A visit to St Luke's

Yesterday I went with some med students to a satellite branch St Luke’s Hospice, opened to address the AIDS epidemic. They have inpatient beds, as well as an outpatient program where you can come in, see the doctor, speak to a social worker, have a meal, and attend support groups with other AIDS patients from the community.

We spent the first few hours in lecture and PBL(!), in which we were actually given resources and left alone to solve the case. We then presented our findings as a group in an informal setting. Is it strange that this was the best PBL I had all year?

(Note to non-medical students: PBL, or problem-based learning, is a much-maligned supplement to our lectures. In the first session, we are presented with a case and create relevant assignments. In the second session, we present our assignments—usually in PowerPoint—and hope to get out early. It could really be so much better.)

Then it was off to patient interviews. I was assigned to a cachexic (wasted) twentysomething man who was sitting wrapped in blankets on the patio. He was newly diagnosed with AIDS and TB, although he wasn’t convinced that he had AIDS. Interestingly, he knew his CD4 count, a marker of HIV.

The palliative care physician we heard from earlier in the morning was careful to note that this was not a place of death, but rather a place of life: “the patients here are close to the end of their breathing life, but they are living.” And yet the patient I interviewed was in hospice for another chance at life, specifically to start a course of anti-retroviral therapy (ARV). It is entirely possible that if he is able to receive the support necessary for ARV adherence—government grants (akin to SSI in the States), nutritional counseling, symptom control, family support, housing, and transport to medical care—he will do quite well for the foreseeable future. In a more rural area in 2009, he would indeed be close to the end of his breathing life; a few years ago in Cape Town and over 13 years ago in the States this would also be true.

It’s also worth noting that palliative care in South Africa is ideally begun at diagnosis, aiming to manage symptoms, improve adherence, and care for the family. It’s actually the first model of palliative care that I was exposed to (more on that later), but is fairly unusual in the States, where palliative medicine takes over at the end of disease-modifying therapies. There is a movement afoot, however, to integrate the two—it should be interesting to see if and how our super-specialized medical system accommodates this.

Oh yeah, and in a hospice where everyone was dealing with TB: negative pressure rooms? No. N-95 masks? No.