As a young palliative care Medical Resident in her native Bangkok, Thailand, Pratana (goes by Noi) Kosolnakorn often used the Palliative Performance Scale (PPS), a clinical tool used to measure and assess patients' performance and developed by Victoria Hospice, which has been translated into seven languages and used around the globe.
In 2012, when Noi had to choose her elective rotation, she did something her Thai peers viewed as exceedingly bold. Aware of Victoria Hospice though the PPS, she decided to fill out the “Contact Us” web form on the Victoria Hospice website to enquire about the possibility to doing her elective halfway across the world. “The next day I heard back from Dr. Christine Jones,” remembers Noi. “With that one click, my life trajectory changed forever.”
Dr. Noi is now concluding her third visit to Victoria Hospice. She has spent the last six months observing clinical administration, following a Year of Added Competency in Palliative Medicine and as part of an 18-month Clinical Fellowship. She is heading back to Bangkok on New Year’s Day. “I’m very excited and sad at the same time,” says Noi.
We sat down to ask about her plans, what she’s learned here, and what she will miss most.
Q What are your plans when you return?
A The first thing I’ll do is eat Thai food. I really miss the spicy dishes back home. I won’t be able to work until my stomach is filled with the spicy food I’ve longed for!!
Then I will reconnect with my team. Before I came here, I was one of the team members in a palliative care consult team. I want to learn what they have done and developed so far, share my training experiences with them, and find out together what can be applied to our context.
My dream and my near-future goal is to set up an inpatient palliative care unit in my hospital. This is a big exciting and challenging project in my country as this is quite a new concept for us.
Q How is hospice palliative care different in Thailand?
A It is different in many ways at various levels.
In my experience, at the societal level, Thais are less autonomous than Canadians. This means that it might not be necessary for Thais to be the person who takes control in every aspect of our lives. For example, patients sometimes rely on their families to make medical decisions for them in order to please the majority of the family members regardless of their own true wishes.
In my opinion, this is another way of viewing patient’s autonomy – they choose to relay their power to their loved ones. Moreover, Thai families work as tight functional units. Therefore, the conversation around goals of care and preferences at the end of life usually happen with family members (+/- patients) rather than with the patients alone.
At the systemic level, there are very few inpatient palliative care units in the country. And among those few places, none of them operate as a tertiary palliative care unit. In addition, modern palliative medicine – meaning the integration of medication – is not largely accepted. In addition, the support system for informal caregivers is not well-developed resulting in relatively low death rate in the homes.
Looking at the religious aspect, Buddhism has significant influence on medical decision-making, including whether or not to receive opioids. They believe that opioids could cloud their minds, which is not a side effect many Buddhists would welcome. Therefore, many people, including the medical professionals, still view palliative care purely as psychosocial care, not medical.
Q What have you learned at Victoria Hospice?
A Of course, there are so many things I’ve learned and observed so far.
Apart from the medical knowledge and skills I’ve learned, I think building a team that works as a family is the thing I most appreciate. I believe that this is the key to everything else. I feel that almost everyone (I can’t say everyone as I don’t know them all!) at Victoria Hospice seems to be happy while working. Everyone collaborates and cares for each other as all are part of a big family. I’ve seen some other places where people with good hearts were not happy with their good work, partly because they were not working in this ‘home-like’ environment.
The other observation I’ve had is the importance of not just collaborating within the organization, but working with others outside Victoria Hospice. Working with people like primary care doctors, home care nurses, or other specialists is what Victoria Hospice is very good at. I think this is very important for providing the best care for the patients.
Last but not least, I appreciate the meaning of ‘opportunity’ more. I’ve been given invaluable opportunities from many people here which allow me to learn things I’ve never experienced. And I think this is an important thing that I’d remind myself to give to other people or the younger generation whenever possible.
Q What will you miss about Victoria Hospice specifically and Victoria more generally?
A Without having to think, everyone here will be deeply missed!
I’m so grateful for the opportunity of knowing you all. Everyone I know is very nice, kind and supportive. All of you are part of my memorable journey here and I just want to take this opportunity to express my sincere appreciation to you all.
For Victoria, I’ll surely miss the charm, peace and quietness of the city – I won’t have this in Bangkok! But mostly, again, it’s the people I will miss.