PORTRAITS IN PALLIATIVE CARE
Palliative care physician Laurie Musgrave on the strength of a small community hospital聽in responding to palliative care needs
鈥淎 lot of people don鈥檛 know that we offer palliative care at the Lachine Hospital. We have a unit with six beds, we offer outpatient care and a consultation service in the hospital. I want to bring attention to this. For us, being able to reach more patients would be a great thing.鈥�
By Devon Phillips. Laurie Musgrave, Medical Director of Palliative Care Services at Lachine Hospital, has plenty to be proud of. She speaks highly of her 鈥渟mall but mighty鈥� multidisciplinary team and how palliative care has evolved in recent years from a few beds scattered throughout the hospital to a dedicated 6-bed palliative unit, consultation service, and an outpatient clinic that allows patients to be followed at home as long as possible. For Dr. Musgrave, ensuring that more patients have access to palliative care is a primary goal.
Q: Tell me about the palliative care department at Lachine Hospital.
A: We are a small, community hospital which is part of the larger MUHC (平特五不中 Heath Centre) network. We have had palliative at Lachine for quite some time. When it started we had a few beds throughout the hospital and then gradually we brought them all together into a 6-bed palliative care unit (PCU) that we are very proud of.
Q: Do you have a dedicated palliative care team?
A: I am very proud of our little team. I like to say that we are small but mighty. We have five physicians who work on our team, a group of nurses who work on the PCU with us, and pivot nurses who cover our outpatient unit. We also have a psychologist who visits our patients once a week, a social worker who offers a considerable amount of help and participates in our multidisciplinary meetings on our PCU, and a spiritual advisor for our patients. We have a pharmacist who assists us immensely with medication management for our patients. I would say this is the core team but we are also fortunate to have physiotherapists, occupational therapists and nutritionists who help us on an as needed basis. We have great communication, we get to know the patients and their families well, and we work well together.
Q: Are there some services at your centre that you are particularly proud of?
A: Yes, our outpatient clinic. When we started offering outpatient services, it was a sporadic thing- this patient needs to be seen so let鈥檚 have them come in sort of thing, and there wasn鈥檛 a real clinic, but now we have an actual full-fledged clinic that runs once or twice a week. This is an achievement.
The other thing that I am proud of is our team approach. Typically in outpatient care, you meet with the nurse, then the doctor and then the social worker, all in separate visits. But we do this differently. We have a big table and the doctor, nurse, patient and their family all meet together at the same time. We discuss together so everybody has the same information and it works really well. Patients feel that we are offering them a team approach and I think that they feel they are part of the team as well as well as their family. The other thing that the out-patient service allows us to offer is a certain continuity of care. If a patient at home needs to be admitted because their symptoms are not well controlled, or they enter into an end-of-life picture, we can offer them a direct transition from home into palliative care, thereby avoiding having to go to the emergency room. Up until now, the clinic has been running on a weekly basis but because of increasing demand, we have started offering it twice a week on certain weeks. There is clearly a need in the community so we would like to offer more outpatient services.
Q: Do outpatient services allow patients to stay at home longer?
A: Yes, I think so. We work very closely with our colleagues in the CLSC, so when we see a patient in clinic we are concerned about who might need extra support, our pivot nurse will communicate that to the CLSC nurse. That collaboration allows the patient to stay at home longer. The patient feels supported and the family feels supported.
Q: Speaking from the position of a physician and the Director of your PCU, can you give me a snapshot of the impact COVID on the practice of palliative care.
A: COVID has affected everyone in some shape or form. In our centre, I don鈥檛 think there is a great change in terms of direct patient care. Obviously patients will see us coming in dressed in ways that they weren鈥檛 seeing us in before with masks, gowns and visors and we look a little scary and from day to day, they might not even recognize us. So now there鈥檚 a distance, a barrier that wasn鈥檛 there before. But we find ways to work around that. What I find most difficult for patients and their families is the limited contact. To not be able to come in whenever they want and see their loves ones, to not have families by the bedside, to not have children visit their parents or grandparents freely, those things are huge factors in terms of how patients feel on the PCU.
Having to restrict visitation is heartbreaking.
Q: Do you have telemedicine in place for palliative care patients and their families? Can you tell me how this works.
A: I am happy to say that from one week to the next we were able to convert our usual in-person clinic to telemedicine. We are managing quite well, but over the phone, you don鈥檛 have the same contact, you don鈥檛 have those cues from patients, you can鈥檛 reach out and touch their hand like you would in person. Most of what we do is by telephone, only a small portion is by video, and that鈥檚 because a lot of patients don鈥檛 have access to the internet. I would say that it is working out quite well. I feel that patients are so appreciative of the fact that we call them and we ask them how they are doing and we check on their symptoms. So they just pick up the phone and talk to us which facilitates the process because sometimes just coming to the clinic is quite physically demanding. A lot of patients are so isolated generally speaking and this is even more true with COVID so receiving a phone call from the doctor and the nurse is very appreciated. Patients feel like they are being taken care of.
Q: Is that a standard practice to make your calls with a doctor-nurse team?
A: For us, yes! Physicians and nurses always do the in-person clinic together so we decided we would stick with same approach for telemedicine. When we call, I introduce myself and the nurse and I tell them that we are on the phone together for them. Sometimes there are family members who participate so even if we are not around our usual big table we are still all present trying to do the very best we can for the patient.
Q: Are there other services offered by phone such as psychological or bereavement care?
A: This is something we really lack at Lachine in terms of outpatient care. We have a psychologist for PCU and a social worker for PCU, but unfortunately they don鈥檛 have the mandate at this point to help our outpatient population. Patients at home often need psychological and social support and sometimes there are complex situations and we would really love to have a psychologist or social worker at the table or on the phone with us helping patients and their families. We do get support from the CLSCs, but they also have limits as to what they can offer patients. These services are definitely on my wish list.
Q: Looking ahead, what does your wish list look like? What are the priorities?
A: I can鈥檛 say enough about the need for more psychosocial support for our outpatients, as well as for our inpatients because our plan is to expand to a 10-bed unit. I would like to be able to offer more whole person care to our patients on PCU, so more psychosocial support and a better physical environment where rooms are really adapted to patients in palliative care and can accommodate a family member staying at night. We need to have a comfortable bed or pull-out couch or something that a family member could sleep on as many want to stay overnight with their loved one. I dream of a very comfortable family-oriented room that is modern in the sense that we have the capacity to do video calls with a family member and I would love for patient鈥檚 families to be able to send emails or pictures directly to the patient鈥檚 screen in their room. That would be my dream and at this point it doesn鈥檛 cost anything to dream!
Q: Do you have good collaboration with your hospital foundation to help support your palliative care wish list?
A: We have excellent support from our foundation. Every year they put on events to help raise money for palliative care. They have helped us get equipment as well as services like music therapy and massage therapy. Maybe I should go to them with the idea of a palliative care suite!
Q: How is the collaboration with various palliative care stakeholders such as the CLSCs?
A: The collaboration with our local CLSC is excellent but they are lacking services. Often it is the same few nurses who are in palliative care and their case loads are extremely high so I think there needs to be more funding at the CLSC level for home palliative care and again, more access to psychosocial support at that level. I think a lot of patients prefer to have end-of-life care at home but it is very difficult for a family to care for someone at home 24 hours a day, but with more help available perhaps that would be possible. We are happy to offer end-of-life care in our unit but not all patients wish for this.
Q: Do you think that people in your community have good access to palliative care?
A: There are always gaps in terms of access to palliative care. To this day, people are still only accessing palliative care late in their disease trajectory. Sometimes they end up arriving in an end-of-life situation and it鈥檚 the first time we are seeing them. We would like to catch them earlier when they are still at home. So early access is still an issue and there is still a lot of room to improve. We are working hard for better, earlier access to care.