Comments of Chapter 7: Supportive and palliative care

Vignette: How it could be

Mr Yeo was an elderly widower who suffered from chronic obstructive pulmonary disease, ischemic heart disease, congestive heart failure and advanced prostate cancer. Despite the spread of cancer
to the bones and the recurrent episodes of urinary tract infection, he suffered more from infective exacerbations of his chronic pulmonary disease and recurrent heart failure.

As he became frailer, his physician in the disease management program transferred his care to a colleague more skilled in dealing with polypathology and palliative care. Having been educated about his own illness and the measures to take, Mr. Yeo knew what to do when he felt unwell one afternoon. He touched a special button on the screen of his home computer. An image of Kala, his home care nurse, appeared.

«Good afternoon, Kala, sorry to bother you», said Mr Yeo into the speaker, «but I'm not feeling very well. This cough which started yesterday is not settling down and I am having difficulty lying flat.»As she continued to speak to him, Kala looked at the readouts from the sensors attached to

Mr Yeo’s telehealth unit at his bedside. She asked Mr Yeo for assistance in applying the blood pressure cuff, the pulse oxymeter, thermometer and stethoscope. She soon recognized that Mr Yeo was suffering an exacerbation of his chronic obstructive airway disease again. She quickly toggled onto the nurseson-duty screen and noticed that advance practice nurse Sharon was on duty.

Sharon, can you swing by and check on Mr Yeo, he is the man living on Red Bridge Road.

Using her palm-top computer with wireless connection, Sharon was quickly able to access his medical records, check on the data from the telehealth unit and monitors and run an electrocardiogram. She was at his apartment within 30 minutes and quickly set about examining him. She checked his medication and quickly called Dr Summers, his home palliative care physician. A course of steroids and antibiotics were ordered electronically. This was sent via courier service to his house within the hour by the neighborhood pharmacy.

Dr Summers took turns with Sharon to check up on Mr Yeo over the course of the next few days. In between, the easy interaction with the telehealth team by his bedside reassured Mr Yeo that there was constant attention. However, unlike previous episodes when his condition recovered well enough for him to get back on his feet, it became obvious that it was different this time around. His cough became more persistent and he was short of breath even when he was sitting up. Even as she was deciding on the care options, Dr Summers proceeded to speak to Mr Yeo to establish his understanding and elicit his views on his condition and management plans. Consistent with previously established advance care plans, a decision was made to withdraw the antibiotics and concentrate mainly on comfort measures. A family conference was also arranged between Dr Summers, Sharon, Jenny (the counselor), and Mr Yeo's daughters.

Yes, this is what he had anticipated, if he was facing an acute reversible condition, he would like everything possible to be done to help him recover. But if he crossed the line and had a severe exacerbation of his long-standing lung disease, he would prefer to be made comfortable and remain at home. Home oxygen therapy and parenteral morphine infusion alleviated his dyspnea at home enough for him to remain comfortable. Video tele-monitoring by the program team gave his family a sense of security. He passed away peacefully about one week after the initial call, with his family by his side. Jenny called his daughter about one month after his death and she reported that Mr Yeo's family had settled back into their previous routine. His daughter was especially glad that he was able to remain at home and that he passed away quite peacefully.

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