Seamless care is a client-oriented system

composed of both services and integrating

mechanisms that guides and tracks
patients
Morna Chua over time through a comprehensive array
of
health, mental health, and social services
spanning all levels of intensity of care.

In Kota Kinabalu, Palliative care is

provided by Aim :
the Palliative Care Unit of Queen
To bring the hospital to the
Elizabeth Hospital
and
home of the patient
the Home Care Program of the
Palliative Care Association.

Associated with more indicated „ An Inpatient Service

preventive care, better identification of
patients’ psychosocial problems, fewer „ Clinic
emergency hospitalizations, fewer
hospitalizations in general, shorter „ Home care program
lengths of stay, better compliance with
appointments and taking of medications,
and more timely care for problems. „ Daycare Service

B t F ll
 INPATIENT
SERVICE

„ 1995 - 4 beds The active total care of patients whose

„ 1996 - 10 beds disease is not responsive to curative
. treatment .
„ 2001 - 12 beds
Control of pain & other symptoms

Presently still catering for of psychological, social and spiritual

patients with advanced problems is paramount .
incurable cancer

The goal of palliative care

To provide a place of rest
is the achievement of the
and to improve
best quality of life
the quality of life
for the patients and their
families . for advanced cancer
patients
 1. Provide good pain 2. Providing information
& symptom control and explore
concerns/issues

3. To provide respite for 4. Empowering primary carer

the primary carer and
the family

Patient area

Kaunter

Lounge
Entrance to
Palliative Care Unit
 Single room
Double bedded room

Prayer room

„ Pain control
„ Symptom control
„ Radiotherapy
„ Chemotherapy
„ Respite
„ Psychological support
„ Final hours

Caring in our service

is holistic

PCU facilitate direct

admission
24 hour service touch
respect
of love for
 Religious beliefs
Specialized and individualized care

2 sessions held weekly

„ New referrals
„ Follow up
„ Topping up of medications

Non governmental charitable organisation

providing free service

HOMECARE „ Covers a radius of

PROGRAM 30km of PCA building

„ Must have a primary

carer
 Home Visit

„ Provides medical aids on free loan basis

Some of the areas visited by

our home care team
Patients registered with PCU may gain direct
admission to the ward when needed. But, the
ward need to be informed.
(all patients registered with PCU will have
phone contact of the unit)

„ Patients from the districts are referred back

to their respective district hospitals
„ Referral back to the hospital with the
treatment ordered for symptom control and
to contact PCU when the need arises.

„ Report of incoming calls and patients

„ A referral form with detailed under the home care program will be
information will be filled up and sent informed to the PCA team every
to PCA . working morning.

„ Always try to introduce home care „ PCA team reports back to PCU
nurse to patient before patient is everyday after their home visits.
discharged
(Fax machine provided by PCA)
„ Home care team can liaise directly
with PCU staff on any problems
encountered by patients at home.
„ PCU staff can contact the Home care
team when patient or family members
call up in case of any problems
„ Medications of patients
„ If patient is not ambulant or not able to
come for review, medications can be
replenished based on the assessment
by the home care team.

Patients stay in hospital is short as they

Weekly case review
are discharged after symptoms are
controlled.
They are given the reassurance that the
home care team will be following up
them and they may be admitted
directly to the inpatient unit when
needed.

This is only possible

„ Care is provided for not just the because of the
patient but the family as a whole;
psychological issues can be the partnership of the
cause of difficult pain control. inpatient unit and the
home care team
working hand in hand.
 ☺ Logistic problem –
☺ Easy/direct access to with the help of the
Palliative Care Unit & the home care program,
patient can now be
Home Care Team adequately cared for
at home especially
when their condition
deteriorates.

☺ Family members are able to cope

☺ Hospital stay can be better when they are taught how to take
reduced care of their loved one and reinforced
by the home care team.
thus the cost too.

Symptom controlled in PCU

Follow-up by home care Patient can still be cared for

at his own environment and
be with his/her loved ones.
 DAYCARE BEREAVEMENT
CENTRE FOLLOW-UP

Difficulties Encountered Teambuilding

„ Communication

„ Policy of hospital

„ Increase workload

„ Expectations

„ Problem in sustaining trained staff

Patients are cared for by

Palliative Care team till
they
‘rest in peace’
With good teamwork,
everything is made
possible.