As most of the pharmacological treatments based on palliative care textbooks and are quite similar, I would like to reflect mainly on non-pharmacological management.

1. Communication
Communication is an inevitable part of clinical process, and is considered as a core clinical skill. Good, patient-centred communication is associated with many important and meaningful health outcomes, including adherence to drug regimens and diets, symptom control, and good psychological functioning of patients.[1] The eliciting and identification of concerns, needs, and preferences of patients enable the health-care professional to tailor information for assessment and management. It is also a suitable way to show empathy. However, communication skills of doctors and nurses are quite limited in hospitals. [2] During my visit in Hospis Malaysia, the communication skills of their staffs impressed me most. They can spend hours talking with patients about their health problems, family, and sometimes even something I considered irrelative to medicine at first. Such detailed talking not only allows them to understand the characters of symptoms, patients’ psychosocial problems, but also helps to establish trust between patient (and the family) with health care professionals. Actually, patients take the main role most of the time, active listening is what doctors and nurses need to do. Active listening signifies the acknowledgement of a patient's suffering, and gives patients the opportunity to talk and express themselves.[3] In patients with serious symptoms, it helps in exploring the causes. Moreover, it also seems able to relieve patients’ worry and distressing when the symptom is intractable. I tried such “talking therapy” in my patients with vague complains before and it worked better than medicine. But I always doubt the use of plain talk in patients with serious symptoms, thinking that patients always would like doctors to do something to relieve the symptom rather than only talking. It surprised me to see symptomatic patients with feel better after a long talk, without medicine. It also makes me think about the purpose of talking. My colleagues and I used to talk briefly, aiming at main symptoms mentioned by the patient and going directly towards them, just like other doctors in China. A professor can finish interviewing an inpatient in 5 minutes and then make prescriptions. We neglected patients’ need as a person, and overrated effects of communications between patients’ and their families. Sometimes people just need an audience, not a solution provider. We also lost many opportunities to establish good relationship with patients’, other than useful medical information. Spending more time talking with our patients—the best teachers, would enable us to provide better care with psychosocial support, which should be an important part of palliative care. For me, initiate a conversation about sexuality and intimacy, and talking about impending death and funeral in front of the patient remain difficult and need to be practiced more.

2. Identify main concerns
Detailed talking provides enormous amount of information, eliciting many complains of the patients. We often take it for granted that the most obvious and most serious symptoms should be patients’ main concern. However, patients should be the one to decide, not doctors or nurses. So listen to patients and find out main concerns is necessary in patient-centred care. I was confused when first being asked “whose concern?” Then I gradually realized identifying patient’s main concern is also an invisible skill. It can lead us directly to patient’s need, rather than what we would like to offer on our own speculation.

3. Team work
A multi-disciplinary team is essential to carry out real palliative care according to the WHO definition of palliative care.[4] As patients may present with all kinds of sufferings, not only physicians in internal medicine and nurses should be involves. In Hospis Malaysia, I witnessed how palliative care was carried out by a multi-disciplinary team including occupational therapists, psychologists, and volunteers. The occupational therapist teaches patients and families skills in positioning and moving, which are quite useful in maintaining patients’ quality of life and deducing care-givers’ workload. Psychologist explores patients’ worries and psychosocial problems, and make symptom control more effective. Volunteers are well organized and help quite a lot in day care. In my team, there’s no occupational therapist or psychologist, volunteers are very loosely organized, offering little help. A lot more need to be done in organizing and administrating the team. Clearly divided work and cooperation between colleagues is also an advantage in Hospis Malaysia.

4. Bereavement care

Actually there is no bereavement care in my hospital, and in China. Palliative care is defined as holistic care, not only clinical care, and should not end with death of the patient. Bereavement follow-up enables those newly bereaved to ask questions about the causes and circumstances of the death, and to share their grief; the follow-up also gives the staff an opportunity to assess their previous service and the need for further support.[5] Bereavement care may as simple as just making a call to the bereaved, or paying a visit, or may as complicated as holding social group meetings. More important, about half of the bereaved expresses their need for bereavement care in one study. [5] It is sorry that there’s no such care provider in China. People hardly expressed such needs, and no one explore. It is also neglected because it is not considered part of what health care professionals should do. The bereaved are not expecting us to offer it as there’s no precedent of doing it. There will be a long way to go to carry out bereavement care in China. Both health care providers and the cared need changed in their point of view.





Some treatments are new to me considering pharmacological management.

1. Potassium permanganate for lymphoedema
I haven’t found any literature regarding potassium permanganate for lymphoedema with lymphorrhea. But it was effective in some of the patients I visited. I’ll continue literature searching and try on my patients.

2. Subcutaneous hydration
Subcutaneous administration of medicines and fluids has been documented in palliative textbooks.[6] However, we seldom use subcutaneous way except when using syringe driver with morphine, haloperidol, or some other limited drugs. The reason might be almost all our patients are on all kinds of fluids, not only for hydration. They all have IV lines. So it is unnecessary to put a subcutaneous line in them. I’ll see the feasibility of subcutaneous hydration in patients who need only hydration, but chances would be slim to find such patients in my ward.



References:
1. L. Fallowfield and V. Jenkins. Effective communication skills are the key to good cancer care. European Journal of Cancer, Volume 35, Issue 11, October 1999, Pages 1592-1597
2. Nicola G. Schofield, Claire Green and Francis Creed. Communication skills of health-care professionals working in oncology—Can they be improved? European Journal of Oncology Nursing, In Press, Corrected Proof, Available online 19 November 2007.
3. Thijs Fassaert, Sandra van Dulmen, François Schellevis and Jozien Bensing. Active listening in medical consultations: Development of the Active Listening Observation Scale (ALOS-global). Patient Education and Counseling, Volume 68, Issue 3, November 2007, Pages 258-264
4. Derek Doyle, Geoffrey W.C. Hanks, and Nell MacDonald. Oxford Textbook of Palliative Medicine, 2nd Edition,2003. Pg3
5. Anna Milberg, Eva-Carin Olsson, Maria Jakobsson, Maria Olsson and Maria Friedrichsen. Family Members' Perceived Needs for Bereavement Follow-Up. Journal of Pain and Symptom Management, Volume 35, Issue 1, January 2008, Pages 58-69
6. Betty R. Ferrell and Nessa Coyle. Palliative Nursing, 2nd Edition, 2006. Page 243