Written by Clare Isabel Ee
The term can be alarming to some, comforting to others, or may otherwise be elusive and often misunderstood.
SALTS Insider sat down with Ms Lau Su Re, Senior Speech Therapist, St. Andrew’s Community Hospital (SACH) to hear about her experiences working in palliative care.
Having graduated from Curtin University (Perth, Australia) in 2008, Su Re worked as a speech-language pathologist for 10 years across various settings in Australia before returning to Singapore in 2018. She is pursuing a Masters in Palliative Care with Flinders University (Australia).
She currently works at SACH as a Senior Speech Therapist, serving in the palliative care inpatient ward, or the Violet Ward. The Violet Ward at SACH provides palliative care services at an inpatient, home and community level for the Eastern part of Singapore, including medical, nursing, allied health, and pastoral care.
SALTS Insider: How did you first start working in palliative care?
Su Re: Looking back, I was always working in it, albeit in small pockets. When I was working in acute care, I would occasionally be referred to see patients to “eat and drink as desired”. They were often terminally ill patients with diagnoses such as cancer. I also worked within the disability sector that supported people with diagnoses such as chromosomal disorders and Duchenne muscular dystrophy. These are time-limiting medical conditions, mostly through genetic inheritance and slow progression of its phenotype.
Insider: What are some joys and challenges of working in palliative care?
Su Re: One of the reasons I enjoy working in palliative care is because it is an area in which the mind-body-spirit aspects matter. This is a true reflection of the complex threads that make up the human experience. When I think I’ve seen just about everything, I will encounter patients who surprise me with their resiliency or have wishes that challenge me to think out of the box.
Being reminded of my own mortality is humbling. I have learnt to say words like “dying” and acknowledge that sometimes, there is nothing I can offer except just to be there for our patients and loved ones, providing them with support.
As healthcare workers, we are often trained to “fix”. However, skirting around the topic and giving “false hope” to patients and their families is more harmful. It is both an art and science to be able to interact honestly and sensitively with our patients and their loved ones, and meet them where they are.
Insider: How do you/fellow colleagues care for your mental and emotional selves while working in palliative care?
Su Re: At work, all of us enjoy a camaraderie that allows us to laugh at ourselves and find humour despite challenging situations. Prior to COVID-19, staff would attend monthly remembrance services for our departed patients. The hospital would also hold an annual memorial service for patients who have passed on and invite their families to celebrate their lives and legacy.
Personally, keeping active is important. I am an Indian classical dancer and ballet student, so I do several hours of dance classes per week. Taking care of my own spiritual health helps me to manage stress. This includes attending church, praying, reflecting, and talking to friends and families to emotionally offload. Having an identity beyond a speech therapist is vital.
"Being reminded of my own mortality is humbling. I have learnt to say words like “dying” and acknowledge that sometimes, there is nothing I can offer except just to be there for our patients and loved ones, providing them with support."
Insider: Here are three oft-heard misconceptions about palliative care. How might you respond to them?
Myth 1: Palliative care only starts at the end of life.
Su Re: It is important to first understand and define what palliative care means. It is “an approach that improves the quality of life of patients... and their families who are facing problems associated with life-threatening illness. It prevents and relieves suffering through the early identification, correct assessment and treatment of pain and other problems, whether physical, psychosocial or spiritual.” (WHO, 2020).
To say palliative care only starts at the end of life is an incomplete understanding. Untimely palliative care may lead to poor symptom control, unexpected emergency admissions and insufficient opportunities to plan for a “good” death (Dalgaard, Bergenholtz, Nielsen & Timm, 2014).
Myth 2: Palliative care speeds up the dying process.
Su Re: Palliative care affirms that dying is part of the natural process, and it neither hastens nor postpones death (IAHPC, 2022). Palliative care is a comprehensive approach to symptom control and helping patients and their families manage problems – which may be existential, psychosocial, physical or all three. Death is inevitable, but it is not accelerated. Palliative care is about responding to patients where they are at.
Myth 3: There is no role for SLPs in palliative care.
Su Re: Many physiological processes during the dying phase occur that impact on mealtime presentation and appetite. Especially in cultures where food forms a huge part of our socio-cultural fabric, loved ones often get distressed when they see patients not eating or drinking. Communication abilities and interactions also change as the patient’s medical condition progresses. Therefore, there is a role for SLPs in palliative care. We know that at end-of-life, patients’ goals shift from physical to psychosocial and legacy-leaving (Boa, Duncan, Haroldsdottir & Wyke, 2014). Our role is not to fix their impairment but harness existing skills to work towards something meaningful for patients.
For example, a patient of mine had a recurrence of laryngeal cancer. The team requested if I could help him to develop a card with his blessings to convey to his son for his upcoming wedding. We had a short time, estimated at one week, as the patient was rapidly deteriorating. Using a total communication approach that changed day to day e.g. typing, lo-tech alphabet board, the patient managed to convey an eight-word blessing telling his son he was very happy. This was printed out, and the patient presented this to his son and daughter-in-law within the ward. The patient passed on a few days later.
"Confronting death and uncomfortable conversations is part of palliative care."
Insider: What training is required for SLPs who wish to specialise in palliative care?
Su Re: As far as I am aware, there are no formal training or specialist programmes for SLPs (please reach out if there are!). I would say it is a combination of reading up on articles, getting involved in forums, network groups, learning on-the-go with mentors, or undergoing an attachment with universities that offer formal, tiered studies in palliative care.
Another type of training is internal. Having an awareness of a condition’s progression and the long-term mapping of a patient’s disease trajectory is a covert re-alignment towards having palliative care considerations at the back of your head, no matter what setting you work in.
Insider: What are some things you really want people to know about palliative care?
Su Re: Two things can be true at once. Confronting death and uncomfortable conversations is part of palliative care. Deep professional and personal satisfaction through achieving meaningful and lasting outcomes is also part of palliative care.
As healthcare workers who encounter life-limiting conditions, it is our duty and responsibility to be aware of palliative care. It does not always need to be at a specialist level, but rather, a readiness to anticipate changes and help the patient think and plan ahead. It is everyone’s business!
Boa, S., Duncan, E. A. S., Haroldsdottir, E. & Wyke, S. (2014). Goal setting in palliative care: A structured review. Progress in Palliative Care, 22(6), 326 – 333.
Dalgaard, K. M., Bergenholtz, H., Nielsen, M. E. & Timm, H. (2014). Early integration of palliative care in hospitals: A systematic review on methods, barriers and outcome. Palliative and Supportive Medicine, 12, 495 – 513.
International Association for Hospice and Palliative Care (IAPHC) (2022). What is palliative care?
World Health Organisation (WHO) (2020). Palliative Care.