Hospice: The Gift of Dignity
By Julie Galosy
Those of us in the “third age” have little use for gifts that we just have to store in rapidly diminishing household space. However, there is one gift that is precious and is provided as a right for all of the residents of Mexico by the public health service: palliative care. Palliative care is end-of-life care not designed to cure or treat a patient, but rather to provide comfort and control pain and symptoms. It is a medical specialty that requires training and attitude adjustment for its practitioners.
The birth of hospice
In San Miguel we have a history of offering this care, first by Hospice San Miguel, founded in 2007 as one of the first full-service hospices in Mexico. During the tenure of the expat-funded Hospice, the patients were treated by a team of professionals in their homes. These professionals included physicians, nurses, social workers, and volunteers. The care-givers in the home also received training to help in the specific plan of care for their loved ones. In operation for several years, Hospice faced the challenge of all Non-Government Organizations (NGOs): sustainability. When Hospice San Miguel closed in 2014, few people knew that a parallel organization was being established within the Hospital General system. In fact, many believed, erroneously, that hospice services and highly specialized end-of-life care were no longer available in San Miguel.
We here in San Miguel are blessed with the leadership of Dra. María de Lourdes Tejeida at Hospital General. After acquiring extensive proficiency through a one-year internship in palliative care at the Instituto Nacional de Cancerologia (INCAN) in Mexico City, Dra. Tejeida, with the support and vision of the Director of Hospital General, Dr. Jorge Vidargas, opened a hospice/palliative care unit at Hospital General. She serves as the administrative head and chief physician of this unit. In addition, she has single-handedly spearheaded the effort to spread the expertise needed to provide palliative care by creating a diploma program at the University of Guanajuato, as well as several internship programs in the specialty across the northeast of the state. Those completing the 250-hour palliative care diplomado program are then eligible to receive a one-month internship at INCAN in Mexico City, where they can learn to put their training to work.
Dra. Tejeida is a gifted teacher who holds seminars and workshops throughout the region. In this way the seeds have been sown to expand the program and create expertise and treatment options. Finally, for those who prefer to be treated outside of the regional hospital system, Dra. Tejeida offers private services for palliative care patients.
With dedicated beds in Hospital General, the Palliative Care unit served more than 400 patients in 2014, its first year of operation. So far in 2015, it has served 579 patients.
The hospice experience
The process for procuring hospice services outside of Mexico is usually based on a determination by a family physician that the patient has a limited time to live—perhaps six months. The same situation is true in San Miguel. There are two avenues for being admitted into hospice care at Hospital General: referral from a primary physician, or through a referral from the Clínica de Salud located in La Lejona behind Mega at Arco Iris s/n.
Primary care referral
Once your primary care physician has determined that you need palliative care, he or she needs to provide you with a clinical summary diagnóstico y pronóstico, which includes a diagnosis of your illness and the time-limiting prognosis. This document serves as your entry into the palliative care system. With this in hand you can go to Hospital General, enter the main door, and simply make an appointment with the Palliative Care unit, Departamento de Cuidados Paliativos. From here a plan of care will be devised for you. If you have Seguro Popular, the government insurance, it is free of charge depending on the illness and the medication required. Otherwise, there is a cost; however, it is minimal. The department of social work evaluates the socioeconomic condition of the patient to determine the fees.
For example, one American patient was in the unit for one and a half months, and the cost was approximately the equivalent of one day´s stay in a private intensive care unit.
Hospital General has allocated two beds strictly for palliative care (hospice patients). Often, even if the patient has chosen to die at home, he or she may need a temporary stay in the hospital to control unusually difficult symptoms that cannot be otherwise treated at home. Afterwards the patient can return home. The plan of care might actually include this return to the home, and the family caregiver will be given instructions to follow for the patient.
Clínica de Salud referral
In the event that you do not have a personal physician or the physician does not want to give you the necessary diagnosis, the Clínica de Salud essentially acts as a primary care physician for you. They can create the diagnosis and the prognosis needed to be admitted into the Hospital General palliative care program. Once that is accomplished, they will call and arrange an appointment with the Palliative Care unit for you, and the same procedure as above will be followed. The illness must be considered terminal and the prognosis for fewer than six months to live. With this diagnosis, the referral can come from an oncologist or, in the analysis of a “failure to thrive,” from the primary physician. Armed with these diagnoses the Palliative Care unit can offer support with a plan of care in the home.
Dra. Tejeida private patients
Certain patients prefer not to go through the Hospital General system. In this case, Dra. Tejeida takes on patients on a for-fee basis. With this option, the patient might be able to remain at home. Dra. Tejeida can arrange a team of specialists similar to those offered by the original Hospice San Miguel to provide treatment and training in the home. The team includes caretakers, a social worker, a nurse, and a grief counselor.
The future of palliative care
Although currently in its infancy, the future of palliative care in San Miguel is very positive. The medical personnel attending the diploma and internship programs will expand the expertise needed for a growing program. As the Mexican population gets accustomed to palliative care as an alternative for end-of-life treatment, the government will respond with an increase in the resources available in the local hospital. Dra. Tejeida says she is looking forward to the day when there will be a separate physical unit dedicated to palliative care in all of the hospitals in Mexico. No doubt she will have a key role to play in that outcome.
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