Dear Sir,

“On a scale of 1 to 10, what is your pain level?”

This is a question which is almost always asked when we go to the doctor for something which ails us. Sounds pretty straightforward, right? But it’s not, actually.

Patient care is broadly categorised into two groups. Those who are sick, injured and/or mentally incapacitated, having a good prognosis of recovering from their ailment and thus will be treated for a goal of wellness. Then there are those who are living with a terminal illness, having explored all avenues of curing their disease and they have made the decision to pursue a life of palliative care. Palliative care is specialised medical care for people living with a serious illness such as cancer. This type of care is focused on providing relief from the symptoms and stress of the illness, and the goal is to improve quality of life for both the patient and family members.

Pals is a phenomenal organisation in Bermuda which employs specialised doctors and nurses who provide cancer patients with quality care, primarily in the home setting in order to enhance their quality of life. It provides support and assistance to cancer patients and their families, and help meet the physical, emotional and social needs of patients. Its mission is to promote health, dignity and independence for the patient, regardless of ability to pay, to the extent of the resources of Pals. Most, if not all, seriously ill and/or terminal cancer patients are regularly seen by the dedicated Pals care team and thus their case histories are up to date with the status of their treatments.

Please note that the following observations are purely from a patient-advocate perspective and by no means are to diminish the merit of the valuable services of either the King Edward VII Memorial Hospital emergency department or Pals. The reason for my writing this letter is to highlight a clear distinction in approaches between those of Pals and the ER when it comes to seeing, evaluating and treating palliative care patients. Specifically, the difference is owing to the lack of information-sharing between the two entities with regard to the history and, most importantly, the current status of a terminally ill patient.

I have experienced many instances of accompanying and sitting at the bedside of one such patient in the ER, a patient whose health history is already in their files, which spans more than 30 years and could fill up several large suitcases. At every ER visit the patient and I have made together over the years, there would first be the procedural protocol of triage, which is the process of quickly examining all arriving ER patients to decide which ones are the most seriously ill and must be treated first. Then, when the patient is ultimately assigned to an ER bed, the inevitable “so what has brought you here”, “tell me about your health history” and “how are you feeling” conversations begin. It is at this point that the procedural inefficiency of our medical system reveals itself.

With the patient often in severe pain, I have routinely observed the nurse-patient discussion, which begins and continues with a questioning rhythm similar to a finely oiled machine — the nurse seemingly oblivious that the answers to every single patient history question they are asking are (or should be) staring right back at them from the chart they are holding in their hand. When the (in this case) lengthy history discussion has concluded to the nurse’s satisfaction, there would then be the inevitable wait for a doctor to order the medication or treatment as appropriate.

I have a suggestion. As I mentioned above, since most, if not all seriously ill and terminal cancer patients are regularly seen by the dedicated Pals team, what if the strictly palliative-care patients could have their KEMH charts “flagged” to that effect with a summary health history sheet and periodic status updates from Pals, to allow a more efficient doctor-patient exchange to take place during an ER visit?

ER visits are not uncommon with these types of patients and having to explain one’s 30-year cancer history, with its associated current quality-of-life management issues over and over again in order to receive what would be purely symptomatic relief, is both procedurally cumbersome for the hospital staff and very stressful for the patient. It is my hope that Pals and KEMH can enter into an information-sharing relationship, which would assist the doctors and nurses at the ER in evaluating this class of patient in a much more efficient and sensitive manner, getting them the relief they need as quickly as possible.

To this end, I have respectfully copied both Pals and KEMH on this letter and look forward to seeing their collaboration in making a positive difference in the ER treatment approach for these patients.

From the Hippocratic Oath:

“I will remember that I do not treat a fever chart, a cancerous growth, but a sick human being ....I will remember that there is art to medicine as well as science, and that warmth, sympathy and understanding may outweigh the surgeon’s knife or the chemist's drug.”

BEVERLEY CONNELL

Pembroke

cc: Chikezie Dean Okereke, MD, Chief of Emergency and Hyperbaric Services, KEMH

cc: Sharon Alikhani, MBBS, Medical Director, Pals