Palliative care has a few different definitions, but essentially it’s symptomatic and holistic care of dying patients. Most of the palliative care caseload have cancer, but the remit covers all progressive life-threatening illness, which can include, for example, AIDS, cancer or neuromuscular diseases. Most palliative care is carried out by general practitioners and hospital physicians, but there are also specialist palliative care teams, who care specifically for patients whose symptoms are difficult to control. I did my elective with a specialist palliative care team, split between hospital and community work in Great Yarmouth.
Why Stay in the UK?
I chose to stay in the UK, and close to home, predominantly for health reasons – I wasn’t fit to travel abroad, due to an illness that sprung up and got in the way just before heading out to Perth in Australia, my original plan. Although I was initially disappointed not to be going on my Australian adventure, this elective has presented me with plenty of reasons why staying at home was a good choice! Firstly, I’m close to my family, so I’ve had the opportunity to see plenty of them. If I’d done the elective as planned I would barely have had time to say “hello” after finishing my exams – an experience that in my case means locking myself in a dark corner of the library for three months – before jetting off to foreign climes. I’ve already undertaken some of my medical training at the James Paget hospital, which means that I already knew my way around, which wards did what, and many of the doctors I’d be working alongside were. Many people enjoy getting to know a new hospital and a new city during their electives, and that’s great, but for me, already knowing the hospital meant that I could focus on learning medicine, rather than learning my way around. Maybe my congenital lack of sense of direction has something to do with that! I’ve also had some lovely weather, as it’s the middle of summer here while it’s winter in Perth, and I’m only a short walk from Gorleston Beach when I want to spend an evening chilling out with a book and watching the ships.
Why Palliative Care?
This is a question I’ve been asked quite a few times since I decided what I was doing with my elective – why Palliative Care, why not something exciting? Fair enough, this isn’t the quickest-pace department I’ve ever been in – in fact, although we’re always busy, I think we see the fewest patients per day here of all the placements I’ve ever done. Although I change my mind about my future career plans approximately every five minutes, my plan when I was looking into what to do for an elective was to work in general practice. From experience I know that GPs are quite involved in the care of their patients at the end of life, but I also know that it’s not an area that’s much talked about – neither Oncology nor Palliative Care are covered as specialities in their own right at UEA, which means that before I started reading up on it for the elective, I didn’t really know much about what would be involved or how to manage patients at the end of life. I also enjoy getting to know my patients and having longer slots of time to talk to people, and have enjoyed the bits of oncology I’ve come across so far in the course, so I decided that Palliative Care would be a specialism I’d enjoy eight weeks in, and would benefit from in terms of learning things I’d use in the future.
What’s the James Paget Hospital Like?
The James Paget University Hospital is a smallish hospital in Gorleston, near to Great Yarmouth in Norfolk. At the moment, there are no specific palliative care beds available, so patients being looked after by the team are spread around the hospital, on whichever ward looks after their medical problem – for example, lung cancer patients on the respiratory ward. There are no hospices in the area, the closest one being Priscilla Bacon Lodge 25 miles away in Norwich. There are, however, some little community hospitals in the area, where patients can be looked after by nurses and seen by their own GPs. Although the team are based at the James Paget, they also see patients in these community hospitals and in their own homes, which allows excellent continuity of care when patients are moving between the various locations. The hospital is, incidentally, named after the surgeon, originally from Great Yarmouth, who named Paget’s disease of the bone.
What Did I Do?
I spent the first part of my elective shadowing members of the team to get a grasp of how they worked together, who did what, and how the team functioned as a single unit. Much of this time was spent shadowing the doctors in palliative care, and seeing how they interacted with other members of the team. I also shadowed the Macmillan nurses to see what they actually did with their patients out on home visits, and went with them to their teaching sessions where they educated staff on the wards about introducing the Liverpool Care Pathway. Once I felt I had a grip on how the team worked, I spent much of my time shadowing the palliative care specialist doctors, but also spent time in Oncology clinic, where I saw some of the patients I had met in a purely palliative setting, having chemotherapy either to improve symptoms or to lengthen what life they had remaining, which gave me an interesting look at the patient’s journey and what different experiences they have coming into the same hospital, for treatment for the same illness, under different teams.
I was also lucky enough to have the opportunity to follow several patients through their journeys. I spent a lot of time talking to one lady who, although they should be able to cure her, needs a lot of symptom management in the meantime. I met her shortly after her surgery and have followed her through for the full eight weeks, seen her discharged from hospital, getting settled back at home, switching her medications back over, and starting to recover. I’ve also, therefore, seen the effect that a terminal diagnosis has on whole families, particularly through the home visits I’ve been able to go on – going into a patients home, I have found, is a great way of getting to know the family dynamics and how the patient’s life really is. I’ve known many patients take special care to come and see the doctor, and do their best to try not to look too ill so that the doctor feels as though they’re helping, whereas when you see them in their own home and the adaptations they’ve had to make to be able to cope with their illness, that gives me a much better idea of how ill they really are.
I carried out an audit while I was there, looking into the dependencies of palliative care patients compared with that of patients on two of the medical wards. This was really interesting, as it meant I had my own workload as well as shadowing, and my own patients to follow up. It has also given me a good experience of what is required to undertake an audit, a process I previously understood to be important but had little insight into its realities.
What Have I Learnt?
Academically, I learnt a lot about symptom management that seems to have passed me by during the course of the medical syllabus. I knew the analgesic ladder as it applied to patients with musculoskeletal problems, but I’ve only now learnt about the management of cancer pain, for example, the conversion between different opiates, and how to work out a good breakthrough dose. I have also learnt a lot about the practical management of neuropathic pain, which is difficult to get on top of effectively, and managing nausea and vomiting caused by various different problems in palliative care.
Palliative care can be very much more patient-centred than most aspects of medicine – because it’s not curative, there’s no one right answer in how to deal with any problems. For example, symptom management can vary widely – I’ve met several patients who preferred to be pain-free but drowsy, and a few others who preferred to be alert enough to really interact with their families, and are willing to tolerate some pain in order to do so. In the management of malignant bowel obstruction, some patients would prefer to vomit more frequently in order to avoid having an NG tube, others prefer the opposite. Although this is the way the palliative care team work, this taught me the difference between having been taught palliative care, and having only studied “standard” medicine and surgery – many members of the medical and surgical teams couldn’t get their heads around not doing what the textbook recommended. There were also a lot of clashes between the medical team and our team, which really opened my eyes to attitudes: some quotes from doctors which I think I’ll never forget, include “Well, he has to have it, that’s procedure” and “He’s dying anyway, what’s the point?” I’m so glad I’ve learnt how to deal with these attitudes now, because I think if I’d met them for the first time when I start my F1 posts (the first year of being a practicing doctor), I’d have been thrown completely.
Contrary to a lot of the more traditional advice for medical students, I did find myself becoming attached to some of my patients – and I don’t think that was an unhealthy or damaging experience. Yes, it meant that I was sad when they died – but it also gave me the ability to get really angry when their treatment wasn’t optimal, and to really empathise with them and talk to them about their problems, and I think these things really helped me to manage patients to the best of my ability. It has also meant that I’ve got to grips with dealing with a patient’s death, a challenge I haven’t often been presented with as part of my degree
Becky Wilson is a fifth year medical student at the University of East Anglia.
beckyannabelle.wilson(at)googlemail.com