Not Just the Preserve of Hospices 

By Alicia Wong, TodayOnline .com 

October 25, 2008

Singapore

Not long after Ms Chan May San placed her bedridden father in a nursing home, she discovered that he had developed a host of medical problems such as bed sores and gangerene formations on his heel and side regions. 

In an email sent to MediaCorp News, the 53-year-old musician also observed that her father’s feeding tube was not washed before each feed. This led Ms Chan to conclude that the nursing home was facing a staff shortage or “perhaps, even insufficiently-trained” personnel. 

For its part, the nursing home recounted the difficulties in caring for Ms Chan’s father. The staff nurse told Weekend Today that he was already ill when he was admitted to the hospital and his symptoms flared up during his month-long stay at the nursing home. 

The nurse also described the 88-year-old man as uncooperative and anxious in his new environment — making care even harder. 

“We try to (live) up to a certain standard. If there was negligence somewhere, we already apologised to her,” the nursing home’s manager said. 

The incident — which, perhaps more than a few patients, their families and the caregivers at nursing homes can relate to — reflects the challenges nursing homes here face. They range from a shortage of manpower to the emotional toil it takes on staff who have to handle patients with various demands and temperaments. 

Hence, when the Ministry of Health (MOH) recently raised the idea of a pilot scheme to help nursing homes look after palliative care patients, the big question arises: Can the nursing homes, with their current resources, take up even more responsibility? 
Medical director of Dover Park Hospice Noreen Chan said that while she hopes nursing homes will take part in the scheme, “a few homes have told me that it is already a struggle doing the day-to-day work; they wonder if they can cope with the extra workload”. 

“More resources are needed for sure, but we may need a review of how services are organised and funded — not just for nursing homes, but across the sectors — in order to properly integrate care,” she said. 

The pilot scheme, proposed by Tan Tock Seng Hospital and approved by MOH, aims to provide guidelines on palliative care for nursing homes. Six homes near the hospital will be selected for the study. 

Nursing homes Weekend Today spoke to were open to the idea of palliative care —if they have support from the Government. 

There are now about 8,000 nursing home beds in Singapore. A survey of 13 nursing homes conducted earlier this year found that while 205 residents in nursing homes died over a six-month period, 55 per cent of them died in a hospital. 

“At present, if a nursing home resident deteriorates, the likely response is to send (him or her) back to hospital,” said Dr Chan. 

“There is no consistent process of care planning; no consistent approach to discussing end-of-life issue, pain and symptom management nor bereavement care,” she added. 

But end-of-life care will be a challenge, said Mr Yong Chow Kew, the human resource finance manager at the Man Fut Tong Nursing Home, since extra facilities, among other things, are needed. 

These terminally-ill patients have to be placed in a single ward so other residents do not “feel their agony”. Staff must also be trained to handle the physical and emotional needs of these patients. “Sometimes, you have to nurse the patient’s relatives as well. It’s very stressful,” Mr Yong added. 

Most training can be done “on-the-job”, he said. But nursing homes will also need support in terms of equipment and medication. 

“I think we are ready (for palliative care). We just need help in terms of medical support,” said Ms Irene Ong, who runs Irene Nursing Home and Serene Nursing Home. 

Currently, if the home has end-stage cancer patients, Singapore Cancer Society nurses will come to administer morphine. 

Ms Ong says she doesn’t mind attending relevant end-of-life courses if they are available. 

For East Coast MediCare Centre, a privatenursing home, administrator Melvin Tan said one consideration is whether palliative care is a viable business operation. 

He hopes that the Ministry of Manpower will allow nursing homes to hire more foreign workers — “not just for nursing, but in other areas like cleaning”. 

Hospitals, he said, could also do their part by referring patients to nursing homes as well as providing the homes’ staff with training on palliative care. 

Dr Chan agreed that there “has to be a multi-pronged approach” when introducing palliative care to nursing homes. Other than guidelines, more staff, mentoring, as well as discussion about end-of-life issues, for example, are needed. 

While it remains to be seen whether the MOH pilot scheme will be successful, “we should try because at this point in time, the community hospice services do not cover nursing homes”, said Dr Chan. 

“Most of the nursing home residents died of pneumonia or other infections, or heart problems, which are very different from the usual ‘cancer-centric’ hospice care population. 

“Do we need a fresh approach for this group of chronically-ill people who are at risk of suddenly turning ill and dying? Perhaps so,” said Dr Chan. 

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