Thursday, December 20, 2018

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.

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