05(02): A brief reflection on palliative medicine

Originally submitted on 2 March 2023 for consideration for the Palliative Medicine Book Prize:

Prior to the palliative medicine posting, I was thrilled to learn that I would have in-person clinical exposure to palliative medicine, a privilege denied to many of my seniors due to COVID-19 restrictions. This experience was particularly poignant for me as my interest in medicine had been sparked by an experience I had more than a decade ago.

In 2010, my mother presented to our GP with a large firm RHC mass and was otherwise asymptomatic. As a never-smoker, never-drinker, and someone who ate healthily and exercised all her life, she had even finished a marathon as an adult! Appropriately, she was referred for an urgent CT Abdomen, and the scan results were concerning. Grappling with the first stage of the Kübler-Ross cycle, we opted for the biopsy, and even had the sample flown to three renowned labs worldwide, including Mayo Clinic. “There would be a higher chance of ruling out a false positive this way, right?”, we desperately thought.

The labs all independently reached the same conclusion – gallbladder carcinoma. Despite increasingly aggressive doses of bevacizumab, her condition eventually deteriorated with multilevel vertebral metastases. On her last visit to her oncologist, the doctor conveyed that there was nothing more he could do for her and that she should “get admitted to a hospice”.

I saw it all – the progressive alopecia which prompted her purchase of a black neck-length wig, and the recurrent emotional conversations between my parents. Her functional decline was so rapid and heart-wrenching. Her cachexia worsened steadily, and soon, her inability to converse became more pronounced. Eventually, she was granted a terminal discharge by Assisi and passed away in our home in April 2011. Through it all, my late mom had the privilege of receiving excellent palliative care from the doctors, nurses, and allied health professionals at Assisi. This effort by the multidisciplinary palliative care team provided the much-needed solace to make the journey as bearable as possible, and it is my wish that more people would be aware of what this nascent branch of medicine can offer to patients and their loved ones.

During my two-day hands-on experience, I had the opportunity to prepare fentanyl syringe packages for a patient at TTSH planned for terminal discharge. This experience gave me a glimpse of what goes on behind the scenes of the care associated with managing patients’ symptoms and helping them to achieve a peaceful and dignified death. I also witnessed a doctor formally document a patient’s death at DPH. After documenting the death, the doctor repositioned the patient into a more dignified posture. In Being Mortal, Gawande remarks that our “ultimate goal, after all, is not a good death but a good life to the very end.” Palliative medicine plays an essential role in this pursuit by providing patients with the support and care they need to live the remainder of their lives with dignity and respect.

As I reflect on my experiences, I am struck by how misconceptions from the part of both fellow healthcare professionals (e.g. getting the palliative care team on board too late to allow for a smoother transition) and patients and their caregivers all contribute to the suboptimal use of all that palliative care can actually offer. Many people erroneously believe that palliative care is only appropriate for patients who are actively dying from advanced cancer. However, the reality is that palliative care can benefit patients at any stage of a serious illness and can help manage symptoms, improve quality of life, and support patients and their families throughout their illness journey.

In conclusion, from this short yet meaningful four-day stint in palliative medicine, I now have an even greater understanding of the critical role that palliative care plays in improving the quality of life for seriously ill patients and their families. I hope to honour my mother’s memory by providing compassionate care to my patients in my future clinical practice. Regardless of whether I find myself specialising in palliative medicine, I hope to abide by the eloquent words of the late Paul Kalanithi in his best-selling autobiography:

The physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.

Nicholas Loh
20 March 2023

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