Photo: Elena Martyanova
Head nurse and coordinator of the three branches of the medical center “Bytes BA Lev”, a specialist in palliative care Gaya, Vachan Hayat told “” in Israel are staff working with those who need palliative care.
In the medical center “Bytes BA Lev” three offices: 80 people connected to the apparatus of artificial lung ventilation (ALV). This is not the ICU, and not the palliative ward and some patients, after the respiratory rehabilitation out of here and back to normal life. But the majority of palliative patients.
“People can live at home, he from the Ministry of Health, for two nurses, and necessary equipment”
– You have a degree in nursing. You have received some additional information in the field of palliative care?
– Yes, of course. I was trained on the course “Specialization in cancer”, and then another separate course in palliative care. And for 10 years I have been helping patients on artificial lung ventilation.
– In Israel, many patients with IVL, much more than officially in Moscow. We think that these patients die in intensive care units or at home, not receiving palliative care. When and how do you come to understand that these patients are many and they should not be in an intensive care and in a specialist unit?
We went to this for a very long time. The first centers offices IVL appeared 14 years ago, and there were also a few people. But our population has increased and aged, and we saw that the demand is growing. Then began to open such centers as ours.
80 patients on the ventilator. What diagnosis are these people doing?
– Very many cases have BASS, with diffuse lung injuries, many PTSD patients after accidents for example. There are patients after surgery who have developed complications. There are those who tried to commit suicide, as a rule, young people, and it’s very sad.
– Who decides on the transfer of the patient on a ventilator?
– While the person is in the hospital, according to the Protocol, the doctors are doing all that he was breathing on his own. If the patient can not breathe, the head of the department must have a tracheostomy. Some time the patient tracheostomy is still in the hospital, and the doctor keeps trying to get him back to normal life. And only in the case of exhausted efforts, the patient is admitted with a tracheostomy in our Department. We have all patients with tracheostomy. At the same time, we are not all patients palliative.
There are patients who are we respiratory rehabilitation, after which the tracheostomy was removed and they breathe on their own.
– Is it possible to transfer the patient with the ventilator home from the hospital?
– It does not happen often, but Israeli law gives such an opportunity. A person can live at home, he from the Ministry of Health, for two nurses, and necessary equipment: bed, chair, ventilator and consumables to him.
– All this for free?
Yes. Everything about the ventilator, and its maintenance and purchase of consumables. In addition, we are in our offices. And if conditions allow the patient to live at home, tested and meet all the requirements of health and safety, only in this case, we can let go of the patient’s home.
– What conditions have to be home?
– First, the electricity must be uninterrupted. Secondly, the apartment should be provided with transport wheelchairs in the bathroom and the bathroom. It all checked. And relatives to be prepared.
You have not a lot of patients going home with a ventilator. Why?
– We are sick were they wanted to live at home and their families. Of course, we support people in their desire to live at home, if the opportunity they have at home, as they say, and walls are treated, and yet. But not always, these components are the same – sometimes people want to go home, but at home, absolutely no conditions. And not all families can take on this responsibility. I have a patient who does not want to go home because he is afraid.
“The man who has no empathy, can not work with such patients”
– How much time a patient on a ventilator may lie in your Department?
– A very long lie here, sometimes for five or six years. That is, for them it’s basically house. If it is not possible to define them in any other home environment, then they remain with us until the end of life.
If the person is unconscious, there is needed more work with his family. Because the family is in a very difficult position, until they get used to the idea that their loved ones will not return to consciousness. We try to surround the house. It’s a TV, a radio player with your favorite music. Or it could be photographs, paintings that people.
To surround the person’s maximum attention and care is something that we can and should do.
Even if he is not conscious?
– How often such a patient can come related?
Very often. There are those who come several times a day, alternating. If the family lives far away, to the extent possible, but most patients come home every day. So, one of our patients every day comes the son, brings a fresh newspaper, prays together with the Pope, talks to him, talks about the latest political news. Another patient is very attached to our team and sometimes prefers about some household service. A man chooses what he prefers.
– And how do you teach the staff to communicate with patients unconscious? After all, many novice employees will not perceive the person in such a state as a complete person – I’m sorry for such words, we get that a lot. Do you have any standards or protocols?
It is very heavy, of course. Every time and at a staff meeting, and when you crawl, I tell my employees: “Treat patients the way you have approached yourself.” So you should always see the person. Unfortunately, in everyday, routine work is forgotten. When this happens, I, as a leader, always react to it. Sometimes having a conversation with you privately, sometimes publicly in the meeting, apart from the specific names, and then people are not offended, but understand their situation and begin to understand what needs to change. In addition, we have conducted various courses for the senior, the Junior and nursing staff: how to treat patients, which they have rights, morally, ethically to approach a range of issues. We had this course. Someone was lying on the bed blindfolded, and he made manipulations – people felt, how hard it is, what is it? In General, this experience is instilled in this way: if you have not seen, do not understand the patient. There are a course of empathy, which teaches our employees, and it is very important.
– That is, empathy should be taught?
– Yes, it is necessary to develop and need to know how to do it. I believe that the man who has no empathy, can not work with such patients.
– And how do you deal with the emotional burnout? How do you keep employees?
– Emotionally burn out. But again, you need to understand that this is your job, and if you used your resources. It gives us strength. But if from the Department is issued a man-we just had a holiday coming, it’s tears of joy in the eyes of employees.
In such offices, like ours, not all patients on mechanical ventilation are palliative. There are patients who are undergo some rehabilitation in this period are with us, and then we transfer them to other departments. One patient recently was a respiratory disease, then we have disconnected from the machine, took out a tracheostomy, and is now an independent person. Sometimes comes to us through the office, greeting the staff, of course, happiness.
Often we go on the office on trips, spend some small parties, and this fellowship gives me strength.
“We go not only to palliative patients, but to anyone at our hospital who need pain relief”
– I know you pay much attention to anesthesia.
– We believe that people should not suffer and that we can make sure that he did not suffer. I can not promise that I will not be able to promise a patient that has come to me in the office. This is very important. We have patients who are unable to talk about their pain, but there are scales on which we determine their pain. Our entire team knows how to use these scales: and nurses and doctors can identify the pain and find patient pain medications. At this point.
– How often do you assess the level of pain the patient?
– If the person only did we. Then, as a rule, evaluate his condition in the morning and evening, but if necessary, the change can be assessed several times – for example, if the patient is unstable, and we picked up the pain is optimally suited for him.
– I heard that you have inside the hospital there is a palliative care committee, which decides on the use of narcotic analgesics?
– Yes, it’s palliative care forum: the physician, the nurse, the director of pharmacy, social worker, physiotherapist, nutritionist and psychologist need. We develop different protocols that are all of our hospital. Call us as required in an office. For example, recently I was asked to help the team, who could not explain to the family. The nurse brought the patient the pills, he took them, but continued to experience pain. It turned out that he did not drink, the drugs, and his wife. Health workers talked to my wife, but she was unable to convince her that these drugs were necessary. I had a long time to talk with her and explain that she would not be able to stand up. And it was necessary.
But it was not a palliative patient?
– No. After all, we go not only to palliative patients, but to anyone at our hospital who need pain relief.
– How are decisions about palliative sedation?
“Intramuscular injection we do not use because it hurts”
It is a very difficult decision, and not all doctors, especially at the beginning, was for this method. But little by little, everyone understands that it is a necessity. We have developed a Protocol that is suitable palliative patient and which is determined in addition to morphine with the task of sedatives suppress the patient cope benzodiazepines. In addition, can be used symptomatic medication, such as vomiting and nausea. But the main drug is midazolam. We have a protocol under which we operate, and the doctors know how much to give and at what point, it uses a special scale that determines the consciousness of the patient. This is very important.
There are patients who say: “I want in certain hours, when I come, my family, to be awake, the rest of the time to sleep.”
They are those who are very hard, they suffer, they do not want to see yourself, see others, relatives and ask to make sure that they have not seen anything and not heard.
This happens in the last weeks of life, and here the individual approach is important to the person. Of course, in such a situation we are working with the patient and family to come to a common denominator.
“It is important to explain to friends that a palliative is not some kind of euthanasia”
– And how do you cook for difficult decisions?
– The family is cooperating with us. By law, we have the right to palliative care for the patient. We should tell the family what the palliative care is and why it is needed. There are families who understand the need for it, and there are others who believe that palliative is the road to death, and it is difficult for them to accept such a situation. And from our side, it is important to explain to relatives that it is important to understand that it does not affect the quality of life. No matter what stage the patient is located.
“If we call at night, it means we did a bad job day”
Recently we had a patient in the last stages of the disease, and despite this, we’ve talked a long time with the family and explained what was happening to her. Son was that the mother continued to treat, and to the last was sure that she needed a drastic medical intervention, but then realized that nothing can be done. There are families, who still need to be treated, the problem is, it is necessary to treat all the nuances.
– That is, from a religious point of view, need to last to treat?
– Yes, because everything from God and God decides when a person comes to die.
– But you have a palliative patient.
– Yes, it is. It all depends on what stage of the disease. He may be hemodialysis or a blood transfusion, can be done by a course of antibiotics.
– I have heard that you have a service that performs a small and essential desires of patients.
– Yes, we have emergency desires. Recently it came to me the son of one of the patients.
It is in Israel, on the sea. When I heard that, I thought that we can help him. Now we are dealing with the ambulance of the wishes on this issue. This is not always possible, of course, because the patient must be in such a condition.
– After death you support a family?
– Of course. Many people hospitalized here for years, and their families perceive this. People get used to each other, and caring man. I, as head nurse, talking to the family, and helping them in obtaining some documents in the state, we have a mashgiah, a religious man who deals directly with the question of the funeral. Our social worker must call the family. If a family has long-standing relations, we will visit her. Religious customs the family is the seven days at home. We send a letter to the family from our center of love.
Is it a random letter or some harvested?
– There is a prepared Protocol, but it is also very important to obtain such a letter from the center, where the closest person.