Dr. Ruth Powys is a palliative care specialist working with EMMS International’s partner INF Nepal at Green Pastures Hospital in Pokhara. Here she gives us an insight into how coronavirus is affecting her work and the communities she serves. She begins by sharing the story of a palliative patient whose care was affected by the impact of coronavirus:
Rahi’s story
Rahi relied upon regular visits from the community palliative care team. His condition was deteriorating rapidly when the coronavirus outbreak began, and his cancer had left him paralysed for the past six months. He had been managing to control his pain through regular low dose morphine. He was happy to be at home and, despite their poverty, the family were able to offer caring support. The COVID-19 lockdown made oral morphine unavailable. Rahi died without access to the essential pain relief he needed. When restrictions on community visits eased, the palliative care team were able to visit his family. His wife shared that the morphine had run out a few days before his death; his pain and distress had increased and, before he died, he was very distressed and asked to go to hospital for relief. He died in the ambulance going to an acute hospital. We are shocked to discover this “COVID-effect” where people with chronic disease needing regular care and medications are negatively impacted with increased unnecessary suffering.
Dr Ruth’s observations of the “COVID-effect” in Nepal
What does your job typically involve each day? How has this changed with COVID-19?
Working with a team, developing our palliative care service through inpatient and community services, with significant training and research keeps us all busy. COVID preparations have caused us to fast-track some aspects of our palliative care development. Since 24 March, the Nepal government imposed an early, strict lockdown, closing borders, restricting all travel, closing schools and offices, and only allowing essential services to continue functioning. People are required to stay in their homes, and this has undoubtedly helped delay the spread of the virus. At Green Pastures Hospital, although we are not a designated COVID centre, we have been preparing to safely continue caring for our vulnerable patient population as well as staff – as anyone could potentially be infectious.
How do you use your palliative care expertise to care for COVID patients?
If patients with COVID have more than a mild disease, they can have many palliative care needs. Breathlessness and agitation are common, and for those who are elderly or with other pre-existing conditions, there is an increased risk of early death. Due to the danger of transmitting the virus, patients and families may need to be separated at a very critical time of life – so present and future grief and loss can be amplified.
How is COVID-19 affecting your region?
We are still in the “waiting” phase as no confirmed clinical cases have been found in Pokhara yet. Nationally, the number of proven cases is currently 772, and increasing, with four confirmed deaths. Numbers tested are growing but are still relatively small. There is a concern now that people with other conditions are not able to access usual treatment, so the risks from other chronic diseases are increasing. If a condition is not considered an emergency, it is difficult for people to attend clinics or hospital during the strict lockdown. The economic fallout is already significant, especially for daily wage earners who may be unable to return to their villages and families. There is no social security backup system, so a lack of food due to no income is currently a more dire and direct threat than COVID for many.
In what ways is your hospital ready for the escalation of COVID-19?
INF set up a high-level task force to advise re decision-making. We have set up hand washing and temperature checks for everyone entering the hospital grounds. All staff have had additional training in the appropriate use of protective equipment, and further stocks have been sourced to supplement stocks of protective gowns and visors. New fever clinics required by government are functioning out of tents, and we have two potential isolation areas if needed – one for acute care and one for end-of-life care. The PC team has been providing extra training covering areas like safe care of deceased bodies (for our staff and also for community groups like churches); use of syringe drivers; end-of-life symptom management; and good communication skills over the phone or from behind a mask.
What challenges do you face in your day?
There are many challenges of developing ongoing services in such unusual and rapidly changing times – construction work on our new Palliative Care centre of excellence is now delayed; staff appointments are postponed until there is more stability, for example. The government closed all community work which stopped our community visits and made it hard to support vulnerable people at the end of life. We are glad that, after five weeks, we were able to recommence some local visits again. Some future planning revision will be needed – as it is unlikely to be able to send staff to India for PC training for some time – so we will need alternative ways of training and upskilling our new staff.
The PC team has had many unexpected opportunities for providing extra training and staff support, increasing a palliative holistic approach relevant both in this potential crisis, but also for everyday ongoing compassionate care.
What lessons learned from other emergencies have helped prepare you for this crisis?
Nepal has faced many disasters and crises – the Earthquakes 5 years ago; border closure; civil war; natural disasters with floods, landslides etc. The community’s experience and memory are that disasters do pass, and people do recover.
What causes you to worry?
Vulnerable people not accessing adequate food, routine medical care, or needed end-of-life care. Risk of the virus spreading and developing into a long-term crisis over coming months exacerbating the current economic challenges.
What keeps you going in the face of a crisis?
God’s grace and encouragement. Our team working together.