MANAGEMENT OF DISEASE AND PERSON – A CONTEMPORARY ISSUE IN MODERN MEDICINE Dr. Folaju O.Oyebola MPhil. Pall. Med. (UCT) Head of Dept. Pain & Palliative Medicine Federal Medical Centre Abeokuta, Ogun State, Nigeria firstname.lastname@example.org
Overview• Palliative care concept• Multidisciplinary Team Care Approach• Journey so far … 2002 - 2011• Day Care Hospice Project – The concept• Sharing experiences – 2 stories• Tributes
Posers• What exactly do we manage in patients, is it the disease / the person ?• How effectively do we manage both?• What are the best way to effectively manage both the disease and the person?• Curative Vs. Care or / Curative and Care ?• Palliative Care # End-of- Life Care?
Disease & the Person Disease PersonCure: Care – compassion, hope etc.• Surgical - Need Assessment along at• Medical least 4-5 domainsBoth applicable in Cancer - Care and Support
WHO Views• “Health is not just the absence of disease, it is a state of physical, psychological, social and spiritual well being” (World Health Organisation,1948).• “Until recently the health professions have largely followed a medical model, which seeks to treat patients by focusing on medicines and surgery, and gives less importance to beliefs and to faith. This reductionism or mechanistic view of patients as being only a material body is no longer satisfactory. Patients and physicians have begun to realize the value of elements such as faith, hope and compassion in the healing process. The value of such ‘spiritual’ elements in health and quality of life has led to research in this field in an attempt to move towards a more holistic view of health that includes a non-material dimension, emphasizing the seamless connections between mind and body.” (World Health Organization (WHO), 1998)
2006 FMCA StudyFMCA Experience Desire for a company• Forty-six (85.2%) of patients • . were of the opinion that the hospital staff do not spend time with them.• While 27(50%) of the respondents affirmed that they did not enjoy a close relationship with the staff.
Care & Support for the Soul FMCA Experience Not my business a). 29 (53.8%) of the respondents were not satisfied with the hospital “spiritual care “ b). 18 yr. old, had Chronic scrotal swelling ? tumor, uncontrollable pain (morphine).Further assessment- Identifiedspiritual distress – Had a strongdesire to be baptized. Rev. Fr. + 2Godmothers intervened & wasbaptized. Pain subsided & familywas very happy
. Duty of Health professionals•• . To cure sometimes• To relieve often• To comfort always (Hippocrates) CURE & CARE - Too often forgotten
Care & Cure• Up to the 19th century, most medical care related to amelioration of symptoms while the natural history of the disease took its course toward recovery or death. By 1900,doctors & patients alike had turned to a search for root cause & ultimate cure. Therapy directed at the symptoms was denigrated & dismissed as merely symptomatic …………(Pain & Symptom control)• [Yet] the immediate origins of misery & suffering need immediate attention while the long time search for basic cure (disease specific) proceeds. The old method of care and curing had to be discovered. Wall P.D Twenty-five volumes of Pain 25:1-4,1986
PC Definition• Is an approach that improves the quality of life of patients and their families facing the problems associated with life threatening illness. • through the prevention and relief of suffering by means of• Early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual. (WHO2002)
PC Definition• PC means patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering.• Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information and choice. 73FR 32204, J UNE 5, 2008• Medicare Hospice Conditions of Participation-Final Rule
Old concept of. Palliative Care• .. Curative Palliative care care Diagnosis Death
Continuum of care- Not End-of Life . Care• . Curative care Chemo, Radio HAART. Palliative Care for Cancer Individual & HIV/AIDS /Family care Bereavement diagnosis death care
. Outcome of introducing PC early after diagnosis• “Among patients with metastatic non-small cell lung cancer, early palliative care led to significant improvements in both quality of life & mood. As compared with patients. receiving standard care, patients receiving early palliative care had less aggressive care at the end of life but longer survival” Jennifer S.Temel, et al (2010), N Engl J Med 2010;363:733-42
Multidisciplinary/ Interdisciplinary• “THE DAYS of lone-ranger clinician are over.“ “The parallel play” model of health care, with each discipline structuring cross-sectional interventions in silo, is terminally ill and on firm do-not-resuscitate status ---- The modern patient with chronic illness needs a group of multidomain experts who work together longitudinally to collectively orchestrate chronic care” Vyjeyanthi S. Periyakoli (2008)
PC & other Hospital CommunityMultidisciplinary Team (MDT) Approach:• Open minded• Team work• Mutual respect• Rx. Both the disease/ person - Cure /Care• • Cooperative / Collaborate TeamsSmall win – HIV/AIDS MDT ProjectFailing - Oncology MDT
Collaboration• Debunk rivalry, never supplanting physicians as each of us needs other.• Strengthen existing referral network.• Education, Training & Research collaboration.• Essence is to jointly manage advanced disease patients to improve their quality of life & improve FMCA health care service delivery.
Palliative care is holistic & inter- . care. disciplinary• .
Journey so far ………Unusual responsibility to model the WAY & startnew service without pre-existing structure !!!!• Strategic PlanningDefine –- Mission,- Vision,- Values
InspirationFMCA hospital Mission Statement• Provide quality and timely clinical and other support services to patients and clients at a reasonable cost within its jurisdiction. “In doing so, we shall adopt a multidisciplinary team approach for the provision of prompt, excellent and cost effective Health care services in Ogun state………….”
Strategies Vision Mission Statement• To improve quality • To integrate palliative of life of clients and care services into the their families and existing health care system using establish a Centre for multidisciplinary education , training team care approach and research.
VALUES• Client first • Sacrifice• Team spirit • Hardworking• Mutual respect • Honesty • Empathy• Accountability
Modest achievementsSmall wins• Morphine – Introduce by PC team against Pentazocine• We introduced MDT to cancer /HIV/AIDS services• First 2 Palliative Care Physicians in Nigeria• Paper presentations-Local, Region & World events• Assisting other sister hospitals to start PC services• Education & Training with our UK Partners 2005,2008,2011• Interdepartmental Seminars -Target patients – Cancer, HIV/AIDS, End-stage Cardiac,Metabolic, Renal and Neurological conditions
Focus Services• Pain / symptom control• Care and support• Bereavement care• Geriatric services – New project• Community outreaches – Home visit – certifyingdead at home.• Palliative Care Education and Training/ UKPartners• Day Care Hospice
Day Care Hospice ConceptAIM- Refer patients for: Inaugurated Jan.2011• Longer consultation time Facilities –• Holistic Care and support • TV• Clients sharing challenges and successes. • Games• Identify Pt. problem & refer to • Drawing & Painting appropriate MDT group.• Collectively strategized on • Kitchen facility clinical & non-clinical problems. Future facilities• Skills & empowerment for • Massage clients.• Social networking with peers • Salon• Temporary stay & stabilization • Bigger Day Care Hospice of clients
Palliative/ Pain Clinic consults received . from march 2008 to June 2011• 70 . 60 50 40 30 20 10 0 2008 2009 2010
. Cancer Case – Story 1•• . A 24 year old lady with history of recurrent breast lump. Had excisional biopsy and histology which confirmed adenocarcinoma. • Had some radiotherapy but defaulted . • Re-appeared 4 months later with metastatic extension to the axillary region. • Had some CHEMO but also defaulted • Presented 4 months later with severe chest pain , pulmonary metastasis and minimal pleural effusion (Surgical + Palliative Care). • A month later, she was admitted to the emergency for attempted suicide.
Problems &. Intervention. . Problems Solution• • . Physical • • . Jointly managed – MDT - Ulcerated metastatic Breast Ca. - Pain - Opioids(Morphine) +PCM - cough and mild difficulty in - Wound dressing- Metronidazole breathing powder • Family meeting – • Psychosocial – Suicidal - Care and Support Depression, inadequate support - Patient find meaning to illness & rejection by family - Family Cohesiveness • Spiritual – • Escaped from the - Religious conflict incarceration - Family requested Parole • Pastor, UCH
Story 2 – HIV/AIDS Continuum of Care• A 30yr old graduate, teacher married 8years ago with two kids.• Lost second child few month after birth.• Husband died of HIV/ AIDS 3years ago• Two year ago she was diagnosed RVS positive and placed on HAART.• last year she lost her 7year old boy to head injury.2nd Relationship• She was lonely/ depressed - this prompted her to search for another relationship.• Pregnant for sero - discordant man (non-disclosure).• Resigned her job &abandoned home to follow new man
PROBLEMS . INTERVENTION• Got to know of other 4• -. • Strategy/ counselling; women & 7 Kids, • - . Advised to be independent & relocate• jobless and was starving, - To re-apply & get her former job .• abandoned by her man Spiritual care & support friend . - We contacted our volunteer her who offered her spiritual care & support- lonely & depressed, wanted Intervention - Outcometo terminate pregnancy/ - Found meaning to her lifecommit suicide. - Became closer to God.• Problems; • Already secured back her Job and- Emotional, returned to her personal home .- Socio-economic & • She was discouraged not to terminate the pregnancy.- Spiritual • Today she is living happily ,Civil servant, part-time hairdresser, attending PMTCT and coping well with the pregnancy.
Tributes – Encouraging the Hearts• Consultants , Units & Departments - Refer patients to us for consultation & collaborate• Palliative Care MDT• Volunteers – Time, resources etc. - support, strategize together with us
THANK YOU• THE HARVEST IS RIPE BUT THE LABOURERS ARE FEW – PRAY THE GOD OF HARVEST TO SEND DOWN LABOURERS.Matt. 9, 37-38Pls. Join us today !!!!!!