Providing palliative care in rural settings brings unique rewards and challenges. While many aspects of the care that rural practitioners provide are similar to that of our urban colleagues, the nature of practice in small towns and rural settings dictates some significant differences.
The likelihood of knowing our patients outside the professional sphere is greater, and we not infrequently find ourselves caring for friends, their families, and colleagues. Absence of direct access to specialist palliative care services mean that much of our patients’ end-of-life care is provided by generalists – GPs, hospital doctors, domiciliary nurses, rural and remote and hospital nursing staff. Geography and distance may require innovative solutions, reliance on telephone consultations, and sometimes admission to hospital earlier than would be the case in urban centres.
Reflecting on my own practice, a special person who exemplifies many of these aspects of rural palliative care comes to mind. Louise was a mother of four, very close to me in age, who lived over an hour from our rural hospital. I knew her reasonably well as I had been involved in her care in her last two pregnancies. I remember her distress as she presented to ED just before Christmas, with a breast lump. She had to wait out the Christmas break before she could access assessment at the regional centre. Surgery followed the diagnosis, and I assisted at her operation in our hospital. Over the next five years, she underwent chemotherapy at the regional hospital, as well as in the satellite chemotherapy unit in the local hospital in which I worked.
As her illness progressed, her symptoms were managed with a combination of hospital visits, phone consultations, and liaising with the rural and remote nurse in her town. Louise knew better than I did as she came into hospital two weeks before her death that she would not be returning home. I found caring for her over the years was simultaneously rewarding and confronting on both a personal and professional level.
The rewards that come with this ability to provide our patients with holistic care “from the cradle to the grave” are immense. However, maintaining our ability to continue to provide effective care when faced with patients we know well requires self-awareness and self-care. So how do we manage this? Some of the factors that are important in maintaining our effectiveness as clinicians include:
- Recognising that it is alright to care. “Compassionate caring” – the ability to engage with our patients on a deeper and more meaningful level – has been shown to decrease stress, burnout and depression in clinicians (Dr Robin Youngson – Time to Care)
- Utilising a team approach – recognising that no one person can meet the needs of a patient and family in the palliative setting
- Creating links with specialist colleagues, and utilising them as a “sounding board” when faced with difficult palliative dilemmas - especially helpful with patients with whom we have a close relationship, or identify with
- Self-care – formal and informal debriefing, having your own GP
- Utilising online resources and chat forums to decrease professional isolation – CareSearch, Decision Assist, Australian College of Rural & Remote Medicine RRMEO
- Ongoing education which can increase our capacity to provide care and decrease feelings of helplessness when faced with challenging palliative issues (PEPA, CPCRE).
Dr Liz Hawkins is the Senior Medical Officer in Atherton, QLD.