The School is currently developing case studies to use in education, one of which will be on palliative care. Part of the case study development involves gathering perspectives and insights from experts in the field.
We spoke with Dr Mervyn Koh, Medical Director at Dover Park Hospice, about how this important field is evolving to meet the needs of Singaporeans.
Dr Koh initially trained as a geriatrician and went on to complete specialist training in Palliative Medicine. He is a senior consultant at Tan Tock Seng Hospital and headed up the palliative medicine department. He is currently on secondment as Medical Director at Dover Park Hospice.
How would you describe palliative care medicine?
Palliative care is an essential health service, one that is in increasing demand with an ageing population and rise in chronic conditions.
There is a myth that palliative care is just for cancer patients in the last three months of life. This likely stems from the early days of hospice care, where these patients were the predominant case load.
Palliative care is also now far more focused on upstream interventions and integrations, working to support symptom and pain management in end-of-life patients as well as those who are still undergoing treatments. Opting for palliative care as a comfort measure to relieve pain or side effects of treatments can improve the overall quality of life.
Palliative care truly incorporates both the art and science of medicine: the science is there to ensure that pain is managed and patients are comfortable and at peace; and the art lies in being able to communicate empathetically with patients and families to help them come to terms with a terminal diagnosis, understand what is important for them at end of life, and enable psychological closure.
Increasingly, a public health approach to end-of-life care is emphasised. Death, dying, loss and care is everyone’s responsibility and part of integrated approaches to deliver care closer to home. The community and other healthcare providers are partners in education, developing understanding, and providing quality healthcare at the end of life.
What are some of the main changes over the last decade?
Just over 10 years ago the National Strategy for Palliative Care in Singapore was set up. A few years later the National Guidelines for Palliative Care were rolled out.
The strategy and guidelines provided a framework to assess what was going well and what areas to focus improvement efforts on. It was also used in some providers, like Tan Tock Seng Hospital, to identify the clinical and business case for developing palliative care services further.
At Tan Tock Seng Hospital, we looked to integrate palliative care within other specialities, such as: intensive care, oncology, the emergency department, and so on. This was to improve the quality of patient care through supporting pain management and psychologically preparing patients and families for the end-of-life phase. It also had the benefit of reducing the cost per patient, through fewer readmissions into hospital and the use of less intensive treatments.
Integration also means that patients know the palliative care team well when the time comes that they are fully under our care in the later stages of end of life. This makes for a seamless transition of care that is psychologically supportive to patients and their families.
Relationships and the development of trust between palliative care and other specialities has been essential to move forward with integrating our expertise and approaches.
As an example, some patients were remaining in the Intensive Care Unit when the goals of care were no longer curative. At the start of the Palliative Care–ICU Collaboration we would have around 20 patients referred to the service from intensive care. This is now around 200 patients per year.
Do you find people are fearful of discussing dying and death?
There does remain a level of taboo around dying and death, but there is now far more public awareness of the importance and value of advance care planning and preparing for the end of life. There have been advertisements and campaigns on advance care planning, more discussions in clinical consultations, and promotion of the use of advance care planning within healthcare.
At Tan Tock Seng Hospital and Dover Park Hospice, students spend time learning about palliative care. Some have reflected that they had not talked about death before and found it to be a positive experience, that they cherish their older relatives more. Also, when they see younger patients at end of life, they have expressed that they are more grateful for their health and appreciative of the care and attention provided to ensure the end of life is peaceful.
We could build on further breaking down taboos around death. Countries like Taiwan provide age-appropriate education to children to help them understand death. This involves weaving in stories into the school curriculum of dying, death and renewal through nature’s life cycles, such as that of the butterfly.
What are the main challenges going forward?
Most older people in Singapore would prefer to die in their own homes. However, most deaths occur in hospitals. Palliative care can work with other specialities to reduce inappropriate care and free up hospital beds. However, there are barriers to this.
The current finance model could be viewed as a barrier to accessing palliative care services outside of the hospital. Many patients pay more for care in a hospice as compared to a hospital, and there is also a lack of insurance coverage for palliative care in a hospice despite it being more cost effective. As a clinician, it is difficult to have conversations with terminally ill patients around funding. The hope is that progress can be made in this area to provide better coverage for persons near the end-of-life phase, so that when they reach the end of life, they can get the best possible palliative care in a hospice.
As Singapore moves further towards integrated models of care, ‘beyond hospital to community’, there is the hope that jobs in the community will become more visible and attractive. However, at present, recruiting staff to work in community and hospice palliative care services can be a challenge. Much of the training in healthcare occurs in hospitals and there can be a fixed view that hospitals are where career progression, opportunities and research endeavours occur.
There are fantastic opportunities for development in the community and hospices – the perception is slowly changing with more secondments into the community and hospices, and more students undertaking education days here.
One of the biggest advantages is that the community and hospices are smaller teams, more like a family, and a key enabler for making improvements is the strong relationships between staff – we are very much a team with a shared view on the importance and value of palliative care to our patients and their families.
I would encourage health workers to look into careers in palliative care, as it is one of the most rewarding and developing fields to work in. There are real opportunities to make a difference to patients, to shape the way that future services are delivered, as well as in research and education.