Brightening up patients’ final journeys

HKEC End-of-Life Community Care Project Team
Hong Kong East Cluster

Set up in 2016, the HKEC End-of-Life (EOL) Community Care Project Team brings holistic care to end-stage patients with cancer or chronic illnesses through medical-social collaboration (MSC), caring for their body, mind, social life and soul. “The final journey of life is not necessarily black in colour. Adding some colours may make it more joyful. In many cases, other than reducing pain through treatments, what they need most are spiritual care and support in daily life.”

Through MSC, healthcare staff take care of patients’ medical needs, while community partners take care of their psychosocial needs and daily life, or even fulfilling personal wishes. “It is quite hard for doctors and nurses to fully understand patients’ thoughts and needs in a short period of time. We thus collaborate with community partners to provide boundless care regardless of location,” the Team explains. “Once, a patient wanted to eat roast goose with her husband in Sham Tseng one last time. It sounded simple but was difficult due to her limited mobility. Her wish was finally fulfilled with the help of volunteers.” In order to help community partners understand diseases and facilitate them in providing daily care to patients, the Team also provides them with healthcare knowledge.

Under the project, both parties collaborate to tailor the most appropriate treatment and care plan for patients. Each patient is assigned with a link nurse who facilitates close communication between both teams and regularly reviews the latest condition. There was once an elderly woman, suffering from end-stage chronic obstructive pulmonary disease, worried that her husband, who also had difficulties in self-care, has to take care of her if her condition is deteriorated. The social worker then explored different EOL treatment options with the patient. “She proposed to sign the ‘Do Not Attempt Cardiopulmonary Resuscitation’ consent form. She said it was a thoughtful decision and felt relieved after signing. We were also glad to make the arrangements according to her wish.”

Facing ageing population, the Team hopes to further promote this service model which leverages resources of both the hospital and community to provide a more holistic care to patients. “With support from community partners, we can rest assured that patients will still be well taken care of after stepping out of the hospital and we can concentrate on medical treatments. There may not be much time left for the end-stage patients but we hope their voices can be heard, and they can enjoy their final journey.”

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