Masterclass 12 - Palliative Care from Hospital to Community

Motor neuron disease (MND) is a relentlessly progressive and incurable neurodegenerative disorder leading to muscle weakness, disability, and eventually death. MND patients have heterogeneous clinical presentation, depending on the population of involved motor neurons. MND may first manifest as weakness in any body segment including the bulbar, cervical, thoracic, or lumbosacral region. The disease progression and survival of MND patients are also variable. 
 
With the liaison with different subspecialties, an integrated MND clinic was established at Caritas Medical Centre (CMC) in 2015. The core team members include palliative care physician and nurse, neurologist and neurology nurse, respiratory physician and nurse, and medical social worker. Based on the needs of individual patients, other allied health teams would be involved. Case conferences are conducted regularly for team members to share information and to determine the management plan.
 
The arrangement of a one-stop integrated clinic aims to lessen patient's burden of multiple hospital visits and to improve compliance, especially at the later stage when patients have significant symptoms and limited mobility. Home visits are conducted by palliative care nurses between clinical visits to monitor their physical symptoms, psychospiritual distresses and social needs, as well as to offer support to their caregivers.


This presentation highlights the key findings of a recent local study conducted to assess the impact of an integrated multidisciplinary clinic on MND patients. Case illustration showcasing MND patients who received palliative care will also be included, highlighting the multidisciplinary approach employed in addressing the complex needs of MND patients. By focusing on holistic support, effective symptom management, and patient-centered care, the quality of life of MND patients and their families can be significantly improved.

Hong Kong's high life expectancy is juxtaposed with its relatively low ranking in the quality of death index. While recent improvements have been made, Hong Kong still lags behind neighbouring regions such as Taiwan and Singapore in terms of home deaths and legislation on advance medical directives (AMDs). Efforts are underway to address these challenges through the submission of legislative framework for advance decision on life-sustaining treatment and relevant amendments related to ADMs and dying in place.
However, significant hurdles remain, including inadequate community care support, caregiver burden, environmental and financial concerns, and an increasing demand for palliative care home service. In this talk, we will explore the critical role of medical social collaboration in facilitating end-of-life care in HK. We will discuss models of collaboration and various options of EOL care in the community.
Moreover, we will highlight the positive impact of a regional palliative care unit that leverages medical social collaboration to assist terminal patients in their final stages of life. By showcasing successful examples, this talk aims to inspire and encourage healthcare professionals, social workers, and policy makers to prioritize and strengthen medical social collaboration in order to enhance EOL care in Hong Kong.