For the last few days I've been volunteering at the local palliative care society, which is a NGO providing free services for very sick patients. What I actually did was follow nurses around patients' homes to help ease their suffering and try make their end days as comfortable as possible. It's depressing, but very noble and admirable.
Just want to note down some of the interesting cases I've seen during my time doing palliative care so far. I'd say all of them are terminally-ill, hence almost none actually have the chance of recovering (but again, I'm not God, so who am I to say?).
1) 33 y/o male with end-stage nasopharyngeal carcinoma. 33!!! Diagnosed 2 years ago. Taken care of by his aged mother. Separated from his wife who left him and their now 4 y/o daughter after his diagnosis. Depends on 3 siblings' incomes and the church. NPC with spinal cord involvement therefore he is paraplegic. Fungating masses visible on right side of his neck and head. Right side of face is distorted. He was at a stage of acceptance when I saw him. He could speak, and he seemed to be anticipating his death quite well. I was glad to see that he was at peace with his condition but listening to him talk about preparing his grave and tombstone with his mother almost made me shed tears (but thankfully I managed to hold them back; wouldn't have been nice crying in front of a patient). He was apparently in denial for some time but 2 days prior to our visit he said that he dreamt of God taking him around heaven, and that was when he knew it was time to go.
2) 77 y/o female with cervical carcinoma, in which a complete hysterectomy was done. Taken care of by her husband who seemed very frail himself as he had an accident several years ago (very severe muscle wasting seeing that his legs were as thin as sticks). Patient's condition was complicated by obstructive uropathy. Nephrostomy done on both sides. BP 90/50 hence severe vertigo. I helped the nurse change her bedsheet which was not an easy task since she couldn't sit up, and while doing that we realised that her right nephrostomy tube was already detached from her body. Even the hole had already closed! Arranged for an ambulance to take her to the hospital. Palliative care specialist predicted she would only have 2 more weeks. :( She did seem like she has accepted her fate, though.
3) 57 y/o male with hepatocellular carcinoma. Diagnosed Dec '08. Has obstructive jaundice (very obvious just by glancing at his sclerae), moderate ascites and oesphageal varices. First presented with severe loss of weight and melaena. Also has body itches. Requires blood transfusion. Hep B +ve. He and his family are in denial of his condition, saying things like, "Don't ask us anything! Don't tell us anything and we won't ask you too!" Not financially stable but refuses to seek treatment from the government hospital. But also complains of having spent a lot of money at the private hospital. Hmm.
4) 83 y/o female with right breast carcinoma. Now this patient was very cute. Cute in a sense that she was so foul-mouthed it was really funny. Diagnosed with breast cancer 5 years ago after she had an argument with her neighbour. Apparently she didn't want to leave her neighbour alone so the neighbour had to spray water at her. She fell down and felt pain on the right side of her chest. Was brought to the hospital and the doctor found a mass on her right breast. When I saw her, the mass was enlarged (and I mean REALLY enlarged seeing that her right breast was easily 10x the size of her left), nodular, red but painless. Has lung and liver mets. Already senile as she talked crap while I was there. Currently stays at an old folks' home in which she frequently picked fights with the other residents, so the management had no choice but to lock her in a room (very sad). She said she enjoys collecting newspapers and making hats/boxes/plates/bowls out of them (her room was really messy and covered with - what else - newspapers). Curses at every single person but was somehow very nice to the nurse and me.
5) 63 y/o female with recently-diagnosed NPC (WHO Type II, Stage IV). Just completed her 2nd cycle of chemo last week. First presented with blurred vision, tinnitus, epistaxis, cervical LN enlargement and hoarseness of voice due to laryngeal involvement. During my visit, she was very weak and was experiencing hair loss, dizziness (probably due to the chemo) and bad cough with a lot of phlegm (postnasal drip). However the nurse and her relatives commented that her voice was much clearer and not as hoarse as before. Perhaps the chemo is slowly working for her?
6) 60 y/o male with renal cell carcinoma and spinal cord compression. Is paralysed arms down. Has bladder enlargement. The nurse went there to dress his pressure sore (which was VERY VERY DISGUSTING) and replace his urethral catheter. I observed how male catheterization was done on a real patient (I only saw it being done on a model back in IMU)- turned out to be very quick and easy because he was paralysed so there was no resistance. Had the largest, nastiest, smelliest pressure sore that I've seen to date (to be fair I haven't seen many pressure sores but even the nurse said this was bad!). Apparently the best way to tend to a pressure sore is to use this thing called URGOSORB. What it does is that when it is stuck to a wound, it becomes a gel that can easily remove all the exudate and sloughy material from the wound, promoting healing. A piece of URGOSORB apparently costs about RM15 and needs to be replaced every alternate day. Imagine how expensive this treatment comes up to! The good news is that pressure sores can be healed in 1-2 weeks after using this.
7) 39 y/o female diagnosed with glioblastoma multiforme 2 years ago. First presented with constant migraines and vomiting. Went for a checkup and found out diagnosis. Decided on surgery as treatment, but came out of surgery in a coma and hasn't woken up since. In fact, she's already in a persistent vegetative state, requiring her to be on a feeding tube. When I saw her she was in a decorticate posture (arms flexed and bent inward on the chest, fists clenched, legs extended and feet turned inward). I felt saddest for this case because I actually saw her graduation and wedding photos in which she looked so beautiful and happy, with long flowing black hair and a nice big smile. Now she is almost bald and looked like she was going through a great deal of suffering. She has 4 children, the eldest is 12 and the last 2 are 4 y/o twins (a boy and a girl). I saw the twins when I went to visit. They were innocently running around and seemed so oblivious towards what was happening to their mother. It was really sad. They are taken care of by their father and maternal grandmother. Their father, the patient's husband, is an engineer and loves his wife to death that he isn't giving up hope at all. He takes care of her so well, sleeps with her every night, gets everything ready for the nurses when they come visit (e.g. stethoscope, BP set, thermometer - although the nurses have their own, obviously, but it's nice to see that he makes the effort), makes his own charts of his wife's daily vitals, urine I/O, etc. Just very touching. When I was there, her mother kept on asking me if her daughter is going to be okay. Asked questions like, "It's been 2 years. Why can't she wake up? Why can't she sit up? When will she be able to walk?". I was tongue-tied. How was I to answer? Even the nurse and the doctor couldn't answer. Heck even the best neurologist in the world will not be able to answer. All they could constantly say to her is that it was up to God. Do I personally think she will come out of it fine? No. I don't. In fact I think that the earlier she goes off, the better it will be for her and her family. And to me that is the worst part, having to think that someone is better off dead.
8) 80 y/o female with intestinal lymphoma. First time visit by a nurse from the palliative care center, so I managed to observe how she clerked the patient (just like our usual history taking, but of course with this there were doctor's notes in the patient's records, blood test results, imaging results etc, so it's much easier than having to take a history from scratch). 2 years ago this patient presented with bouts of vomiting and constipation and she claimed to have undergone an abdominal surgery to correct this (what surgery was this exactly, she couldn't tell). Dec '08 she had the same problem again, and this time she said they did an intestinal bypass and found a huge tumour sitting on her intestines. They then diagnosed it as a lymphoma. She has since had severe weight loss (definitely more than 10kg in over 2 years), anaemia, ankle oedema (is currently treated with diuretics), hyponatraemia, hypokalaemia and hypoalbuminaemia (side effects of the diuretics/malabsorption). H/O hypertension but BP at time of visit was 100/60. Can't sit/stand up. Appetite is still very poor. One of her brothers died of NPC (suddenly I'm very aware that NPC is pretty common over here), other siblings, parents (who have passed away, obviously), children, grandchildren are/were healthy. Doesn't want to undergo chemo, which I suppose is a good decision for someone her age.
So. That's about all. Will write about my half-day at the infamous Hospital Bahagia Tanjung Rambutan (psychiatric hospital) next time. Haha. It was interesting... and very scary.
