INTRODUCTION
Our hospital, which is a district general hospital located in the north of Singapore, started a pilot program using telemedicine as a tool to provide care for residents in nursing homes. We commenced the service in late 2010 with the installation of a dedicated broadband-based telemedicine communication system (comprising monitors, cameras, and a microphone system) with a nursing home cum hospice run by Catholic nuns from the Canossian Order. This service comprised telemedicine consultations (tele-consultations), multidisciplinary team meetings, mortality audits, family conferences, and nurse training sessions. The objective of this program was to improve care in nursing homes and reduce unnecessary admissions to the acute care hospital, especially for those residents near the end of life.
CASE REPORT
The patient, Ms. C, was a 92-year-old woman with a history of hypertension, Stage 4 chronic kidney disease, psoriasis, chronic anemia, urge incontinence, diastolic heart failure, hemorrhoids, and osteoarthritis of the knees. She had been admitted to another acute care hospital in February 2012, after a fall which was complicated by a right intertrochanteric fracture. The patient and family opted for conservative management of the fracture. She was subsequently discharged to the aforementioned nursing home, within 4 days of admission.
While in the nursing home, her general condition deteriorated, she became more frail and dependent, and spent most of the time in bed. As part of advanced care planning, she chose not to be transferred to an acute care hospital in the event of an acute illness.
On the morning of April 30, 2012, she developed sudden-onset breathlessness. The nurse manager of the nursing home took immediate action by administering intranasal oxygen and arranging for an urgent telemedicine consultation. The patient was seen via the videoconferencing system within the hour. The nurse manager at the nursing home, who was trained in conducting tele-consultations, assisted in this urgent care session. At the start of the encounter, the patient was noted to be breathless, pale, and tachypnoiec. She was, however, conscious, and able to indicate that there was no chest tightness or discomfort. An electrocardiogram (ECG) was obtained, which showed sinus tachycardia with no changes indicative of pulmonary embolism or acute cardiac ischemia. However, as the ECG leads were being removed, the patient became obtunded and began to develop “labored” breathing. Her condition progressed within a short time frame with her breaths becoming slow and shallow, heralding the onset of the “active dying” phase of her illness. The pastoral care staff, a nun, was summoned immediately and the family was informed of the patient's imminent death. As the patient was a Catholic, the pastoral staff prayed and sang hymns for her in her dying moments. The attending nurse manager proceeded to clear the bed of the ECG wires and other clutter and make the patient as comfortable as possible.
Ms. C died peacefully within 20 minutes of commencement of the consultation, in the presence of the nurse, the pastoral care worker, and the palliative care physician, who observed and guided the proceedings from a distance, via the telemedicine communication system. Unfortunately, the patient's family did not arrive at the patient's bedside in time.
Death was pronounced at 1100 hours via the telemedicine system, as being caused by acute myocardial infarction.
On arrival at the nursing home, the family members felt reassured and expressed relief that a physician had been on hand to manage the patient near death. Although the physician had not been physically present at the patient's bedside, he had been “present” (in a virtual sense) through the telemedicine communication system, and had been able to give guidance on the management and care of the patient until the moment of the patient's last breath. The family, although not expecting their mother (the patient) to die, was comforted to know that she had not died alone, but in the company of a team of professional caregivers and, especially, that there had been medical supervision during the time of the patient's death. The general practitioner (GP) who subsequently signed the certificate of the cause of death at the nursing home felt that the “presence” of a physician at the patient's death helped him sign the form with confidence, and proposed that this should be the practice for all deaths in the nursing homes. The stakeholder who felt the most benefit was the nurse who assisted in that final consultation. She felt empowered to care for the patient in a calm and confident manner knowing that there was someone “guiding” and “supervising” her in the task of preparing for the patient's death, albeit from a distance. She concluded that the patient had had a “good death” in the nursing home.
DISCUSSION
There is a growing trend toward the use of technology in healthcare today. Similarly to how technology has come to play a large role in our daily lives, the use of web-based applications such as Skype and other Internet-based telecommunications systems and social media such as Facebook is becoming more common in the field of palliative care (Cleary, Reference Cleary2011). Battley et al. (Reference Battley, Balding and Giligan2012) reported how a young Hungarian woman in her late 20s, dying from lymphoma, used Skype to keep in touch with her partner and their two children in Cork, while also staying in touch with her mother in Hungary, during her final days in the hospital and immediately before her death. However, the Skype connection was withdrawn at the time of the patient's death to spare the patient's mother the agony of seeing her child die right before her eyes.
Ms. C was an ailing elderly woman who had led a full life. She was a staunch Catholic who had given her son and daughter to the lay religious work of the Church. She and her family had earlier decided that she should spend her last days in the comfort and care of the Canossian Sisters, who ran the nursing home where she had been living. We were summoned to see the patient on the morning of her death unexpectedly and outside of the planned schedule of regular weekly tele-consultation sessions. The patient had become breathless and tachypnoeic suddenly that morning. We chose tele-consultation over an in-person visit, which would have required us to drive nearly 30 km to our destination. On a good day the journey would have taken 30 minutes.
As the patient went through the various stages of death, events occurred rapidly and in quick succession. We were witnessing a compression of the dying process from a distance: losing consciousness, pallor, cold and clammy skin, labored breathing, mottling of the skin, and “the death rattle,” the last breath. In the words of the first author (JAL), “It was surreal but it brought us so much closer to the scene of that final event of life.” Even as palliative care physicians and geriatricians working among the dying and immersing ourselves in death, very seldom do we find ourselves actually being with the patient right until the last moment, when the patient breathes the last breath. More often than not, we see the patient struggling with symptoms and the family trying to cope with the pain of seeing their loved one die. Very rarely do we witness the final moment that separates life from death in the acute hospital setting. Witnessing “the peaceful cessation of life” can bring much comfort and closure, not only to patients' families, but to the professional caregivers as well. In retrospect, we made the right decision about using our telecommunications system, as the encounter with the nursing team and the patient was “just in time.” If we had taken the “physical visit” path, we would have missed being with the patient and the nurses at the all-important “last moments” of the patient's life.
We believe that technology could be harnessed to bring patients and families closer to each other and allow the healthcare team to be “closer” to the patient and the family as well. The possible applications are countless, such as in symptom management, advance care planning, clinical audits, interdisciplinary team meetings, continuing medical and nursing education, and many other areas. The use of social media and blogging is also fast becoming a means to cope with grief and bereavement (Petrecca, Reference Petrecca2012). Telemedicine could have a role here as well.
Our hospital is undertaking a research project using telemedicine to provide better care to nursing home residents by conducting the abovementioned activities. Apart from providing good care to such patients, our goal is also to reduce unnecessary transfers and admissions to the acute hospitals, thus allowing our residents to die in their preferred place. The concept of “dying in place” is gaining traction in healthcare, especially in Singapore where the population is the most rapidly aging in the world.
CONCLUSION
It is important to point out that the tele-consultation process can never replace the real physical encounter between clinician and patient. The warm touch, the hug, the wiping away of tears can never be performed remotely. Neither can it be conducted by proxy nor will it ever be anywhere close to real physical touch and the presence of a human being. However, between a telemedicine encounter or worse still, nothing at all, the former could act as a better bridge between patient and physician or nurse.
