In Xia Min's view, the hospice ward is like a "social womb", providing pain relief for those who return to the "infant state" of the dying elderly, providing nutrition, warmth and care, so that the dying moments of these terminal cancer patients become quiet and peaceful.
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Beijing News reporter Li Cong Editor Yuan Guoli Proofreader Fu Chunyan
The central health center in Mazhan Town has opened three hospice wards.
This southernmost town in Zhejiang is 108 kilometers away from downtown Wenzhou and 28 kilometers from Cangnan County, surrounded by mountains on three sides and facing the sea on the other.
Xia Min, the director of the health center, is a native of the local area, and after witnessing the suffering of many patients with advanced cancer, he tried to open a hospice ward in a primary medical institution such as the Mazhan Central Health Center.
From January 2021, the Hospice Department of Mazhan Central Health Center officially accepted patients. Most of the patients admitted to the hospital are over the age of 65 and the average length of hospital stay is 15 days. Every month, four or five patients complete their last journey here.
Despite many problems such as lack of professionalism, insufficient manpower and losses, "still very rudimentary", Xia Min is optimistic and has a longer-term idea. In addition to improving hospice services, he also wants to build a professional team, develop family beds, and provide door-to-door hospice services.
▲ March 21, the building of the Mazhan Center Health Center. Beijing News reporter Li Cong photographed
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A farewell that you have to go through every month
At 8:00 a.m. on March 14, the morning stalls in Mazhan Town were covered with white steam, and the elderly drove electric tricycles to send their children to school. At this time, the handover of the medical staff of the Mazhan Central Health Center was also over.
The Mazhan Central Health Center has 5 floors, and the 4th floor was originally an obstetrics and gynecology ward. With the opening of the town's highway, the journey to Cangnan County Hospital was shortened from one hour to half an hour, and gradually, no one chose to give birth to a child in the health center.
The obstetrics and gynecology department was then converted into a geriatric department, and later a third of the area was converted into a hospice ward. In the eyes of the health center's medical staff, this is like human life, which has been moving forward in a single thread.
Stepping out of the elevator on the 4th floor, you can look up and see the nurses' station, which is no different from other hospitals until you pass through a frosted glass door that says "Hospice Care".
Beige corridor walls, hardwood floors, greenery that don't "wither", and if it weren't for the bed in the room with blue-and-white striped sheets, the area wouldn't look like a ward.
There are currently only three wards in the palliative care ward, called "Warmth", "Warmth" and "Warmth". There is a bed in each room, and under the door number of each ward hangs a bouquet of "never fade" flowers, "falling" a few butterflies.
On the same day, Zhou Juntong first went to the hospice ward, where she was the head nurse of the geriatric department and hospice ward.
Zhou Juntong shuttled between the two sides of this glass door every day, where there seemed to be an invisible line, on the one hand, people who were hospitalized for treatment because of chronic diseases, on the other hand, terminal patients with a survival cycle of less than three months; on the one hand, they were actively treating and hoping to regain their health, and on the other hand, they hoped that they could reduce pain and peacefully move towards death at the end of the life.
On this day, she was going to send an old man out of the hospital.
This is the third day that 91-year-old Zhang Yuan is lying in the hospice ward. A month ago, he was diagnosed with advanced liver cancer. When he was pushed to the health center by his nephew in a wheelchair, the old man was suffering from severe pain caused by perforation infection in the abdominal cavity.
Vomit with blood, a rapid heart rate, a high pressure of 70 and a low pressure of 50, procalcitonin (a small molecule protein that is highly sensitive to bacterial infections) and a white blood cell explosion, he groaned, hoping that the doctor could give him a shot of painkillers.
Subsequently, Zhang Yuan was admitted to the hospice ward of the Mazhan Central Health Center. Faced with the frenzied pain, the old man received 10mg of morphine injections subcutaneously every day, or two doses of morphine suppositories.
The old man did not know the words on the glass door of the hospital, nor did he know what palliative care was. He just felt that the single ward here was quiet, the flowers in the room were beautiful, and the doctors and nurses would come to see him several times a day. More importantly, he didn't hurt so much.
But Zhou said that although the pain has been controlled, the elderly have become increasingly sleepy due to severe abdominal infections.
At 9 a.m., through the window of the ward, I could see that the fog in the mountains had not yet dissipated. "Grandpa, get up and get dressed." Zhou Juntong bent down and shouted tentatively.
The old man Zhang Yuan, whose eyelids were closed, immediately responded, not knowing where the strength suddenly came from, his right hand propped up on the bed and sat up on his own.
Zhou Juntong was stunned, and suddenly his nose was a little sour. She knew that the old man, who was already dying, still had a breath, thinking of going home to accept the final farewell of his relatives.
At 3:30 p.m., Zhou Juntong received a call from the old man who had passed away. At that time, she had not yet had time to sort out the old man's discharge settlement information.
Such a farewell, she has to go through almost every month.
▲ Head nurse Zhou Juntong is trimming the nails of patients. Courtesy of respondents
Controversy erupted
The Mazhan Central Health Center is preparing to create a hospice ward in 2019.
Dean Xia Min grew up in Mazhan Town. In childhood, my sister had bleeding from her upper gastrointestinal tract. At a young age, he carried his sister around to seek medical treatment, which also laid the foundation for his ambition to study medicine. After many years of study, he returned to his hometown and worked here for more than 20 years.
"Not knowing how to deal with the pain of patients with advanced cancer" became the beginning of Xia Min's exploration of palliative care.
He always remembered a patient, a friend of his father's. The patient, who had a cancer attack, rolled around on a hospital bed in a health center, shouting in horror. Xia Min, who was outside the meeting, asked the doctor to prescribe painkillers to the patient, but the doctor believed that the patient should be transferred from the treatment point of view.
Xia Min understands the doctor's caution and concern about the clinical use of painkillers, but in the face of a large number of terminally ill patients such as terminal cancer who endure pain, "I really don't know what to do," he said with a frown.
In addition to the patient's pain, there are many things that Xia Min is confused about. For example, when the hospital declares "no therapeutic significance", where should the patient go, how to alleviate the pain endured by the patient at home, and what should be done about the fatigue caused by the long-term care of the patient by the family?
Xia Min believes that a place is needed to support the terminally ill patients, and the primary health center is the most suitable place, "the fallen leaves return to the roots, and it is closer to home to achieve this effect."
When Xia Min had this idea, it coincided with the need to apply for a special specialty at the Mazhan Central Health Center, and he "targeted" the palliative care department.
With no patients, no data, and no operation, Xia Min relied on her lips and the evaluation experts of the Wenzhou Municipal Health Commission. The theoretical knowledge was all learned by him from the Internet, and he did not expect to get a unanimous vote in the end, "This is a people's livelihood project, which shows that everyone is very supportive."
However, inside the health center, when the hospice ward began to prepare, it did not get "unanimous approval".
The first is opposition from geriatrics. Zhou Juntong confessed that her resistance came from the "unknown". Most patients in hospice wards have a lifespan of less than three months, and the risks and pressures of nursing care are high, which is a new challenge for nurses.
Doctors are worried that this department does not reflect the value of scientific research, and worry about performance appraisal and income problems.
Colleagues in other departments didn't understand either. The 4th floor ward of the Mazhan Central Health Center originally had 32 beds, and the newly established hospice ward occupied one-third of the space, but could only provide 3 beds, which wasted space and resources and could not bring outstanding benefits.
To this end, the health center issued regulations to give certain policy preferences and subsidies to the hospice department, the president took the lead in learning hospice courses, and sent doctors and nurses to the county hospital for pain assessment, cancer pain medication and other hospice related training.
At the end of 2019, mazhan central health center, with reference to the setting of hospice wards in other hospitals, invested 300,000 yuan to build a palliative care ward integrating three beds, an activity room, a farewell room, a talk room and a dining room.
Here, the director is the director of the geriatric department, the head nurse is also the head nurse of the geriatric department, the practicing physician is the inpatient department, the psychological counseling work is responsible for the public health department, and the Chinese medicine practitioner also joins the consultation. With the combined efforts of multiple departments across the entire health center, a hospice team was formed.
▲ On March 21, the hospice ward of Mazhan Central Health Center. Beijing News reporter Li Cong photographed
Non-"standard" salvage
In January 2021, the first patient admitted to the hospice unit, Chen Wencheng, a 30-year-old local.
Chen Wencheng, who suffered from liver cancer, was sentenced to "death" by a hospital in Shanghai, and his wife took him back to his hometown. Because of his acquaintance with Xia Min, Chen Wencheng was admitted to the Mazhan Central Health Center.
The curtains of the wards were tightly drawn, and the abundant sunlight of the seaside town could not shine in at all.
Zhou Juntong remembers this patient with advanced liver cancer, "he can't accept this (illness) because he is still very young."
Chen Wencheng did not eat or drink, his face was sallow, he was more than one meter and seven tall, and he was only 40 kilograms when he was the thinnest. Due to the severity of ascites, lying flat would compress the organs, so he could only sit half and half lie on the hospital bed. He doesn't talk, he doesn't look at his phone, and he often stares blankly ahead.
This was Zhou Juntong's first time nursing a patient in the hospice department, and in addition to completing the necessary nursing work, Zhou Juntong tried to chat with Chen Wencheng, but did not receive any response.
However, tumor complications do not give anyone buffer time. On the evening of the sixth day of admission, Chen Wencheng ruptured and bled heavily from varicose veins in the stomach, blocked his airway, and soon faced suffocation.
Chen Wencheng's wife decided to rescue her. Intubation, cardiopulmonary resuscitation, defibrillation, Li Run, a resident doctor in hospice ward, and nurses reacted instinctively. However, due to the serious liver failure, in the early morning of the next day, Chen Wencheng was declared dead due to ineffective rescue.
According to a 2014 study, CPR was initially developed for acute conditions such as myocardial infarction, and in patients with advanced malignancies, the probability of rescue success is no more than 10%.
Recalling the original practice, Zhou Juntong admitted that in the end, invasive rescue such as tracheal intubation will actually increase the pain of patients, which is somewhat in conflict with the principle of palliative care. But patients and their families were not prepared for death, and healthcare workers were not prepared.
"Unless the patient's family says there is no need for rescue, it is like instinct." Seeing the heavy bleeding, Zhou Juntong subconsciously predicted whether the patient's breathing was going to be blocked, and immediately considered tracheal intubation or other treatment methods.
Although it was a less "standard" palliative care, a few days later, Chen Wencheng's family sent a pennant to thank all the medical staff in the hospice ward of Mazhan Central Health Center.
When each patient is admitted to the hospital, doctor Li Run will explain to the patient's family what is hospice care and ask whether they are ready to no longer receive invasive rescue such as cardiopulmonary resuscitation when they suddenly have a disease.
Of course, this "readiness" is not consistent. "I need to talk to my family many times. Talk once when you are admitted to the hospital, and if your condition changes slightly, you have to talk to your family once," Li Run said.
The survival cycle is much shorter than expected, such as sudden bleeding and other accidents, even if additional pain will occur, the family members will still change their minds and choose to rescue. In a quiet, slow "decline" process, the family is more receptive to giving up rescue. It takes time for patients to accept, and it takes time for families to accept.
▲ On March 21, the hospice ward of Mazhan Central Health Center. Beijing News reporter Li Cong photographed
Analgesia is the first step
For most of the hospice team at the Mazhan Central Health Center, it was the first time they had been exposed to hospice care, and it was "still a bit ignorant."
Xia Min always sighed, "When I first started doing it, we didn't quite understand it. If you want to do a good job, you are not professional enough. But the good thing is that "the patient can always be here for the last few days."
There are three criteria for admission in hospice wards: the patient and his or her immediate family are aware of the contents of hospice care services and voluntarily accept the palliative care services provided by the undergraduate department; the patient's estimated survival is less than three months; and the card function status score is below 50 (often requiring human care).
In the whole year of 2021, a total of 50 people were treated in the hospice ward of Mazhan Central Health Center, some of whom were introduced, some of whom were found by themselves, and some of whom were transferred from higher-level hospitals.
Pain management is the first step in palliative care, and there is no "body" analgesia, let alone "heart" and "spirit".
Before the hospice ward was officially established, in 2020, the Mazhan Central Health Center had admitted some terminal patients who were rejected by other hospitals.
The "burst of pain" in the advanced stage of cancer is a problem that Li Run once faced, and some patients will have symptoms of numbness and convulsions throughout the body. Li Run frankly said that at that time, there was no full understanding of cancer pain, and the dosage of ordinary people was still referred to in the medication, so the pain treatment effect was not particularly good.
After the establishment of the Hospice Department, after a period of study and exploration, he became more decisive in medication.
For the average person, a morphine injection of 100 mg a day is a lethal dose, and for the "burst pain" of patients with bone metastases cancer, some patients will even use 600 mg of painkillers a day, "How much pain do you say they have to be?" Painkillers have no ceiling effect."
A large number of painkillers taken in the current period have established tolerance in the body, the dose of painkillers has been continuously improved, and side effects such as vomiting and constipation will give way to the actual feelings of patients at the moment.
In addition to analgesia, in daily nursing, Zhou Juntong often reminds nurses not to add additional pain to patients, such as vascular puncture must be successful. There was once a patient with puffy hands and feet and blood vessels that could not be found, and In order to ensure a return of blood, Zhou Juntong could only risk choosing the blood vessel at the thumb joint of the patient's right hand for puncture.
Meeting the individual needs of patients, including psychological counseling and achieving wishes, is a higher level of hospice care services.
In terms of treatment, Li Run believes that the wishes of patients can be met within a controllable range. For example, some conscious patients are not willing to get injections that day, so the appropriate degree can not be injected; or patients feel very tired, and they can suspend treatment for a day.
Li Run, a doctor at the Mazhan Central Health Center, is communicating with the patient's family. Courtesy of respondents
The word "cancer" is still taboo
"Getting dying patients to know and accept their condition is a complicated thing," Zhou said.
Whether to talk to terminal patients about the condition and death, and how to talk about it, is a problem that the patient's family must face, and it is also an ethical dilemma that medical staff will face. In most cases, medical staff will listen to the patient's family members.
In Zhou Juntong's heart, the most ideal state is that after the patient is admitted to the hospital, he uses medical means to alleviate the pain, and through their companionship and psychological counseling, let the patient accept his illness, alleviate anxiety and fear, complete the last wish, and go to another world without regret.
In reality, all the families of patients entering the hospice ward know that death is imminent, perhaps in the coming months or days.
But most patients don't know. When they are admitted to a hospice unit, they also ask, "When can I be discharged?" Even when he left, he didn't understand: "Obviously it is a small illness, how can it not be cured?" ”
At this time, Zhou Juntong will be poor in words, and can only respond to peace while comforting, "It's almost fast." All she could do was go to the ward a few more times a day, talk to these patients, help them trim their nails, play checkers with them, and so on.
The word "cancer" is still taboo. In communication with colleagues, Zhou Juntong will use "liver C" instead of "liver cancer". At the mention of the word, her voice suddenly became very soft, even though she was not in the ward at the time.
On the walls of the hospice corridor, a map of the course of human life is drawn with clock stickers. At six o'clock in the morning, it is the first entrance hall, at nine o'clock in the morning it is the first entrance hall, at three o'clock in the afternoon it is to start a family, and at twelve o'clock in the middle of the morning, it is full of children and grandchildren.
This is an element that Chinese medicine physician Xu Lichun wrote down during her visit to Ruian Hospital, and she felt that this would give patients a hint that human life is always coming to an end.
Patient Cai Xiang is an exception. He is in his fifties, tall and cheerful, and is an "old friend" of the medical staff of the hospice department. He is the "best quality" patient in Zhou Juntong's mouth - sober-conscious, accurate in his understanding of his condition, and relatively high acceptance of death.
In 2020, Cai Xiang was diagnosed with a malignant tumor of the lungs and was estimated to have a one-year survival period. That year, he regularly needed to go to the health center for anti-inflammatory drugs and cough medicine because his lungs were inflamed. Cai Xiang is often very proud, "I have lived for more than a year and have earned it."
On April 11, 2021, when Zhou Juntong saw Cai Xiang again, he was lying on a flat cart and the cancer cells had metastasized to the spine. "I'm afraid we can't do it this time," he said, trying to laugh and joke, and finally his face twisted due to the pain in his chest.
Cai Xiang has lived in the ordinary ward outside the glass door on the 4th floor many times, and has also seen the comings and goings of the hospice ward. He told Zhou Juntong that his child had grown up and had nothing to worry about.
In the last days, Cai Xiang also tried his best to maintain decency. When Zhou Juntong went to turn him over or dispose of excrement, he would say very politely that he would let his wife come and get it.
"We're still very junior"
"We are still very rudimentary", Xia Min has a clear understanding of hospice care in the health center.
According to the World Health Organization's International Agency for Research on Cancer, 3 million people died of cancer in China in 2020 alone. As early as 2016, when the National Committee of the Chinese People's Political Consultative Conference held a forum in Beijing, some members mentioned that less than 1% of the terminally ill patients in the mainland can enjoy hospice care services.
Since the establishment of Beijing Songtang Hospice Hospital, the first hospice institution in China, in 1987, hospice services have slowly advanced in China. There is a huge gap between the huge demand and the actual supply, which is more pronounced in the rural areas of the townships at the grass-roots level.
The "lack of professional psychological counseling" is a problem recognized by the hospice team of Mazhan Central Health Center. There is a big gap between conventional humanistic care and systematic psychological construction in clinical medicine, and palliative care can only alleviate physical pain now, and there is still a long way to go to alleviate psychological pain.
The construction of hospice wards also puts forward higher requirements for the medical strength of health centers. Xia Min said that hospice care can not rely only on comfort, nor is it completely abandoned treatment, such as patients should not have left so early, once there are complications or electrolyte disorders, etc., what needs to be treated is still to be treated as soon as possible.
In addition, losses are a bottleneck restricting the development of the hospice industry. In the Mazhan Central Health Center, taking the complications of patients with advanced lung cancer as an example, the cost of each hospitalization of patients is 7,000 yuan, and the patient only needs to pay more than 1,000 yuan out of pocket after the medical insurance is reimbursed. Subsequently, the medical insurance paid by disease group (DRGs), and the health center allocated 3,000 yuan to 4,000 yuan to the medical insurance fund. Therefore, for every patient admitted, the health center will "lose" 1,000 yuan to 2,000 yuan.
Through Xia Min's efforts to negotiate, in 2022, the local medical insurance initially decided to settle according to 350 yuan per day. Li Run felt that this price was still far from enough. They calculated that nutritional support and painkillers for dying patients need at least $500 a day.
In the face of losses, Xia Min looks at the long term, and hospice care itself can bring a certain brand effect, and can also drive the occupancy rate of other chronic disease patients. The hospice ward is a loss, but it is not a loss to put it together with the geriatric ward.
"Dying is a problem that everyone faces, we take out a part of the funds to do this, now we can't see the benefits, but after a few years, the whole society will definitely see it, and the value will be reflected", Xia Min is very optimistic.
In the process of exploration, the palliative care ward of the Mazhan Central Health Center is slowly developing.
It is the common wish of all medical staff in the hospice ward on the 4th floor to better improve the content of hospice care services such as physical nursing, psychological care, pain management, and nutritional support, and to meet the wishes of patients and their families.
Xia Min is ready to absorb more talents and build a professional team. At the same time, the number of beds in hospice wards will be increased, family beds will be developed, and door-to-door services will be provided; cooperation with higher-level hospitals will be cooperated; outpatient publicity and awareness of hospice wards will be increased; and new healing services such as music therapy, aromatherapy, and spas will be tried. The Mazhan Central Health Center is blazing a new trail.
Although everyone in the hospice department of Mazhan Central Health Center wears several hats, everyone has their own plan for the development of hospice wards. Zhou Juntong wants to take palliative care courses, Li Run prepares to further study cancer pain management, Yin Tingting of the Department of Public Health prepares for exams related to psychological counseling, and Xu Lichun also tries how to use acupuncture to relieve pain.
Six kilometres away from the Central Health Center, the waves are lapping tirelessly against the coast as they were hundreds of years ago. Ten meters away, a new 11-storey hospital building has been erected, and when completed, there will be an entire floor there as a hospice ward.
(Zhang Yuan, Chen Wencheng, Cai Xiang are pseudonyms)
Duty Editor Kang Hee-hee