kasi DNR/DNI na." Hmmmm... I can feel my blood starting to boil.
I asked as nicely and as calmly as I can (it was good that I just finished eating a yummy food during the Lunch lecture by Dra.RR) if I could possibly talk with the ER doctor. Did I mention that we also placed the SHPM's contact number on the referral?
I explained to him that even if its DNR/DNI, any condition that can be reversible we are going to treat it so as to improve the quality of life of the patient and the family. It doesn't mean that we are just going to neglect every single patient who is DNR/DNI or refuse a patient hospital admission for that matter.
"Tama po ba ang pagka-intindi ko na hindi ninyo pwedeng i-admit c Lola kasi DNR/DNI na xa?"
My blood did boil eventually; here I am being told that "it is already out of your jurisdiction, kasi nasa sa amin na ang patient,"
"Why? Is the patient dying na ba?"
I know I was rude to him at some point and I did not say thank you. I just asked him to give the phone to the relative. And since, he doesn't want Lola to be admitted because of the DNR/DNI, then I instructed the relative to retract the DNR/DNI - Lola was then admitted.
It seemed stupid that a hospital admission depended on the DNR/DNI status.
This made me recall how I treated patients like Lola before I started this Supportive Hospice and Palliative Medicine training; and it made me thankful that I have this chance to correct my mistakes and thus, learn the uniqueness seen and the fulfillment felt in this other side of patient care. -0-
I am one of the five fellows-in-training; under the tutelage of four dedicated Palliative Care Specialists, supported by an outstanding Family Medicine Department, in Supportive Hospice and Palliative Medicine Program, that is only being offered by the best training institution of the country.
-0-
I am learning.
I am willing.
I am thankful.
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