Teaching Palliative Care in Vietnam – Part 2

Alex T.Q. Nguyen, M.D.

Clinical Fellow, Harvard Interprofessional Palliative Care Fellowship

PGY4

Teaching Palliative Care in Vietnam – Part 2

During the second week in Vietnam, in the hot and humid weather, we commuted daily to the newly open City’s Children Hospital in Binh Chanh District of Ho Chi Minh City to provide clinical training for the pediatricians who participated in the palliative care course. They were divided into smaller groups of 8-12 trainees and were asked to provide palliative care assessment for pediatric patients ranging from the NICU, PICU, to Infectious Diseases ward. As part of these exercises, they were given different cases selected by the Palliative Care Consult Service. Of note, this is the only children hospital in Vietnam with a full-scope palliative care service that includes two physicians, a nurse, a psychologist, and a social worker.

Bedside teaching by Dr. Melody Cunningham in the NICU at City's
Children Hospital in Ho Chi Minh City

The most challenging cases involved patients with neurological injuries. Again, the conversation surrounding withdrawal of life-sustaining treatments were difficult. A number of the trainees had a difficult time differentiating between withdrawing life sustaining treatments with physician-assisted death. In addition, the concept of brain death is not viewed as actual death by Vietnamese laws, and it is not uncommon for brain dead patients to have cardiac arrest while on prolonged ventilatory support.

We also had very interesting and stimulating discussions about pain assessment in pediatric patients who lack the ability of verbal communication, especially neonates. Often, when a patient becomes unresponsive, pain assessment falls off the checklist in the ICU. We discussed the importance of understanding how certain diagnoses afflict pain or discomfort to a verbally capable patient, then how to translate that understanding of pain-inducing mechanisms to provide adequate pain control for a nonverbal patient.

At the end of the course, each group of trainees had the opportunity to present their cases to the rest of the class. It was their showcasing of what they have learned from the course and what lingering questions they hope the audience could help answer. One of the themes throughout this course was the cultivation of resiliency and self-care for the physicians who are the front line providers taking care of very sick patients. Burnout is not a unique phenomenon that only occurs in the U.S. In the under-resourced Vietnamese medical system, the number of patients a doctor sees each day can easily triple that in the U.S., and the support that Vietnamese doctors receive from their supervisors and colleagues are minimal to none, especially in the community setting. Teaching this palliative course in Vietnam makes me become more appreciative of the medical training environment that I’m currently part of in the U.S., albeit its downfalls. And helping to spread the knowledge of palliative care globally is extremely gratifying as the field is still young and the needs are exponential.

Teaching Palliative Care in Vietnam – Part 1

Alex T.Q. Nguyen, M.D.

Clinical Fellow, Harvard Interprofessional Palliative Care Fellowship

PGY4

Teaching Palliative Care in Vietnam – Part 1

During the first week in Vietnam, I assisted in teaching a palliative care course to Vietnamese physicians who are pursuing their specialist training. The two-week course took place at University of Pharmacy and Medicine in Ho Chi Minh City and the specialists came from various disciplines of internal medicine and pediatrics. The first week of the course consisted of mainly didactics with some small group discussions. The topics of these didactics ranged from pain management to communication skills to ethical principles for patients with serious illnesses not limited to just cancers. Some of the course’s participants spoke English. However, many of the trainees came from provincial or rural areas, therefore, the course was taught in Vietnamese. There were faculty who was fluent in both English and Vietnamese who helped teach the course and also translate for the faculty who came from the United States and South Africa. As a bilingual Vietnamese American, I had the chance to improve my medical Vietnamese, help with translating the conversations, and participate in the discussions with the Vietnamese physicians.

What I found was most difficult was the discussion involving withdrawal of life-sustaining treatments. What governs Vietnamese medical ethics are not necessarily the same as Western medical ethics. Almost universally in Vietnam, doctors do not recommend withdrawal of life support. This is viewed as giving up. Often, life support is withdrawn when the patient’s family can no longer afford paying for the care. Many of the patients with serious illnesses do not have the financial capability to pay for prolonged hospitalization. Unfortunately, a person’s wealth dictates the type of care they receive in the medical setting. Interestingly, even though doctors in Vietnam tend to practice paternalistic medicine, and very often the patients and their families expect that type of care delivery, if the patients or families demand continuation of life support despite poor prognosis, their doctors would almost never decline.

During the small group discussions, I also learned about the lack of access to opioid medications in Vietnam. With a simple medication like morphine, which we take for granted in the US, many doctors in Vietnam feel uncomfortable with prescribing because they have never been exposed to morphine in their training. Therefore, patients can only get access to morphine if they come to a major medical center. In addition to the difficulty of obtaining a morphine prescription, now they have to find a pharmacy that can fill the prescription. For patients who live far away in a rural area, it would be impossible to receive good palliative care.

All the faculty and participants of the palliative care course

Another interesting topic that was taught in the course was grief and bereavement. Similar to medical training in the US, Vietnamese medical schools do not teach about this topic adequately. Although, culturally speaking, it is much harder for Vietnamese physicians and patients to talk about emotions and psychological distress. Besides talking about the various stages of grief, we also discussed the relevance of religion, spirituality, and psychotherapy in helping patients’ families coping with death of their loved ones. At the end of the first week of the course, each participant wrote down on a piece of paper a memory or name of a deceased patient whom they have taken care of, these papers were collected and burned at a local temple as part of the memorial service.