Affiliations: Pamela Youde Nethersole Eastern Hospital, Hong Kong
[Special acknowledgement to Dr Kwok Sing Ng, CP Mr Victor Kong, SWA Ms Christy Lee]
Ms X was a 50 years old lady having hormonal-responsive, HER-2 positive breast cancer with multiple metastases in Feb 2013. She was initially managed in Hospital A, with chemotherapy and radiotherapy given, later defaulted follow-up. Afterwards, she had started to receive Tamoxifen and Herceptin since Mar 2014 in our Unit, eventually passed away in Dec 2015.
Characteristic Exceptions Demonstrated by Ms X
Throughout her treatment process, she demonstrated several characteristic exceptions.
Exceptional keen for hospitalization- prolonged stay in our Orthopedic unit for 537 days and 215 days in our unit without clinical indication.
Exceptional plan for hospitalization- after discharge from Hospital A, Ms X went to different hospitals and requested admissions.
Exceptionally being refused- because of Ms X’s violent behavior, several hospitals marked ALERT not to admit her.
Exceptional treatment refusal- Ms X refused most management as planned for her.
Exceptionally irritable- she attacked staff and generated ward conflicts multiple times. She was diagnosed having adjustment disorder, delusion disorder and personality difficulties.
Family Background and Psychosocial Formulation
Ms X had no contact with family after quarrel at her adolescence. She was an ex-jewelry saleslady. Lived alone in a public housing unit and a Comprehensive Social Security Assistance (CSSA) recipient. Ms X was discriminated by her neighbors too. After onset of her illness, she refused home. Ms X was defensive and hostile towards hospital staff. Nevertheless, she was nice and helpful towards other patients. For instance, she shared pizza with other patients in ward and assisted daily task of another elder in ward.
Ms X was referred to clinical psychologist for illness coping. Rapport building turned out to be a challenging task, as she appeared interpreting any assessment as an attempt to label her as mentally ill. Due to Ms X’s defensiveness and downhill physical condition, intensive psychotherapy targeting delusional beliefs or personality issues was not a realistic option. Instead, psychological intervention focused on providing emotional support and problem solving on her immediate concerns. Efforts were made to facilitate insight regarding how her cognitions affected emotions and medical treatment.
Last Journey and Team Reflection
When Ms X was very weak, she still did not disclose any after-death business. Our team paid much effort to find if Ms X had self-arranged her funeral matter before. Multiple NGOs were contacted and ultimately our social worker was able to identify one to address Ms X’s final need. During the last moments of Ms X, chaplain was invited to see her, our staff and social worker accompanied her at bedside. Conveyable comforts words like “let go” through her ears were done to enhance her spiritual peace. Ms X’s last wish of funeral concern was addressed and fulfilled at her final moment. She rested in peace without lingering time.
Even though Ms X was an exceptional challenging patient to care, we still tried our best to preserve her dignity and the humanity. Our team awareness was increased after debriefing was done regarding to our own emotions and feeling towards Ms X’s care. Mutual staff support with good team spirit was vital for this kind of challenge.