Dr. Leung Suk Hing, Dr. Joseph Ninan Palliative Care Association of Kota Kinabalu Dr. Chitra R.

Palliative Care Unit, QEH, KK

(Spehar et al., 2005).

full time nurse coordinators (NC) 1 part time doctor

PCA Community Setting Home visits

PCU Hospital Setting

Liaison Enables:
1. 2. 3. 4. 5.

Regular Friday afternoon meeting between PCA and PCU Communication Accessibility Joint Family Conference Medication

Case 1:

53-year-old, married muslim Bajau lady.

Squamous Cell Ca Cervix, Stage 2 B, Dx 2008. August 2008 completed concurrent chemoradiotherapy

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.

 Exploratory

laparotomy showed that the disease was very extensive involving all loops of the bowel and the peritoneum June 2011, a rectovaginal fistula was detected, 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 only after her bowel had opened. continued to live an active life, going out and visiting friends daily

 She

had five children whose age ranged from 24 years to 35 years husband lived with his second wife and she lived with her children commuted between Kota Kinabalu and Kota Belud, a rural town

Her

She

 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 with ascites
colostomy bag was used to catch the discharge.

 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.
patient was in Kota Kinabalu at the time.

The NC

called up the patient and found that the patient was scared and in great distress because there was a large amount of black color discharge from the abdominal mass

 The

patients condition was worsening and the family was unable to cope NC tried to arrange for the patient to be admitted to PCU Unfortunately the medical officer could not be contacted Finally NC was able to discuss the case with the staff nurse and arranged direct admission for the patient

Case II:

 49

year old male, Chinese, married with three children aged 9 to 15 years 2011, Dx Stage IV, squamous cell carcinoma of the lung

October

 He

worked as a lorry driver and his wife is a home maker. mortgage for the single story terrace house which they lived in had been paid off. the event of patients death, the wife planned to move in with her family member and rent the house out as a source of income.

The

In

 Mr.

Wong had expressed his wish to die at home. during his final hours with death rattle, 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.
Wong was unable to respond verbally

However,

Mr.

 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.
the changes in Mr. Wongs facial expression, the family members felt relieved that he understood and was agreeable to be admitted to the hospital .

From

 NC

immediately liaised with PCU and arranged for ambulance and direct admission to PCU.
Wong died the next day peacefully with all the family members with him.

Mr.

Case III:

 58

years old housewife with three children.

November

2011, at the time of presentation, she had metastasis to liver, spine, and cervical and mediastinal lymph nodes.

the

primary source of malignancy remained undetermined despite extensive investigation including immunohistology, MRI, CT scans, mammogram, tumor markers, and EGFR mutation analysis in Sime Darby

 She

initially presented with mid thoracic pain and lower limb weakness of two weeks duration.
of spine showed multiple bone metastasis. She received one fraction of radiotherapy to the spine in Kota Kinabalu. machine broke down after one

MRI

radiotherapy

fraction.

 was

referred to Sime Darby Medical Centre to complete the palliative radiotherapy and further investigation.
she returned home for chemotherapy. had undergone major investigation and treatment in the private sector.

Subsequently

She

 After

receiving one cycle of chemotherapy, patients friend, who is a PCA volunteer, referred her to PCA.
spending about two hundred thousand dollars on all the expenses, she was having financial difficulties in paying further medical bills. requested to be referred to a public hospital.

After

She

 Her

case was discussed on the regular Friday meeting. to PCU was arranged in the following week for her to be assessed by the oncology team promptly whether it was to her benefit to continue with chemotherapy.

Admission

Case IV:

 21

year old male, medical student .

Dx osteosarcoma of right distal femur.

2009, He

suffered repeated recurrence with metastasis to both lungs and mediastinal lymph nodes despite surgery, radiotherapy and multiple lines of chemotherapy. 2011, Above knee amputation was performed.

March

 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

 During

the day of the last admission before he died, his chest pain and dyspnoea progressively got worst.
steadfastly refused hospitalization.

He NC

promised him that direct admission to the ward would be quickly arranged and an ambulance could be dispatched to send him there anytime he was ready to accept admission.

 Late

in the evening he called NC and agreed to be admitted to PCU. admission was facilitated smoothly and efficiently.

His

Case V:

 Mr.

Teh was a 62 year old divorced retired welder.

diagnosed with Squamous Cell carcinoma of the larynx. chemotherapy, radiotherapy, and tracheostomy. 2011, laryngoscopy showed that the tumor was eroding the base of the tongue and the epiglottis.

2010,

Underwent

July

 Mr.

Teh came to Kota Kinabalu from West Malaysia when he was a young man. wife divorced him and probably returned to Indonesia with their three children in 1997 They had never been in contact with him since then.

His

 He

had eight siblings whom he had lost touch with over the years. lived alone in an isolated rented dilapidated wooden house with no cooking facility.
got around by driving his old car.

He

He

 On

the day of a routine visit late in the morning, he was found to be weak and tired with body odor There was redness and colored discharge from the tracheostomy He 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 own needs such as food and personal hygiene, PCU agreed to admit him for respite care immediately

1.
2.

3. 4.

5.

Timely admission to PCU as a preferred place to die. Expedite consultation to explore the feasibility of further palliative treatment for patients. Prompt direct admission to PCU for symptom control. PCA NC can arrange for direct admission of patient to PCU after consultation with PCU medical officer or staff nurse when the situation warrants it. Respite care for patients and their family.