Timothy Liu is currently undertaking a Master’s in Public Health at the Saw Swee Hock School of Public Health, in addition to his role as Chief Executive Officer of Dover Park Hospice. For the past two years, he has also been handling and managing the impact of the Covid-19 pandemic.
What led you to undertake the Master’s in Public Health?
Since 2016, I’ve helmed Dover Park Hospice and I come from an engineering and business background. I wanted to gain further insights into health and healthcare and learn public health concepts and tools that I could bring back to Dover Park Hospice.
I found the modules around programme design, implementation, monitoring, and evaluation particularly useful and will draw on the learning from these courses going forward.
The pandemic hit while I was undertaking the Master’s and so the course shifted to mainly online learning. The online lectures were as engaging as ever and the different platforms meant that we could work in small groups and edit a document at the same time. Social media messaging also enabled some of the social interaction to develop. It is hard to imagine how we could have continued the course without the technological solutions.
Fitting in the course was a challenge while responding to the pandemic, but I felt it was even more valuable to gain an in-depth understanding of public health at this time.
The Master’s involved a practicum project, which aims to bring together the public health skills and knowledge learnt during the course to research a specific issue, analyse information, and be able to communicate findings and key messages effectively. I found this useful as I could apply the theories and concepts learnt during the course to a real-world issue.[/vc_column_text]
What topic did you choose to explore in your practicum?
Singapore has one of the highest prevalence of kidney failure and diabetes-induced kidney failure. In 2019, there were nearly 8,000 patients on dialysis as a result of kidney failure.
Many of these patients will go on to access palliative care services, but there can be challenges around awareness and understanding of the services and continuity of care.
Through a literature review and interviews, my research aimed to explore the patient journey and factors that influence the initiation of palliative care for renal failure patients in Singapore.
What were some of the attitudes towards renal and palliative care in your research?
There is strong belief in the population that dialysis is life-giving and patients and family sometimes assume that life is normal again and their life expectancy is similar to those who are well.
Dialysis can prolong life for a good number of patients, however, it is still a life limiting treatment option. Dialysis and palliative care are equal, complementary and life limiting options for end stage renal failure patients.
Interviewees highlighted that there can be varying degrees of readiness to move to palliative care and accept their health prognoses – from patients, families, and healthcare professionals.
A referral to palliative care can be viewed as having no hope for the future, with feelings of being abandoned by the healthcare system and having been given up on by their care professionals.
Even if a patient is ready to accept their terminal condition and withdraw from dialysis or be referred to palliative care, there can be a lack of acceptance of end-of-life care by the wider family.
In some extreme cases, families just wanted the physical presence of their loved ones. This was the case despite the cost challenges of continued care, dialysis being no longer beneficial to patient, and the patient having a poor quality of life.
Even if both patient and family are ready to accept the patient’s condition, some clinicians may not be ready, particularly younger clinicians. Interviewees outlined that some doctors would try to persuade younger patients to prolong life through dialysis.
What were some of the findings around the delivery of services?
A key message was that the healthcare system is relatively siloed. Early stage renal failure is usually under the care of primary care, middle stages under renal specialists, and end stage managed by renal specialists and as a last resort, by palliative teams at the hospital or opting for hospice care.
The current accessibility and transitions are challenging for patients and can seem disjointed because of the way the system works. Multiple handoffs from one setting to another can risk information being missed, poor patient and family experience, as well as being inefficient for providers.
We need to find ways to better co-manage patients so that transitions will be seamless. A major mindset shift is perhaps needed for dialysis to be seen as a form of palliative care.
Another message was that palliative care support should be in place sooner for patients. There is also a need for a focus on upstream interventions – particularly around awareness of prognosis, preparing individuals and families for the end of life phase and also pain management and comfort.
At Dover Park Hospice we have recently embarked on Programme IMPACT (Integrated Management and Palliative Care for the Terminally Ill Non-Cancer Patients) with Tan Tock Seng Hospital to extend home care service to patients with end-stage organ failure. We hope these services will expand and develop into models of care that meet the needs of these complex patients.
What do you view as the priorities going forward?
We need to focus our efforts on developing a framework and model of care for these patients and encourage discussion between renal and palliative care colleagues on how to better manage transitions and co-manage patients.
We also need to work towards crafting sensitive public health and patient messages along the various stages of renal failure, particularly how palliative care support complements renal care at the end stage of renal failure.
There are also key challenges to address around affordability of palliative care; this goes beyond renal failure patients, but is critical to ensure that patients receive palliative care based on their needs.
At the individual level, despite the government having provided generously for dialysis treatment with subsidies and public donations, dialysis can create a financial burden. There are many other costs of care in community, for instance getting to and from dialysis centres and many other hidden costs which can be a financial burden to the patient and their family. Patients can be very concerned if their condition is placing a financial burden on their family.