Dealing with dying patients is draining for palliative care practitioners
Strain, long hours and caring for dying patients affect palliative care doctors
Please don't move house, in case I come back and I can't find you.
These were the words that his nine-year-old brain tumour patient said to her parents on her deathbed.
Such emotional scenes are part of the job for palliative care doctors, said one who visits patients in their homes.
Dr Lee (he did not want to give his real name), who is a staff member of HCA Hospice Care, said his hospice sees 150 deaths a month.
"So you can imagine the amount of death we experience," said the 50-year-old.
HCA Hospice's staff, including doctors and counsellors, visit patients in their own homes.
The difficulties that palliative care professionals face on the job is well-known.
A local study to be published next month found that palliative care doctors in a community setting, like Dr Lee, are at a higher risk of experiencing burnout.
Speaking to The New Paper last Tuesday, the naturalised Singaporean shared that he joined the palliative care field in 2005 after a stint at the National Cancer Centre, in part out of curiosity.
"When I was in oncology, I realised that not every patient responds to chemotherapy, or end (their lives) beautifully. So where do they go?" he said.
After spending a decade in palliative care, first at Assisi Hospice, then at his current hospice, Dr Lee realised that the trickier patients are those who are adamant on a cure, and opt for alternative medicine.
Sometimes, he has to watch as patients writhe in pain because they refuse to take morphine, as instructed by traditional medical practitioners.
He remembers one such case involving a young man. "He refused to see us any more after the oncologist told him that his disease had spread beyond control. He said his Chinese physician promised a cure.
"The patient died within a week and left behind three young children without making any preparations for them," Dr Lee said.
The emotional stress of the job does not come from the patients alone. Often, the patients' families add to the strain.
Some would try to involve him in legal tussles related to wills and inheritance. Others would force him to tell white lies.
"They don't want me to tell the patient his diagnosis, or say I'm from the hospice. They feel the patient will slip into depression and die faster if he finds out.
"But it is against the ethics of a medical professional to lie to a patient," he said.
There have been the odd requests too - calls for home visits in the middle of the night only to realise all the patient needed was a neck massage.
"The only way to take a break is when I take out my SIM card," joked Dr Lee, who is married with three daughters.
He has also had to take over a colleague's duty at the last minute after promising to take his daughters out for dinner. "They have gotten angry with me for that, but I know they will understand when they grow up," he said, adding that his wife is supportive.
One way to keep going is knowing how to de-stress, Dr Lee said. Being Buddhist, spiritual support and meditation helps him to unwind.
What also contributes to job satisfaction is the appreciation shown by patients' families, Dr Lee said.
For instance, a family once donated all the money collected during his patient's wake - about $30,000 - to HCA Hospice.
When asked if he regrets taking up this 24/7 job given its demanding nature, Dr Lee shook his head.
"Life can never be perfect. There is always give and take. If you find this profession is meaningful, I think you will continue to walk this way," he said.
As our society ages, there will be a growing number of people not just needing palliative and hospice care, but the preference for many is to be supported and cared for at home
- Dr Ong Yew Jin, medical director of the Singapore Cancer Society.
They don't want me to tell the patient his diagnosis, or say I'm from the hospice. They feel the patient will slip into depression and die faster if he finds out. But it is against the ethics of a medical professional to lie to a patient.
- Dr Lee on the dilemmas he faces when dealing with relatives of dying patients
Manpower crunch poses challenges for home hospice care
Home hospice care is the type of end-of-life care that most people hope for.
But it will be a struggle to sustain this type of care if the manpower crunch keeps up, palliative care doctors cautioned.
"If there are fewer medical and nursing resources available to support 24/7 services, and the burnout and turnover rate are higher in the home care setting, this type of care will be difficult to sustain..." said Dr Ong Yew Jin, medical director of Singapore Cancer Society.
There are 51 accredited specialists in palliative medicine in Singapore, but only an estimated 34 of them work full-time. This works out to less than one full-time palliative consultant per 100,000 people - less than half the ratio recommended by Palliative Care Australia, added Dr Ong.
Adding to the strain is the distribution of resources, he pointed out.
"Most (palliative care nurses and doctors) are based in the hospitals or inpatient facilities.
"As our society ages, there will be a growing number of people not just needing palliative and hospice care, but the preference for many is to be supported and cared for at home," he said.
Quoting a study on burnout among local palliative care practitioners which he is a part of, Dr Ong noted that home care hospice providers are at higher risk of experiencing burnout.
"This leads to a high turnover of staff particularly in the home care setting, compounding the situation," he said.
Tan Tock Seng Hospital's palliative department head Dr Mervyn Koh said managing burnout in this field can be tackled in two ways.
One way is for organisations and the government to continue to increase their support for adequate staffing in palliative care and to manage long working hours, especially in the area of home hospice care.
"There is also a need to recognise the increasing importance of work-life balance and make provisions to understand and accommodate staff who often are playing other roles - like parent, or child caring for a sick parent.
"We also found in our study that organisational activities allowing time for common 'de-stressing' and 'team-building' activities help reduce burnout," Dr Koh said.
He also pointed out the need for those working in the field to recognise the signs of workplace burnout and have healthy coping mechanisms.
"Perhaps this is also a national problem as highlighted by a recent study by Randstad showing that Singaporeans find it hard to let go of work even when on holiday," he said.
WORKERS IN HOME HOSPICES FACE HIGHER RISK OF BURNOUT
One in three palliative care practitioners suffers from burnout, says a local study.
Those who work more than 60 hours a week are nine times more likely to be burnt out compared to those working 40 hours a week.
The study, which will be published in July's edition of the Palliative Medicine journal, is a collaborative effort of practitioners from Tan Tock Seng Hospital, HCA Hospice Care, National Cancer Centre, Assisi Hospice, the National University Cancer Institute and Dover Park Hospice.
It looks at the prevalence of burnout, psychological distress and the use of coping mechanisms among those working in palliative care.
Palliative care practitioners - nurses, doctors and social workers - were surveyed between March and April 2013 using a tool that looks at emotional exhaustion, depersonalisation (an unfeeling response towards patients and family) and lack of personal accomplishment.
The study also found that those who work in home hospice care are more at risk of burnout and psychological distress, compared to those in hospitals and inpatient hospice care.
Coping mechanisms that proved to be effective in combating burnout include having realistic expectations and meditation.
BY THE numbers
1 in 3
Palliative care practitioners who suffer from burnout, according to a local study