2020; Volume 21, No 11, November

In the IAHPC Survey on COVID-19 and follow-up interviews, members described both problems and solutions. This is the second of two stories we are publishing as a result; the topic is workplace issues. The first story, published in October, was on patient care.

Workplace issues:

How Members Are Adapting to the Complex Challenge of COVID-19

By Alison Ramsey
IAHPC Newsletter Editor

Because it is such a complex challenge with so many unknowns, the COVID-19 pandemic has exposed weaknesses in the many different support systems that clinicians and caregivers rely upon. The IAHPC member survey in late spring shows that clinicians struggled with the lack of: evidence-based procedures, training, necessary equipment, essential medicines, and employers who provide the support that fosters good mental health among staff members.

Existing cracks in support systems widened dramatically, and even systems that appeared to be robust were found wanting. More than a few, however, quickly adapted to cope with a situation no one could have fully prepared for.

“There was a lot of education, but not much actual information given to staff about infection numbers, morbidity, and recoveries,” says Dr. Julia Ambler of South Africa. “We noticed a big change when management started to email all staff with daily updates.”

Scrambling for PPE & meds

“I wear pajamas from home, my tennis shoes, and plastic glasses,” says Dr. Nineth C. Baltodano Algaba in Nicaragua, who had to buy her own protective gear, which is both very expensive and scarce. “We use surgical masks, not N95. I use it all week.”

Although Dr. Ednin Hamzah’s Hospis Malaysia proactively ordered up to a six-month supply of essential medicines directly from pharmaceutical firms in February, PPE wasn’t on the radar: they were caught with only a two-week supply of surgical masks, gowns, and other gear. “From March to May there was a great scramble,” he reports. “Thankfully, we did get enough.”

The opposite was true for Felix Mokandu Angasa of Kenya, where Kenya Hospices and Palliative Care Association acquired PPE but was caught without sufficient pain relief medicines, resulting in stockouts. “Morphine powder became very scarce,” due to lockdown issues in providers’ countries, agreed Mercy Wachiuri of KHPCA. Once the government stepped in, supply was restored.

“There has to be morphine availability at the grassroots level,” stresses Dr. Babita Varkey of India. Also in India, Dr. Stanley C. Macaden reports that the pandemic revealed the strength of their decades-old “Family Driver” home care program, which offers certified training to family caregivers, enabling them to administer injectable morphine. “The Family Driver is the most appropriate, cost-effective, and practical way to help people to die at home peacefully.”

In the Philippines, says Dr. Noel Pingoy, the government relaxed its guidelines so that doctors — not just those with a special license — could write prescriptions for controlled medicines.

Connecting via telemedicine, and radio too!

“The huge drawback [of telemedicine] is that we are using our personal cell phones, which means there is really no protected time from patients at all,” says Dr. Julia Ambler of South Africa.

In Zimbabwe, Dr. Agnes Chipo Tererai has the same problem. “I wish I had a group practice so that we could take turns, and allow ourselves to get rest and debrief as a team. I still do a lot of paperwork after the phone consult; I wish I could have a computerized health system that allows me to document and keep records as I talk with patients and their families.”

To effect public education In Uganda, reports Fatia Kiyange, “we have adopted innovative ways of engaging with communities, mainly through programs on radio stations,” working closely with local health advocates.

Weaknesses & strengths
of online education

Dr. Armando Arita of El Salvador reports that weekly palliative care classes vanished when the pandemic landed, but resumed in a new form: “team chats” and sharing of useful books, guides, and manuals. Several team members are taking online workshops. “We continue learning,” he says, although the will to do so can be dulled by the exhaustion that accompanies long, draining workdays.

“Medicine cannot be taught only electronically,” says Prof. Lyubima Despotova-Toleva. of Bulgaria, “but there are many technical advantages that significantly contributed to a better quality of teaching and learning.” Prof. Despotova-Toleva an editor and author on e-education and e-medicine, highly values the mEducator program she attended that trains participants how to adapt medical education materials to instruct any level of student.

“It was a lot of heavy work,” she adds, “but nowadays the mEducator experience is invaluable.”

In the USA, Dr. Laura Morrison said that online training was poorly attended as health care workers were pulled into crisis staffing; also “many people died without family, so some training was around helping people say goodbye to their loved ones remotely.” Yet Madeleine Juhrmann’s institution in Australia unexpectedly experienced “a higher level of participation and engagement... Participants from regional, rural, and remove areas have been able to access training, where they would normally face great hurdles to receive face-to-face training. Also, online formats reduced costs through eliminating overheads.”

Stressful workplaces
hit nurses hard

The number of available nurses waned in Guatemala, a situation that many experienced as health caregivers got sick themselves or had to stay home to take care of their families, which resulted in “more work with fatigue,” says Silvia Rivas. It resulted in errors and ill-tempered nurses, perhaps especially so because, faced with a staff infection rate of nearly 22%, the administration gave days off to clinical personnel — doctors, psychologists, social workers — but not nurses.

“Despite psychological support,” says Dr. Simone Cernesi of Italy, “some staff are under a high level of stress.”

COVID-19 may provoke
institutional changes

Staff at Kees Lodder’s workplace in New Zealand collaborated on a four-page document filled with constructive feedback and suggestions, at the behest of their CEO. One issue was addressed before the CEO resigned (not for COVID-19-related reasons), and staff are hopeful that other issues will be, too.

“Many changes need to be made at the policy level for provision of complete care during pandemics,” notes Dr. Varkey.

To learn more about Kenya Hospices and Palliative Care Association, visit the IAHPC Global Directory of Palliative Care Institutions and Organizations.

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One member answered one question from our COVID-19 survey with a very personal perspective. We asked him to expand on it; this is the result.

Facing My Own Fear of Death

By Dr. Porter Storey
Boulder, Colorado, USA

In palliative medicine, the effects of the fear of death are obvious, and its cause not hard to discern. Retirement has given me time to explore my own subconscious fears and COVID-19 has certainly brought them center stage. Cicely Saunders taught us to look for the physical, psychological, social, and spiritual dimensions of our patient’s complaints, and this framework might also apply here.

My physical worries

Physically, I think less of my own bodily demise than I do of bringing home a deadly disease to those I hold dear, particularly my wife. I do not relish the idea of greatly increased pulmonary disability or neurologic sequelae either; I even cycle now with a mask. Our American inability to wear masks consistently is greatly prolonging the hardship and difficulty of this pandemic.

My psychological worries

Psychologically, the little we know about this disease makes it hard to make choices. Is it safe to travel? Is it wise do go to the clinic for preventative care? The wearing of masks is a constant reminder of how scared we need to be, and so isolating. My little brain constantly warns me when going into a business establishment that I might get COVID-19 and die! I miss my colleagues and patients terribly and dare not visit with friends indoors, for fear of passing on a lethal disease. What a strange time this is.

Social effects

Socially, we seem to be torn apart by the splintering effect of COVID-19 and fear of death. The rich retreat to their “getaways,” leaving many others to cope with unemployment and the stress of home schooling. In times of lack, tribal rivalries have always become more apparent. Those of us with enough to eat are generous where we can be, but wrestle with survivor guilt and a foreboding of doom.

My spiritual solace

Spiritually I have always found solace in nature and contact with the cycles of life. The terrible forest fires in the western U.S. bring the destruction of our life-giving forests into my home. It is hard to breathe. As I ponder the teachings of the mystics in many religions, letting go of our egoic clinging entails opening up to our subconscious wounds.

I am trying to befriend my death fears like the Buddha did with Mara, his tormenter. I have a long way to go!

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