Category Archives: Medical Matters

Palliative Care in the Home

A Filipino Experience

On the heels of last week’s Bruce’s Blog, about caring for a loved one in the home, we publish this week an excerpt from Bruce’s book, The Freedom Handbook for Living & Retiring in the Philippines, written by the adult child of a terminally ill parent who nursed her while living at home in Manila.  The event occurred several years ago, but the story and the advice are still totally applicable:

Margie’s Experience
Caring for a Parent
When we first got the diagnosis that Mom, in her eighties and very active, had colon cancer it was not only a shock, but we also had the hope and expectation that she would get better. We had hoped that she would be able to go through chemotherapy and radiation, which would bring her into remission, or perhaps even a total cure. Sadly this was not to be, and instead we were faced with a steady decline in her strength. Mom remained positive and strong throughout her illness, a testimony to her faith and all the people she cared so much for.
Early on the doctors asked me if I wanted my mom to know exactly what was happening.
I can only say that the decision I made at the time was what I felt was best for her and for our family. My mother was always fiercely independent. I felt that she would want to know exactly what was happening to her, and that she was perfectly capable to make the decisions she felt most comfortable with. She was also very intelligent, and I was sure that if we tried to keep things from her, that she would figure things out on her own . I felt that we needed to be able to trust each other, not knowing what might face us.
However when Mom had to have a stoma, the doctor did not seem to think that she would be able to have surgery at a later date to reverse this procedure. The stoma would be permanent. I asked the doctor at the time to keep this information from her, which he agreed to do, as he and I both hoped she would have an easier time getting used to this new way of life if she felt it would be temporary. We would break the news to her a little bit at a time, to give her a chance to process and deal with it.
As my mother was in the recovery room, having just had her stoma surgery, the doctor came out to talk to me and gave me the worst diagnosis I could have heard. I was totally unprepared for it. He tried to soften the blow as he stated that the extent of my mother’s cancer was worse than they had thought, and that it was his belief that she would only have three months left to live. Chemotherapy was no longer an option.
We stayed for quite a while in the hospital after the surgery; a few weeks. Mom made the decision that she would like to go home, and not return anymore to the hospital. In order to comply with that desire, I set up her bedroom at home as a hospital room, and I hired four nurses who would work in shifts, but live at her house for the duration. I organized with the hospice for amazing palliative care doctors to come regularly to visit mom at home (Editor’s Note:  please refer to the Index of Professionals, “P”, Palliative & Hospice care for recommended institutions). I had no idea what I was doing at the outset, but by the the end of the experience I can say that I was an expert at managing this situation.
Should you want to do the same for your loved one as I did with mine, I would like to share with you a few suggestions:
As a family prepares to take the patient home, on the day of discharge, the hospital gives them a list of medications and supplies necessary to care for the patient. The day that a patient is being discharged is already a stressful day; it is not a good day to run all over town looking for the things that you need so that the patient remains comfortable. In order to prepare for a smooth transition, request that this list of medicine and supplies be given to you a few days in advance of the patient being discharged. This gives the family a chance to get everything ready beforehand. This would make the move from the hospital to the home smoother and less hectic for all concerned. Also, you will have whatever you need on hand so that the patient does not have to suffer while a needed item is obtained from somewhere else.
The hospital should also provide you with a list of all the pharmacies in your area (especially the ones which are open for 24 hours) so that the family is not hunting around, trying to find what they might need. Perhaps a survey should be taken of where to buy certain medications the patient might need, as I found out that not all of the pharmacies have a steady supply of medications needed for I.V. use.
Lists of suppliers, complete with phone numbers and addresses, can be obtained from the hospital as well as their recommendations for suppliers of things such as oxygen tanks, suction machines, hospital beds, I.V. stands, and an ambulance service (Editor’s Note:  ELRAP highly recommends Lifeline Philippines as an ambulance service, please consult Index of Services & Supplies for contact information as well as last month’s Medical Matters blog). Some of these items may not be needed immediately upon leaving the hospital, but the need may arise once the patient is at home. If an emergency happens, the family is left in total panic as they are unprepared to obtain the items they will need.
When we first left the hospital, they suggested that I get some of the medical supplies from Bambang (in the old part of Manila). Although they had quite a lot available there for lower prices than in Alabang or Makati, I did find that it was not always advisable to buy too much of any item since things change, and you sometimes end up with too much of one item that all of a sudden you don’t need anymore. Also some items available in Bambang were of inferior quality, and caused more anxiety than the savings were worth because you could never depend on them. For instance in the case of the stop cock used for the I.V., the ones that I got from Bambang would break constantly, and start leaking, so they had to be changed more often, and ended up costing more.
If the family will need a nurse or a caregiver, or both, once the patient is at home, they should already have found, interviewed, and hired these people while the patient is still in the hospital (Editor’s Note: for Nursing Services, please refer to the Index of Professionals “N” Nurses (readers who would like to recommend a service, please send us an e-mail with the information to (we will have your recommendation vetted with much appreciation), otherwise, we would suggest consulting the local hospital for nurses and/or caregivers). The nurse and/or caregiver can learn directly from the doctors and the nurses at the hospital exactly what is required to care for the patient. They will know not only the procedures and medications, but they will also meet and come to know the doctors. This makes communication between professionals much smoother.
There are agencies where you can hire nurses and caregivers, but these are usually quite expensive (Editor’s Note: about US$300.00-400.00 per month in salary). In my case, I found that the nurses who were recommended by the doctors or through friends were not only more affordable, but better than the ones I interviewed from the agencies. Also, they came with excellent references, as I knew and trusted the opinion of most of the people they had already worked with.
You must assume that most family members, such as myself, have no medical experience when they are faced with taking a patient home, and are totally unprepared for what this means. It becomes quite an overwhelming feeling to know that the care, safety and responsibility of caring for someone you love rests totally in your hands when you have no idea what you are doing.
I was very lucky to work with doctors who did not mind my endless questions, emails, and the letters I would leave at their offices. They treated me with patience and respect. Even though they must have been perhaps annoyed with me at times, they were always understanding. I believe it is important to find doctors who you are comfortable with; they will be important members of the journey you are taking, and you and your loved one must be able to be open and forthright with them.
I cannot stress enough the importance of this. From the beginning an open and honest relationship needs to be established. There are many wonderful, competent doctors in the Philippines, and though it may take some homework on the part of the family or patient to find the ones who you can communicate with, it is well worth the effort and will ease the stress of the situation in the long run.
Families should be informed of establishments such as Alabang Hospice, or other organizations where not only can they borrow equipment, but they can also get counseling and spiritual support.
For example-Asian Hospital has a support group for families and patients with cancer, while Alabang Hospice (a.k.a. Ruth Foundation) has people who volunteer to visit families to help them through difficult times.

Lifeline Ambulance Rescue Philippines A Very Reassuring Prospect

I interviewed Michael Deakin, the managing director and the dynamic driving force behind Lifeline Ambulance Rescue Philippines, and I have to say that the man is impressive. This product of a Filipino-British upbringing is as passionate about his mission as he is well-versed and well-informed about his business. Michael has transposed two of the primary philosophies from his background in the hotel, restaurant, and hospitality industry onto the ambulance & rescue company he runs. The first is, “We serve you first, in the expectation of payment later”, and the second, “What we serve you is a quality product.”

“Our policy is to never refuse a call, no matter what.” Michael tells me during our interview. Since 1995, Lifeline has been instrumental in saving over 86,000 lives. In 2013 alone Lifeline was instrumental in saving the lives of 9,865 people. Michael measures Lifeline’s success in lives saved rather than in money earned; but he makes sure that there is enough money in the bank to keep the operation not only going, but growing!

Lifeline Rescue was founded by a group of doctors in 1995 to meet a need in Metro Manila for reliable ambulance service. It has since then morphed into what it is today, the first, and the only, dedicated “Emergency Quick Response” (EQR) service in the country. Lifeline are the only fully-equipped ambulance service, staffed with EMTs trained to international standards. Lifeline offers a Medical Evacuation Service by land, sea, or air, anywhere in the country. Airlifts are done in coordination with other service providers, both private and commercial entities, such as Lion Air, SOS International, Assist America, and Philippine Airlines, to name just a few of their partners.

Lifeline has a rapid response within the Metro, arriving on the scene on an average of between 8-12 minutes after the call is placed. The “Red Room”, the 24-hour dispatch room, maintains an internationally-awarded radio communications network and is staffed by highly-trained emergency nurses who receive and direct the calls, dispatch the ambulances, keep themselves updated on current traffic situations, and offer support and medical advice while coordinating with Lifeline’s doctors. Each response team is composed of two licensed nurses or a nurse and an EMT as well as a transport officer. All are highly trained in advanced life support techniques and receive their credentials from the Austral-Asian registry in Australia, following the US model for qualification.

Lifeline’s EMTs are trained in the C,A,B protocols (“C”, circulation; “A” airway; “B” breathing) perfected during the Iraq and Afghanistan wars. The primary concern is to maintain “C”, circulation. “B”, breathing is the last of the three concerns because, as Michael says, “…you can stay alive for five minutes without oxygen. We’re doing CPR to maintain circulation, and therefore minimize brain damage. So even if you’re not breathing, we can breathe for you, but establishing circulation is the most important thing now because if we can’t establish circulation, the patient is dead within minutes…from shock.”

A patient goes into shock from dehydration, during an accident situation, usually from loss of blood. When a patient is dehydrated, the veins collapse, which then makes it difficult to get hydration into the patient to prevent shock. It’s a vicious cycle. Lifeline uses a device called an “intraosseous cannula” that represents state-of-the-art technology for patients who are “in extremis” from shock and/or respiratory failure. “The device is basically a drill which the EMT shoots directly into the bone marrow of the shoulder or the shin of the patient…and yes, it hurts. The device provides the EMT with an access point to effectively administer fluid into the body of the patient in an emergency situation, effectively preventing shock. All of Lifeline’s emergency crews are provided with the device and the training to be able to use it correctly.

On the highways, Lifeline’s EMTs follow the rescue protocols of the American Highways system as well as those of the German Autobahn system. They implement the German extraction protocol, popularly known as the “jaws of life” for vehicular accidents on the highways. Michael notes that there are an average of four extractions from vehicular accidents every week, so the training and equipment are being put to good use!

Their rescue vehicles are outfitted with American equipment and, in Michael’s words, “look just like the ones you see on TV” which is very reassuring somehow, as they look so “western” and “First World”.

A membership with Lifeline for a single person costs P1,000.00 per year (roughly US$22.00), or P3,000.00 per year (roughly US$68.00) for a family of up to ten people, including household staff (maids, drivers, gardeners). Even with the low cost of membership, about 50% of Lifeline’s calls come from non-members. “Lifeline operates on the same principle as a restaurant” says Michael, “the patron comes in and enjoys the product and services with no prior outlay of payment. Those products and services are extended to him or her on the presumption of payment; at Lifeline, we do the same. Our policy is “no questions asked” at the time an emergency call is made. We extend our products and services in order to stabilize the patient, and then, three days later, we send the bill in the hopes of payment. We’ve been stiffed a few times, but for the most part, payment has always been forthcoming.”

The basic costs of answering an emergency call are covered by fees from Lifeline’s membership base as well as by retainers paid to them by their corporate clients. As to the part of the bill over and above the basic costs incurred, Lifeline can and does organize user-friendly payment plans for their clients.

Because of their reputation in the industry, as well as their affiliation with an extensive network of physicians, partners, and hospitals, Lifeline guarantees that even unidentified and presumably indigent patients will always be admitted to a hospital for treatment.

“In the beginning, hospitals did not want to accept such patients because there was no guarantee that they would be paid.” says Michael. So, in the early days before Lifeline’s reputation proved itself out, the ambulance crews were instructed to hand over the keys of the ambulance to the hospital administration in order that the vehicle itself serve as a guarantee of payment for the patient that had been brought in. That protocol is still in place, but these days hospitals are more willing to admit any patient brought in by Lifeline.

If ever an admission for treatment needs to be insisted upon however, Lifeline’s crews carry with them copies of the law that states that hospitals may not refuse service to any person in need of emergency attention. Further to that, each crew is also equipped with recording devices and often also cameras so that they can maintain a record of what has been said and done in any given circumstance.

“We had a case,” Michael tells me, “of a Caucasian man, presumed to be a foreigner, who had been in a bad car accident. He had been driving a cheap car, he was dressed in shorts, slippers, and a t-shirt, with no ID of any sort (not even a driver’s license, it should be noted), and he wound up under a truck. The accident happened in Batangas, outside of Metro Manila, and because the patient was unidentified and presumed to be indigent, hospital after hospital refused to accept him, using the standard excuse in such cases, “we have no room”. Rather than waste time trying to argue with provincial hospitals, Lifeline (meaning, of course, Michael) called in a favor at Makati Medical Center, one of the best hospitals in the country. The patient was driven to Manila, and MMC straight away admitted him.

Makati Medical did stipulate, however, that if the patient would be unable to pay the bill, the hospital would have to come after Lifeline for the payment. Michael did not object.

“The guy was in a coma for over two weeks, with the bills piling up, and during that time we were trying to find out who he was.” Lifeline called the Embassies, foreign companies, bars frequented by foreigners, you name it, in an effort to find out who the fellow might be. Nearly three weeks in, says Michael, “we got an e-mail from a woman in Hong Kong, with a photo of her missing husband, and sure enough, it was the guy! He turned out to be the head of a multi-national corporation there, and he was fully insured.” He had come to Manila for a meeting and decided to make a long weekend out of it before returning to work in Hong Kong, and that is when he got into the accident.

If, unlike the man in this story, a patient were to remain unidentified and unclaimed, eventually they would be transferred to the DOH (Department of Health) or to a government hospital where, being considered indigent, quality of care would be limited by the (very little) amount of funding available for indigents. The moral of the story, then, is always carry ID, and let your family know where you are!

Although they chiefly operate—at the moment—in Metro Manila, Lifeline rescues people from anywhere in the country.

In one instance, a young woman hiking in the province accidentally fell off of a mountain, and then could not be found in order to affect a rescue. The Army and the Marines were called in and they started their search for her at the base of the mountain and were working in an upward sweep, but it was already late afternoon, and soon night would be falling.

Lifeline was called in at this point, and they quickly pulled in one of their best rescue doctors (who was literally in his car with his family and about to drive away on holiday), still dressed in his leather office shoes and work clothes, and put him on a waiting helicopter and flew him to the site of the accident. Pilot and doctor thought they spotted the injured girl, but the pilot could not land on the mountainside. Hovering about a meter off the ground, he called to the doctor, “Just jump a little, Doc!” which is exactly what the doctor did. He went off to find the accident victim while the chopper hovered in place, night falling. Having taken too long, and being (in those days) under a strict “no fly at night” FAA regulation, the chopper pilot tossed out the medical rescue gear and headed back, leaving the doctor behind on the mountain. The doctor returned, triumphant at having located the victim, and found the helicopter gone, but gear on the ground. He picked up the gear, attended to his patient’s injuries and loaded her onto the stretcher, and now, in full darkness, walked her down the mountain by the tiny light of his stethoscope. They were met by a contingent of the Marines about half-way down.

In another instance, a group of friends had gone to the island museum of Corregidor for the day tour, but due to rough seas, the return trip was cancelled. One of the group panicked as he was diabetic and had not brought insulin with him since he had not expected to be gone from home for more than a few hours. Lifeline was called, insulin was procured, and a helicopter was dispatched to Corregidor. The diabetic gentleman was waiting at the helipad, and upon receiving the insulin, he promptly injected himself right there and then. As the chopper was about to depart, he asked the pilot if he could have a ride back to Manila, whereupon the pilot said, “Sure! Hop on in!” and back they went.

The anecdotes go on and on…

“We can rescue anyone from anywhere, or transport a patient anywhere. It’s really just a matter of budget.” says Michael. The cost of an airlift runs P80,000.00 per hour (about US$1800.00 per hour) and the fee for a patient always includes the turnaround time. A “golfer’s rescue” which essentially means picking up a patient by helicopter and transporting him straight away to the hospital, is P50,000.00 (about US$1,100.00) on average. The insulin drop on Corregidor, in the story above, was P37,000.00 (about US$850.00) including the extra passenger on the return flight to Manila. Payment plans for any of these services are easily worked out after the emergency has been resolved, as per Michael’s philosophy.

Lifeline isn’t just a rescue ambulance service. Over the years, under Michael’s guidance, it has become ever so much more than just that. For example, Lifeline, together with service providers and partners, maintains 24-hour ambulatory care clinics, complete with diagnostic services, in several of the top residential subdivisions, schools, and residential condominiums within Metro Manila.

They are partnered with the MRT (Metro Rail Transit) system within the city as well as the highway system on Luzon to provide emergency response.

Lifeline provides a service called Home Care, for patients “who need or desire outpatient medical care in the comfort of their homes. This is especially beneficial to the chronically ill, disabled, post-operative, or palliative-care patients who have difficulty finding their way to the hospital for a routine medical check-up or a change of dressing.” Lifeline coordinates with the patient’s personal physician in order to extend care at home for the convenience of both patient and doctor.

“We also provide what we call our “Go Home” service—as in “go home to die in the peace of your own home among your family and loved ones.” Lifeline have transported end-of-life patients from one end of the Philippine archipelago to the other, and they have also coordinated the effort of repatriating foreigners to their home countries.

“Right now,” says Michael, “we are coordinating an effort with the British Embassy for the repatriation of an indigent British national who is dying.” Embassies will generally not underwrite the cost of repatriating one of their nationals (or their remains), but they are mandated to facilitate the process on behalf of whoever is paying the bill for the repatriation.

In the case of an indigent patient, in this instance a foreign one, Michael tells me, “The mayors in the provinces are often very generous to their constituents—even to foreigners who are their constituents, as long as that foreigner has not been known to be belligerent, a drunk, or a bully. Should a constituent have a medical mishap—an accident, or a heart attack…” for example, many provincial mayors have been known to dip into their discretionary fund to help an indigent person to get some necessary financial aid for medical assistance. “But of course, it is really best to be well insured!”

This particular gentleman is being airlifted from the province to Manila, where he will be ensconced in one of the Lifeline clinics for a few hours of transit time, comfortable and well-attended to, while he waits to board his international flight back to the U.K. Lifeline will have transported him from his home in the province every step of the way until he is safely and comfortably aboard his flight home.

Last—but certainly not least—Lifeline offers an Emergency Prevention Service called “DOC” or “Driver on Call”. This service provides motorists with a better way to get home safely should their ability to drive become compromised by intoxication, medication, illness, or other causes. “DOC” keeps impaired drivers off the road and gets you (the impaired driver) and your vehicle home safely. Once Lifeline’s drivers arrive, you will hand them your car keys and they will NOT return them to you. The service is available to anyone and everyone. Once a call is received, Lifeline dispatches a company vehicle with two drivers, one of whom drives the client’s vehicle home (with the client as passenger), and the other of whom follows in the Lifeline vehicle. Clients call the same emergency number, 16-911, and the cost of the service is P500.00 (about US$11.00).

Although Lifeline presently functions chiefly in Metro Manila, by the middle of 2015, just in time for their twentieth anniversary, they will be just as entrenched in Cebu, Davao, and Dumaguete as they are in the Metro.
By 2017, Lifeline will be operational in every major city in the Philippines.

That, may I say, is a situation I find very reassuring!