A journey into palliative care

Dr Howes' first experience with palliative care was during his elective in medical school which he spent in hospice where he gained an appreciation for the holistic nature of symptoms control in palliative care.

After medical school, like most South African doctors, he spent time in internship and community service in the Ekhurhuleni District. During this time, he got to understand how palliative care was not adopted in hospital care. Noticing patients were not receiving comfort care or were being resuscitated unnecessarily led Dr Howes to speak to patients, gathering evidence that families wanted to be informed about end-of-life decisions.

In this environment, he was able to challenge the approach to palliative care through collaboration with the internal medicine department. This resulted in a reduction of additional tests and interventions. He subsequently took on a project to qualitatively document the decisions made at the end of life in the hospital setting.

After community service, Dr Howes started as a locum professional at a palliative care practice and completed a post-graduate diploma in palliative care. Sadly, he experienced a bereavement himself at this point; however, this really helped to understand the more psychological, social and spiritual aspects of palliative care.

Since then, he has been in palliative care in private practice, which he notes is "a happy coincidence between personal values and ethics". This has been an environment in which he feels secure and competent but also has space to learn.

Starting the conversation about palliative care

Dr Howes' typical day includes home visits and GP practice. He is limited to seven patients a day to make sure he doesn't experience compassion fatigue.

He tells us that there are three scenarios that he experiences in his day-to-day work.

The first scenario is where the family that is ready for a conversation and where he'd largely just listen and try not to be directive. These patients are often already seeking hospice care.

The second scenario is a family that can start the conversation but is not ready for hospice, but perhaps will be open to seeing a supportive care specialist. "This area is very rewarding as you get to be honest and direct about the medicine and integrate the understanding of loss," says Dr Howes.

"The last group is families we may see in the bereavement stage or in the last few hours of their life. . They often never integrate the idea of dying into their reality." Consults with palliative specialists are often driven by the family. These families often struggle with complicated bereavement.

The Advanced Illness Benefit

In partnership with HPCA (Hospice Palliative Care Association) and PALPRAC (Association of Palliative Care Practitioners of South Africa), Discovery Health Medical Scheme's Advanced Illness Benefit is designed to provide appropriate care and dignified choices to members at the end of life.

With the support of a dedicate care coordinator, a medical adviser and a clinical team, members have access to a comprehensive basket of care that is paid from the hospital benefit. The basket of care includes a comprehensive list of medication required in palliative home-based care. Counselling support and quick authorisation of oxygen is also offered as part of the benefit.

Eligibility is determined by entry criteria based on prognosis in the next 6 to 12 months. Referral networks include palliative care doctors and various hospices.