While the impact of COVID-19 in Malaysia is acutely felt in hospitals dealing with the pandemic, nurses working in the community setting play an equally critical role in the response to this situation. Stephanie, a good friend of mine, is a Community Palliative Care Nurse taking care of palliative patients at their homes. This is her reflection on how the COVID-19 has affected her patients and her work in the community setting…
“Stephanie, you'd better be prepared to buy some necessities and store them at home. The COVID-19 situation is not looking good. COVID-19 cases will only increase as there is no vaccine and it's spreading fast.” This was a message I received in the middle of a busy working day, two weeks before the Movement Control Order (MCO) was announced.
Working as a palliative care nurse, caring for patients with life-limiting illnesses in the community, I am aware of the COVID-19 cases in the country but heedless of the dire situation. If the message is true, what will the future be like for the patients and family in the community? How are we, as community healthcare workers, going to manage patients at home? Will they be living in agony? What about my personal wellbeing? These are the questions that I keep pondering every day. Worries, confusion and fear of the uncertainty started to creep in.
Soon, the day arrived. 18th March 2020 was Malaysia's first day of MCO.
There were new changes in the daily development of the COVID-19 situation. Hospitals were discharging patients in a hurry. No new cases will be accepted. We were not allowed to send patients back to hospital even for a possible reversible symptom. Neither were we allowed to downsize a not-so-important ward into a respiratory ward. Appointments were deferred to three months later. The list went on and on.
With all these rapid changes, I was constantly being alerted by any new updates from my upper management, fellow colleagues and the Ministry of Health. New care plans were being discussed according to the daily happenings, in order for us to continue our duties in the community, while trying our best to keep ourselves safe and comply with medical ethics.
I remember I was excited when I received a case of a patient with cancer coming back from China. She was tested negative for COVID-19 but was unsure for her family members who will also be travelling back from China. I reminded myself that I needed to be extra vigilant when I visit them at home. Initially, I didn't feel the need to be paranoid just because they were returning from China. However, due to all the speculations by my team members, doubts and fear started to grow in me.
The fear did not stop the usual care I gave to my patients. Rather, I had deep thoughts on how I would render care to her or other high-risk patients. I planned the protective measures to take. History taking through my phone, donning personal protective equipment (PPE) outside the door of the house, addressing patients’ physical and emotional needs, examinations, wearing and disposing of used PPE. Followed by next steps in my car - calling the doctor for further examination of the patient, preparing medications and lastly to pass the medications to a family member through the door to minimize physical contact. Any further questions were resolved through phone calls. It was a process too thorough to be handled alone. There were other questions too. What about the examination kits that I brought? Should I sanitize them before bringing them for the next visit? What if I transmit the virus to other patients and their family members, or to my own family or even my colleagues at work? I was apprehensive and anxious about missing the tiny details that could potentially risk bringing harm to others and myself.
Day by day, as the number of COVID-19 cases rose, my exposure to COVID-19 increased too, as I continued to visit patients and family members at home. I had no difficulty asking them the golden questions of fever, cough and travel history, however I doubted that they answered them honestly. I'd experienced it during home visits. Family members who came back from high-risk countries were not isolating themselves in a room and sometimes not declaring their travel history. They were walking around the house as usual. Social distancing was not practiced even though it was informed prior to the visit. Nearly half of my patients preferred not to have home visits, but the rest were grateful for the visits.
Based on my observations throughout the MCO period, the patients and their family in the community were affected the most. Their medical appointments have been deferred; this means treatment and dispensing of medication will be disrupted. Movement restriction would mean an income restriction as well. Family members and private caregivers were stopped by policemen while they were on their way to patient's house to provide care. This caused emotional stir-ups. Patients felt left out and were unable to reach out to the community healthcare workers and family members for care. It created fear in them. Fear of the uncertainty, fear of suffering and fear of dying alone.
Overall, I did not feel that the MCO affected my patient care too much. Yes, it took a lot of time because of the roadblock, otherwise the traffic flow was very smooth. I’m not allowed to enter into certain nursing homes or old folk homes to visit patients. However, this is dependent on the patient's family effort to make things work. I just needed to modify work procedures, such as putting on PPE before visits, initiating patient care differently for certain patients depending on the situation, making more phone calls and to assess patient's conditions via the phone. Most of the time, I am still able to find a way to manage the situation with the help of patients and family members.
I feel that the first week of MCO started off a little chaotic and scary, but things improved as we entered the second week. Group discussions with other members of the community healthcare team about our experiences and difficulties enabled me to cope better. Furthermore, the plans and advice from our medical and nursing management that were adapted from reliable sources such as the World Health Organization and Malaysian Ministry of Health eased the situation. I feel more supported and less afraid. As this pandemic is so unpredictable, I feel that it will be beneficial if there were some training or simulations on how we manage a home visit with high risk patient or family members, so that we can be more diligent and safe while going about our daily duties.
Stephanie On
Community Palliative Care Nurse
For More Information on COVID-19 and Palliative Care :
Ministry of Health Malaysia - Current COVID-19 Events
World Health Organization- Current COVID-19 Events
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