Palliative Care went from nobody's business to everybody's business
In 2014, the wife of the Governor of Jakarta, Mrs Veronica Basuki, announced her wish for palliative care to be available at every District Hospital in Jakarta. Overnight, Rachel House was propelled on the path towards transformative scale; and the seeds that we had patiently planted over the years blossomed to bring forth a health system that is now ready for palliative care.
“Business as usual” - with expanded coverage
In late 2013, we expanded our coverage to involve community volunteers - empowering them with the necessary skills and knowledge to help provide home-based palliative care for children from the marginalised communities living with cancer or HIV. The trained volunteers under our Community Network in Palliative Care(“CNPC”) Program are now collaborating with medical professionals at primary health centers in Jakarta (who are also included in the palliative care training) to bring the much-needed care to patients at home.
2014 also saw the beginning of our work in designing the curriculum for accredited palliative care short courses for nurses under the Clinic-in-a-Box Program. Our Clinic-in-a-Box Programwill be piloted in 2015, in collaboration with the National Nursing Association (PPNI) and the nursing faculties of several major universities, to equip nurses with home-based palliative care skills and financial skills to allow nurse to practice independently. It is our hope that the “Clinic-in-a-Box” trained nurses combined with the CNPC trained volunteers will help alleviate the suffering faced by many today due to the critical shortage of medical professionals in Indonesia.
Our Gratefulness & Thanks
The awesomeness of the journey in the last 12 months is something that none of us could have predicted. The part we played was simply to stand ready for the occasion. I am grateful to the entire Rachel House team who stood up to the challenge, and most of all, to all our faithful and wonderful supporters – volunteers, partners and donors - who continue to champion the cause and rally around us. Thank you.
Death – The Last Frontier
I have asked myself the question “How do I want to die?” countless times in my life. Depending on how I feel at the time and at what stage of my life I am at, the answer often varies – from passing away peacefully at old age to dying heroically in a fire trying to save a kid. Of course, all this assumes I even have a choice in the matter. All too often, we don’t have a choice. Death comes quickly and takes us, and our loved ones away. But what’s worse is that sometimes death comes slowly and you’re dragged through the dying process painfully and slowly.
In the two months I’ve spent with Rachel House, I’ve come the closest face-to-face with death than ever before. It’s easy to write off death when you’re only 20, because you think- surely it’s not going to come soon! I still have so much more time! But the patients at Rachel House don’t even have the opportunity to reach 20 years of age before they are robbed of their lives forever. It’s infuriating and saddening.
The first patient I met was a tiny little baby boy named Andi. He was HIV positive. He was so tiny- “like a melon”, was how Prita (Rachel House’s Program Officer) described him. He was only 4 months old, and had the tiniest fingers and toes, and it just makes you marvel at how small a human being can be. Andi’s mother was only 18. She was two years younger than me, married and had a boy to call her child. She was also wholly unprepared to be a mother.
One of Rachel House’s nurses, Neng, interacted with Andi’s mother and grandmother in Bahasa Indonesia. We caught parts of the conversation, didn’t catch most of it, and largely settled for gazing at Andi and observing the body language of the people around us. Andi’s mother was also HIV positive. She had been taking medication for a while, but stopped recently because she felt fine. She had also ‘forgotten’ to bring Andi to the hospital for his checkup. Andi’s mother was a beauty; she had long black hair and big eyes. She fiddled with Andi’s cot and laughed a lot, not quite meeting Neng’s eyes most of the time. Andi’s grandmother carried little Andi in her arms and looked onto the conversation with a defeated air.
Many thoughts filled my head as we walked away from Andi’s house that day. Above all, I wondered- Is there someone who can be blamed for the situation? Andi did nothing to deserve all this pain and suffering aside from being born into this world; his mother may have made some bad decisions but ultimately, in her situation it must have seemed like she didn’t have any other options aside from getting pregnant and being married off. And I went away thinking, man, life can be really unfair sometimes to some people.
It is stories like these that make me realize just how much of a blessing Rachel House is to these families. Crucially, I think the nurses and staff at Rachel House see the suffering and go out of their way to alleviate it. They never stop at “Wow life is so unfair!” They go beyond and give their all in order to help one more child live the rest of his or her remaining days without pain. Andi passed away a few weeks later, suddenly and unexpectedly. We mourn his passing, but ultimately if his last days were lived painlessly and without any suffering, then that might really have been the best outcome for everyone involved.
How can we help the terminally-ill children from Jakarta’s poorest families find peace?
Since our last report, we are thrilled to announce a significant breakthrough in the ongoing effort to educate medical professionals in Indonesia about the importance of palliative care. With the support of the Singapore International Foundation and the wife of the Governor of Jakarta, Mrs Veronica Tjahaja Purnama, in her role as the Chairperson of the Jakarta Cancer Foundation (YKI DKI), we will soon be offering a three-year course in palliative care for practicing medical professionals in six District Hospitals (RSUD) in Jakarta and several National Referral Hospitals. We couldn’t have achieved this landmark goal without your continued support, so a huge thank you to the Global Giving community. This step is only one along our journey towards bringing pain and symptom relief to every child in need, and we invite you to walk along with us as we continue.
Since 2006 when Rachel House was established, we’ve been working tirelessly to help terminally ill children in Jakarta’s poorest areas. If you were to come along with one of our nurses on their home visits, you would be welcomed into the homes of families living in the most disadvantaged parts of the city: near rubbish dumps and filthy ports. Some of our patients have no place to call home: under a tree during the day, and in the mosque at night. Most of the care we provide is for children during the most critical stage of their battle against cancer or HIV; we know they will most likely not have much time left, but we want to give them the dignity and comfort to enjoy their remaining days. This is a difficult task, but often it is made harder by the lack of awareness amongst the medical community and the public about palliative care.
Our dream of being able to provide the best care to every child living with life-limiting conditions from the marginalized communities is finally being realized. Between 2009 and 2012, we worked with the Singapore International Foundation to train the first group of medical professionals in palliative care. This new breakthrough that will allow us to bring palliative care to all medical professionals in the hospitals in Jakarta is the result of years of campaigning and hard work: from formalized roundtable discussions, to the day-to-day uphill struggle our nurses experience in their efforts to change the perceptions of doctors within a strict hospital hierarchy and win them over to the path of alleviation of pain. Through the new palliative care course, which will involve an intensive week-long training (comprising classroom and beside teaching) bi-annually over a 3-year period, with a week-long practicum once a year in between, we hope to bridge this knowledge gap.
This exciting new step helps Rachel House achieve one of its fundamental initial goals: that of increasing the knowledge of palliative care across the Indonesian healthcare system. In order to help patients traverse the journey seamlessly from the hospital to home, more work needs to be done at the public health clinic (Puskesmas) level, as well as the community volunteer level. Rachel House has already made significant progress in both areas through its Community Network in Palliative Care (CNPC) Program and Clinic-in-a-Box Program (see our previous reports for more details).
Your support has been invaluable in helping us get this far, and we hope you will continue to now journey with us to the next exciting stage – that of making palliative care available to every child in Indonesia allowing them to live their remaining days amongst their loved ones, with dignity and in peace. We hope you will help us achieve our vision for a better world.
The Future of Palliative Care in Indonesia.
On 26th March 2014, Rachel House hosted a groundbreaking Roundtable event, inviting key players in healthcare in Indonesia to come together and discuss the alternative pathways of introducing palliative care into nursing school curriculum in Indonesia. Dr. Suresh Kumar, Director of the WHO Collaborating Centre for Community Participation in Palliative Care and an expert on community-based palliative care, came from India to attend the discussion and to share his experiences.
The event brought together key influencers in healthcare in Indonesia with senior representatives from the Ministry of Health and the Ministry of Education, major universities and hospitals across Indonesia, the heads of National Nursing Association, National Bachelor of Nursing and Diploma of Nursing Associations – to discuss ways of improving general knowledge about palliative care amongst medical professionals and the critical collaboration needed between stakeholders to make this possible.
Currently, palliative care is not well understood amongst healthcare professionals in Indonesia, with the majority of them unable to even define it. Rachel House’s homecare service that makes availablepalliative care for children in Jakarta’s poorest areas and its work in raising community awareness is largely unorthodox.
The event was a great success. Dr Suresh Kumar presented a compelling argument that with the increase of medical knowledge, more people will be living longer and may therefore require long term and dedicated palliative care. He advocated community-based palliative care to avoid Hospitals being overburdened, mobilising volunteers in the local communities to care for the elderly and the infirm in their homes. This model echoes that of Rachel House’s Community Network in Palliative Care ("CNPC"), which was piloted in 2013 in several neighbourhoods in Jakarta’s poorest areas – providing access to health assistance for those who may not have access to hospital care.
The roundtable discussion made important progress in underpinning the key issues that need to be addressed in Indonesia in order to improve access to palliative care. University representatives suggested there was a fundamental challenge today as many lecturers have little practical experience in palliative care and therefore are not able to pass the crucial knowledge of pain and symptom management onto their students. Therefore, many nurses feel overwhelmed when they begin practicing, avoiding patients who may need palliative care as they feel unequipped. The representatives from the Ministry of Health and Ministry of Education both acknowledged that changes need to be made to the syllabuses in universities to adequately prepare nurses, and training and development for professionals in hospitals are needed to help accommodate palliative care.
Everyone left the event with a real sense of excitement generated by mutual understanding and agreement, which gives hope to the possibility of palliative care being implemented in the healthcare system in Indonesia. It is now crucial for the participants to lobby support in each of their own constituents in order that palliative care can take root. It was a wonderfully positive day with the long-term dedication and behind-the-scenes work of Rachel House staff being recognized and supported by key bodies.
For many of us, imagining the plight of a terminally ill child is impossible. When death becomes a reality of life, any small kindness can help to improve a child’s remaining days.
At Rachel House, we help terminally ill children find peace and happiness at the end of their lives. We work in the poorest communities of Jakarta to raise awareness about palliative care, to look for new patients, and to make a difference to the healthcare system in Indonesia on a larger scale.
Since our last report, our nurses have travelled hundreds of kilometres along the back roads of Jakarta to reach patients in their homes, offering pain relief, advice for the parents and a shoulder to cry on. We need more nurses to spread out further into the poorest areas of Jakarta, and to raise awareness in the community.
We will tell you the story of one little girl, Karina, and how Rachel House has been able to help her. How many more children are there who need our help?
Shining a light on those in distress
Karina is a three-year-old girl who has lost her mother and brother to HIV. Karina's father is a gentle spirit, also suffering from HIV: now, they only have each other.
The family moved to Jakarta from their village to earn a living. Karina and her father are living in a car park during the day and sleeping in a rented room at night. Without a residence, they are struggling to get a permit to access healthcare. They have to rely on the kindness of the healthcare centres and on Rachel House nurses to get the medicine Karina needs. Her father is also suffering with his own symptoms, which makes it difficult for him to care for her.
Karina suffers from HIV and Lung tuberculosis, and recently her symptoms have been getting worse. She is unable to eat without vomiting and she cries out for her mother. As she finally realises that her mother and brother won’t be coming back, she withdraws into herself, clutching a photograph of her lost family members wherever she goes.
Without the weekly visits of Rachel House nurses, it would be impossible for Karina’s father to get the medication to ease her condition and improve her quality of life. Due to strong relationships forged with the healthcare centres, the nurses are able to lobby for treatment and help the father get the permit he needs. Karina’s life is hard enough, and if we can ease her pain and greet her with a smile, we can improve her quality of life. A little joy goes a long way.
Training volunteers and community members
From one tree, you can make a thousand matches…
Stories like Karina’s are why Rachel House was founded: on the belief that no one should suffer alone. Our other aim is to change the healthcare culture in Indonesia and the developing world. As in the Western world 30 years ago, palliative care is new to many healthcare professionals here. When a child is terminally ill with cancer or HIV, and when treatments are no longer viable, it is difficult to convince the doctors that it would be kinder to manage their pain and symptoms to make their final days comfortable than it is to keep putting them through painful treatment.
Community Network in Palliative Care (“CNPC”) Program
After careful community research, we set up the CNPC program in late 2013 to help spread the awareness about the aims of palliative care amongst community volunteers and the general population in Jakarta. Targeting the poorest areas, this program has proved very successful in making connections and encouraging collaboration between healthcare centres, nurses, community volunteers and hospitals. It has helped demonstrate that teamwork and communication are needed to give these children the best possible experience in the last days, weeks or months of their lives. Despite being run mainly by one nurse, this program has got off to a flying start. Now we need further help to grow the program and maintain the good work it has already achieved.
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