A good end, a good farewell, and a good living

June 23rd, 2020 in International News

Palliative care reflections in the COVID-19 pandemic

Authors: Xuying Li, Yongyi Chen, Boyong Shen, Xianghua Xu
Institutions: Hunan Cancer Hospital

In the late spring, flowers are like brocade, the sun is shining. During the vigorous spring which is full of warm, the cold has passed away! Nothing can stand in the way of spring! But this winter and spring transition in 2020 is destined to be forever engraved in the hearts of all people, becoming an untouchable pain.

The novel coronavirus raged all over the world in hard times. From February 11 to March 22 this year, I had led totally 16 medical health care professionals in the Hunan Medical Team supporting Huanggang City in Hubei Province in China. We were mainly responsible for the treatment of COVID-19 patients. Most of the team members were assigned to the intensive care units. Patients in these areas were in severe and critical condition. Some of them even had no chance to have a farewell with their loved ones before dying. What’s more, in order to avoid transmission of infection, they were immediately put into the body bag for cremation. Their family members couldn’t see them for a last glance. What a pain which cannot be healed for a long time. I often think, as one of the palliative care workers, what can I do for my patients facing inadequate preparation and limited conditions? How to help the terminally ill patients say apologies, gratitude, love, and goodbye to the people they care? How to achieve a good end, a good farewell, and a good living that palliative care advocate?

There was an old lady lived in the ICU, who developed respiratory failure combined COVID-19 and heart failure. She had experienced three rescues and was pulled back from the brink of death each time. Occasionally she woke up, opened her eyes, looked at me, and stared outside the window. I understood that for her, the unfamiliar surroundings, no family’s company, medical staff wearing layers of protective equipment made her afraid and lonely. Considering she was unable to speak on a ventilator, I asked her to express her needs with winks. When I asked her if she wanted a video with her family, she closed her eyes deeply. Then I took the department’s dedicated mobile phone, videoed on her daughter. I told the daughter that her mother’s waking time was less and less, I hoped she could seize the opportunity to talk with her mother and express apologies, gratitude, and love to her. Daughter cried out gently: “Mom, due to the isolation requirement, please forgive me that I can’t do filial piety at your bedside, I will take good care of my brother and maintain a good family order. Your lifetime is toil and did not enjoy a few days of happiness. I feel so regrettable that I often make you angry inside. Please do cooperate with the treatment. We will wait for you forever.” The patient closed her eyes with tears slipped across her face soundlessly.

Two days later, the patient’s heart rate and blood pressure dropped with the blood oxygen couldn’t be measured. She lost her consciousness and was in a coma. The doctor telephoned her daughter once again, told her that it might be hard to save back this time. The daughter said that her mother believed in Buddhism, hope the health care workers could find the bodhisattva’s red rope which was kept in her mom’s duffel bag. She hoped this red rope could be accompanied by her mother until the last moment. I found the red rope and wrapped in the wrist of the patient. The video was linked to the daughter and other family members, her daughter began to cry at the moment. As a nurse expertise at palliative care, I knew it was time for the family members say goodbye to the patient. I reminded the daughter that her mother could still hear what happened although not able to express. Her mother would be fearful and worried if they kept crying. The daughter understood what I meant, and let all the family members said a few words to the patient through video. Finally, the patient passed away in everyone’s memory peacefully. The daughter requested that according to the local custom, she wanted her mother grabbed some money in hand at the last moment, which will be decent. We wiped the body of the patient with water and disinfectant twice, combed her hair, changed new clothes for her. We found 10 RMB in the belongings of the dead and put it into her hand. After the death of nursing, we connected the daughter again. Her daughter tears were streaming down her face and she thanked us through the video when she saw her mother’s tidy hair, serene countenance, clean clothes, as well as the money holding in the hands. She extended her gratitude for all we had done for her mother in this particular period. A brief funeral was arranged. Paramedics bowed collectively to the patient three times with her favourite Buddhist music downloaded online. I burst into tears when the undertaker’s workers transferred her to the funeral home. I said in my heart silently, “There is no pain on the road to life grandma.”

The implementation of palliative care is never a single kind of thought, nor should be only one mode, but should be based on human nature combined with the actual situation, adjusting measures to local conditions and varying from person to person. In Chinese traditional culture, it is a taboo to talk about death. The sudden epidemic of COVID-19 doesn’t give any psychological preparation to a lot of patients and their family. Numbers of patients had to cease their happy life abruptly and passed away without dying words for their loved ones. For infection control considerations, their family members couldn’t company the patients, which will be the lifelong regret and guilt for the deceased’s families.

Under the global pandemic of COVID-19, the work of palliative care has the work of hospice care has changed. Online communications could be utilized for the family meetings, group consultations, the family visits to reduce regrets between the patients and family members. We could adopt online psychosocial interventions not only to comfort the isolation of emotion but also let the families participate in the patients’ treatment, understand and fulfil the patients’ last wishes. In this process, the medical staff has become the ties between the network platform, patients, and families. Although there are many alternatives for an in-person meet, medical staff is still the biggest source of support for patients and their families. When everyone is scared of COVID-19, in addition to trying our best to rescue patients, all health care workers should do our best to let the deceased rest in peace and reassure the living. In the midst of life and death, it is the shining light of humanity of palliative cares that giving life a warm ferry!

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May 8th is World Ovarian Cancer Day

May 7th, 2020 in Hot Topics, International News

The world faces an unprecedented global health crisis at present, and we’d like to thank all nurses on the front line for your incredibly hard and vital work either looking after people with Covid-19, or patients with other very serious conditions, such as women with ovarian cancer.

The fact that you care so much and are willing and able to undertake such an important role is no surprise to us. We and very many of our patient organisation members know what a key role you play in helping to look after women with ovarian cancer, no matter where they live in the world. Addressing the disparity of nursing roles and utilisation of specialist skills is something we will support you within future, be that fine-tuning and streamlining training across large regions where specialist cancer nurses exist or advocating for the key role that oncology nurses could play in lower and middle-income countries, supporting prevention, screening, early diagnosis, specialist treatment and palliative care.

The wide disparity in roles and interaction with nurses was seen in The Every Woman Study, carried out in 2018 by the World Ovarian Cancer Coalition. 1531 women from 44 countries took part, and during our testing phase, we found it almost impossible to ask a standard set of questions that could be applicable to all, because of the very different duties nurses undertook, and the different levels of interaction with women. The following table showed the wide disparity in nursing contact, in countries where we had more than 40 respondents. Overall 75% of women undergoing treatment for ovarian cancer had some form of contact.

Where nurses are involved in care, on the whole, they are involved in most aspects of care from diagnosis, surgery, chemotherapy, follow up and acting as a contact point. They are more likely to be specialist nurses around the time of chemotherapy (78%), follow up (57%) and answering questions between appointments (60%), than on diagnosis (43%) or at surgery (48%).

Respondents were largely very positive about the role that nurses play in terms of their care, despite the wide variations in tasks and specialisation. Just over half (51.6%) said that nurses were able to provide important continuity of care, and a third of respondents who had nursing care said the nurses were a good source of information on ovarian cancer (35.5%), had more time to spend with them than the doctors (33.8%), we’re able to signpost to other services (31.1%) and that women felt able to ask them questions that they could not ask the doctors (30/8%).

Overall the findings of the Every Woman Study show very wide variations in experiences between and sometimes within countries, and that this provides opportunities to improve the survival and quality of life for women no matter where they are. Similarly, the wide variations in access to and roles of nurses involved in cancer care tell us that much more can be done to strengthen the value nurses bring to the experiences of women with ovarian cancer not just in high but also low and middle-income countries, and that we will support you in this quest as soon as we are all able to focus once again on these matters.

For more information about the Coalition visit www.worldovariancancercoalition.org and to read the Every Woman Study Report click here.

The nursing management practice in mobile cabin hospital, Wuhan China

May 6th, 2020 in ICNN Articles

Author: Huifen Wang, Yining He, Xiaocheng Huang, Yongyi Chen, Bo Xu
Institutions: Hubei Cancer Hospital, Oncology Nursing Committee of Chinese Nursing Association

In order to deal with the outbreak of pandemic of COVID-19 in Wuhan, China has established 16 mobile cabin hospitals to treat patients infected by COVID-19 with mild symptoms. Mobile cabin hospital is a kind of modular health equipment, which has many functions such as emergency rescue, surgical treatment, and clinical test. With good mobility, rapid deployment, strong environmental adaptability, it could undertake many emergency medical rescue missions. The establishment of a mobile cabin hospital can effectively relieve the pressure of the shortage with the medical resource in Wuhan and will become a veritable cabin of life. Since the outbreak of the epidemic, nurses at Hubei Cancer Hospital have actively applied for front-line services, and a total of 100 outstanding nurses have been selected to fight the epidemic, providing care for patients with COVID-19. The innovative nursing management in a mobile cabin hospital is distinctive from that in other general hospitals.

  1. Setting up of the mobile cabin hospital
    Three medical teams from Hubei Cancer Hospital took over three mobile cabin hospitals. The 1200 beds in Wuchang mobile cabin hospital are divided into three parts including Area A, B, and C. Hubei Cancer Hospital was responsible for the construction of A1 area which was comprised of 120 beds, 20 doctors and 40 nurses. Nurses undertook treatment, care, psychological support, health education, infection control, meal ordering, food delivery and distribution of living materials in this ward unit. They also were responsible for the management of Hongshan mobile cabin hospital containing 120 beds, 17 doctors, and 31 nurses. The team has been responsible for it for 60 days. Finally, 364 mild patients have recovered successfully under meticulous care. They also have established the party school mobile cabin hospital and were in charge of the F1 area with 65 beds, 20 doctors and 30 nurses, and 93 mild patients.
  2. Preparations of the mobile cabin hospitals within 48 hours
    There were two days for preparatory works of the mobile cabin hospital. Before the admission of patients, they might furnish medical area and living area with all kinds of cabinets, camp beds (not beds), bedside tables, treatment vehicles, blood pressure monitors, blood oxygen monitors, infusion racks, medicines, disinfection facilities, bedding, and toiletries for patients, etc. They tried their best to place the ward units to meet a criterion of hospital standards. They reasonably divided the whole place into several functional areas like clean area, potential pollution area, contaminated area, medical staff channel, patient channel, etc, and posted corresponding signs in each area. In order to better meet the clinical need, they formulated the workflow to guide clinical nursing work, including how to receive, treat, nurse, check and take medicine.
  3. The environment and medical supplies management of the cabin
    We accepted patients and inputted their information into internet. After they settled in their beds, we do some assessments, take temperatures, take oxygen saturations, draw blood and gather pharyngeal swab, do health education, bed unit sorting and so on. They also distributed meals, masks, fruit, milk, towels, clothing, etc. for daily use to patients. At the cabin hospital, they were responsible not only for the care of the patients but also for the management of the cabin and the daily life of the patients.
  4. Humanized shift arrangement
    At the beginning of the shift, nurses worked in the cabin for 6 hours. If we include the time of wearing and taking off the protective clothing, handing over and other works, it was approximately about 9 hours of working time. After a long time of working with PPEs, the nurses might suffer from chest tightness, nausea and vomiting, hypoglycemia, dizziness, as well as other discomfort symptoms. Some nurses often missed meals in the cabin, they could not get enough energy they need.”It can’t be going on like this.” According to the actual situation, several investigations were arranged among nurses and managers. Considering some of the nurses might feel uncomfortable after a long period working in the cabin, the working time was adjusted accordingly. The 4-hour shift system was finally determined. Four-hour shifts, six shifts a day, four to six people per shift, one or two more people for throat swabs or blood collection.
    A group leader was responsible for the management of rescue beds in the ward unit, and a senior nurse was arranged as rescue nurse. Each group also has one nurse in charge of a fire evacuation. In addition, each shift will have a mobile nurse. They would take the place in case there be a situation of someone sick or things like that.
  5. Psychosocial support
    The patients admitted to a mobile cabin hospital were those who’s virus detection result was positive for COVID-19 with no severe symptoms. Due to the unfamiliar environment and simple living conditions, many of them will feel anxious, suspicious, fear, hopeless, and isolation. Nurses would do a psychological assessment and deliver psychological support to the patients. Psychological counsellors would be appointed to offer them a face-to-face conversation to release their pressure. Also, volunteers would be available to connect with their family members and increase their social support. Additionally, kinds of activities to relieve physical and mental pressure was arranged for them. A temporary library was set up to provide a variety of books also.
Figure 1. The establishment of Wuchang mobile cabin hospital
Figure 2. The nurses were drawing blood
Figure 3. The nurses were making ward rounds with doctors

Nursing experience for severely ill patients with Covid-19

May 5th, 2020 in International News

Jiangxi counterpart support Suizhou anti-epidemic nursing experience sharing

Authors: Jinhua Hong , Dan Luo
Institutions: Jiangxi Cancer Hospital, Jiangxi Hospital of Traditional Chinese Medicine and Western Medicine

At the beginning of 2020, after the outbreak of Covid-19 in China, according to the unified deployment of the National Health Commission, Jiangxi Province has sent three batches of 389 medical team members to help Suizhou City, Hubei Province.25 cases of severely ill patients and 50 cases of critically ill patients have been managed in Suizhou Central Hospital. The nursing experience is now reported as follows:

  1. Higher nursing manpower requirements.
    Because it takes time to put on and take off protective clothing, and, it is inconvenient to move with protective clothing, goggles, and three-layer gloves, the nursing staff consumes a lot of energy, requiring higher manpower. In the Covid-19 Severe Ward, the number of nursing staff is configured according to the bed-to-care ratio of 1: 6, and each shift is 4 hours to ensure that the nursing work is carried out in an orderly manner. Through our selection, all intensive care personnel have been trained in intensive care and have intensive care experience
  2. Characteristic schedule with collocation of nursing staff in Jiangxi and Suizhou.
    Due to different cultures, different ward environments, and different dialects, we use characteristic schedule method. Nurses from Jiangxi are mainly responsible for patients; the local nurses in Suizhou are responsible for office work and coordinate with external. Each shift must have at least one local nurse.
  3. Closely observe the changes.
    The condition of critically ill patients change rapidly, the patient condition should be observed at least every half an hour. Focus on monitoring body temperature, breathing rhythm, frequency and depth, and blood oxygen saturation. Accurately record the amount of 24 hours in and out, observe the vomit and stool frequency, nature and amount. Nursing staff should fully understand the patient’s condition, be familiar with the results of various tests performed by the patient to provide information and evidence for treatment and care. For patients with high fever, it is better to use traditional Chinese medicine acupressure coordinated with physical cooling.
  4. Oxygen inhalation.
    Severe patients can be given oxygen by a high-flow nasal cannula or mask according to the situation. Patients receiving oxygen by nasal catheter should wear surgical masks.
  5. Strengthen respiratory management.
    Strengthen the patients turning over, back kowtows, and suction, follow the doctor’s advice to cooperate with prone position to improve lung ventilation and promote sputum excretion. Patients using non-invasive ventilator should adjust the parameters of inspiratory pressure, expiratory pressure and oxygen concentration according to the doctor’s orders. For patients who need to establish an artificial airway by tracheal intubation or tracheotomy, the nurses need to adopt closed-type sputum suction and perform artificial airway management under the implementation of three-level protection measures.
  6. Keep patients comfortable and dignified.
    Strengthen communication with patients, produce dialect-specific cards; implement patient skincare, oral care, etc. Pay attention to patient privacy, and keep patients clean, comfortable, and dignified.
  7. Provide emotional support and humane care.
    Considering patients with Covid-19 are quarantined from their loved ones for a long time, they are in lack of family and social support, often show anxiety and fear. Nursing staff should accurately assess the patient’s psychological state and needs, provide appropriate emotional support and humane care, help patients to contact with their families by telephone, WeChat or video, and give support and encouragement. At the same time comfort the patient’s family.
Figure 1. Patients with anxiety and difficulty breathing in the Covid-19 ICU ward of Longmen District of Suizhou Central Hospital. Psychological counselling was conducted by Hong Jinhua to guide patients to adjust their breathing and relax.
Figure 2. In the Covid-19 ward of Wendi District of Suizhou Central Hospital, Luo Dan performed closed suction for the patient and observed the color, nature, and volume of the sputum.