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Opinion: Palliative Care – Can The Hospital System Improve?

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Opinion: Palliative care - Can the Hospital System Improve?
Until you come directly in contact with it, you don’t really understand or appreciate the anxiety and the angst faced by the aging, when they are up against the medical system.
My mother-in-law, who’s closing in on 90 has lived an active life. She is mild-mannered, not aggressively social, but does keep in contact with a few people at the community club she used to frequent.
Of course, along came COVID-19 to slam the door shut on her activities, confining her to the walls of an apartment.
Fortunately, there are no children or pets to aggravate the situation with their needy ways, and things moved along quietly and efficiently, thanks to home deliveries.
But already by then, you could see her slowing down as her movement — both physical and social — was curtailed.
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After the pandemic restrictions were lifted, when life started returning to normal, she was hesitant to go out.
Not having caught COVID-19, and hearing all the talk about the vulnerable elderly, she opted to play it safer than safe. She hardly ventured out. Her frailness became more apparent.
But she would still mask up and go for a short morning walk by herself and make her way about the apartment.
The Big Dip
Opinion: Palliative care - Can the Hospital System Improve -Scanning
In early July, my MIL woke up slightly later than usual. Her right eye was having trouble waking up. We brought her to A&E at NUH, where she was warded for tests.
The usual challenge was finding a bed for her, so she was placed in a large ward where the staff were constantly on the move.
By the second day, her right eye was permanently shut and after a number of scans we were informed she had a tumour in her pituitary gland.
The small pituitary gland sits at the base of the brain and controls your hormone levels.
There was also some internal bleeding, and the doctors recommended stopping the aspirin, though there was the risk of a stroke.
My MIL was adamant she didn’t want to have any invasive surgery or scopes done. She was still uncomfortable with the memory of her husband going through a gastroscopy and losing his voice, only able to speak above a whisper after the procedure.
Of course, we followed her wishes.
With not much else to do, she was sent to St Luke’s for therapy to build up her strength to return home. By this time, after nearly a week in hospital, she was unable to walk unassisted, so swiftly do muscles atrophy.
Fed a daily diet of porridge and unable to stomach most of it, along with the bad news about her health which she was still unable to digest, she remained uncommunicative and detached.
A mini stroke meant she had to be sent to NUH again by ambulance. And then it was back to St Luke’s.
A Wrong Call
Opinion: Palliative care - Can the Hospital System Improve - Ambulance
A doctor’s appointment was set up at NUH which required transferring her in an ambulance.
It was an extremely unsettling experience for her having to be conveyed by ambulance to the hospital, only to be told she didn’t have an appointment that day!
Just an apology. Nothing else from the hospital. How often does this happen?
After two months of being in hospitals, my MIL who had walked into A&E had to be pushed home in a wheelchair, unable to look after herself. Lying in a hospital bed had reduced her limbs to poles, unable to bear her own weight.
As she was discharged, we were given a list of upcoming medical appointments.
There were around a dozen different appointments over a four-month period for a variety of issues.
She had already made it clear she didn’t want any invasive treatment so, what was the point of going to a surgical clinic? What is the point of seeing other specialists who would only have at best a status quo report?
Each trip would necessitate inconveniencing her and the family to make a pointless trip to the hospital, to run more tests; none of which would improve her situation.
Addressing Pain Points
Opinion: Palliative care - Can the Hospital System Improve - Xray
In the case of my MIL, the decision was to address pain points, literally.
If there is pain or fever, or she injures herself, it would be important to get her to a hospital.
If there’s no pain to be managed, then the pain of the process should be addressed. Will it make much difference to my MIL if we skip or ignore appointments?
Having a geriatrician would be a good move.
So, instead of blindly attending every appointment, the geriatrician would assess the elderly patient, their medical issues and determine which are the appointments that should not be missed, and which are the ones that could be delayed or even ignored, if the patient feels it unnecessary.
Use More Tech For Patient Welfare

For a country that is pushing hard to be a smart nation, why can’t more emphasis be placed on activating artificial intelligence and algorithms to help align patient appointments so that as many of them could be arranged on the same day to minimise disrupting the elderly who largely want to be left in peace?

Each visit to the doctor may require an ambulance service, which costs over $100 (not claimable by insurance), and down time for anyone accompanying the patient.
As Singapore society ages even further, there will be more such elderly who will be in similar situations to what my MIL is going through.
Hospitals should take a more customer-centric approach. Consider the customer first — in this case, the patient — and not the need to run batteries of tests that eventually result in a large bill and no real benefit for the patient.
No doubt, insurance could cover most of it, but by the end of my MIL’s stay, her bill would probably come up to $50,000 for no one’s real benefit other than the hospital’s bottom line.
But what this episode also highlights is the suddenness of change when you’re elderly, and how it can dramatically alter the patient’s life and that of the immediate family.
From more hospital visits to hiring a caregiver and dealing with a system that charges for everything at every step of the way, your household expenditure is pushed up.
My MIL didn’t slide gradually into a state of high dependence. She fell off the edge. In a matter of weeks, she went from being independent to being totally dependent.
It’s important, then, to have your issues in order. Ensure your decisions when it comes to end-of-life matters are in order, and that you are clear about what should be the approach should your circumstances take a drastic turn.
Read the article Reflections on Dying with Dignity to get a clear picture of your options.

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