Thursday, May 5, 2011

Esther Luo, Ho Chi Minh City, Viet Nam, April 2011

In 2005, the Ministry of Health of Vietnam launched a palliative care initiative for which Dr. Eric Krakauer has been the primary technical advisor. Dr. Krakauer is also an attending physician on the MGH Palliative Care Service and Director of International Programs at the Harvard Medical School Center for Palliative Care. The Ho Chi Minh City Cancer Hospital, where Dr. Krakauer has provided intensive training and technical assistance for the past two years, has taken the lead in developing palliative cancer care in Vietnam. I came to Vientam with Dr. Krakauer and Dr. Frank Ferris, Director of International Programs at The Institute for Palliative Medicine at San Diego Hospice, to assist the Ho Chi Minh City Cancer Hospital develop a palliative home care team.

We formed three home care teams comprised of American clinicians and Vietnamese physicians and nurses. In my home care group, I was paired with Mary Wheeler, an American hospice nurse. Together, we worked with three other Vietnamese physicians and six nurses. All the nurses had recently started working in the newly established 10 bed inpatient palliative care unit. From day one, I sensed a tremendous amount of energy, passion, and desire to bring palliative care to the patients at their homes.

Our first patient was a 73-year-old retired nurse diagnosed with metastatic lung cancer in 2006. In 2010, she had received 6 cycles of chemotherapy. She currently lived home with her daughters who were her caregivers. We traveled by van to visit her in her home. Our nurses carried with them a "medical bag" which included things such as stethoscope, blood pressure measurement, hand sanitizer, and gloves. She reported symptoms including back pain, dyspnea, and decreased appetite. We quickly learned that she was reluctant to use morphine for pain and dyspnea. Instead, she was using Diclofenc for pain. Her daughter told us that she "knows everything about her disease." The daughter also wanted to keep their mother at home and only treat her symptoms. She is Catholic and there was a rosary hanging close to her bed. Our nurses conducted the bedside interview while our Vietnamese doctors talked with her family.

During my debriefing session in the afternoon, we asked our group about their experience and concerns about doing home care. The doctors were concerned that they will be asked questions they cannot answer by the patient or the family members. The nurses had concerns about seeing patients at home since many of the patients are used to seeing only doctors. The nurses felt inadequately prepared in their communication skills in caring for patients with cancer and physical examination skills. In our small group we talked about the concept of a team and how this can help both the physician and nurse to out to each other for help. We did some role playing as a way to practice communication skills when talking to patients and their family members.

For two weeks, we traveled to patient's homes and conducted evaluations in the morning. In the afternoons, we discussed our cases using the Squares of Care developed by Dr. Frank Ferris. The most amazing thing was to see the collaboration between the Vietnamese doctors working side by side with their nurses.

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