In 2001
Dr. David Brumley & Lyn Edwards RN
Traveled to:
Cho Ray Hospital, Ho Chi Minh
City and Campus 2 of The Cancer Hospital,
Ha Noi Vietnam

Lyn Edwards RN Gandarra Palliative Care Unit, Ballarat, Victoria, Australia

Dr. David Brumley

Highlights

In Vietnam it is not common to directly discuss the diagnosis with the patient, but after much discussion the participants in our course were more comfortable with this idea.

A network of computers, with internet access to allow distance learning and access to palliative care information on the web, was installed in Ho Chi Minh City, Cu Chi, Hue and Ha Noi.

Lyn Edwards

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Full Report

REPORT ON A PALLIATIVE CARE VISIT TO CHO RAY HOSPITAL, 
HO CHI MINH CITY (HCMC), VIETNAM
NOVEMBER 2001

Professor Ian Maddocks and his wife Diana, Lyn and David Edwards, Dr. Khiem Ngo, Elaine Magruder and Dr David Brumley flew to Vietnam to teach a 5 day introduction to Palliative Care at Cho Ray and to oversee the installation of computers with internet connection in Ho Chi Minh City, Cu Chi, Hue and Ha Noi. The computers have been installed to allow distance learning and access to information on palliative care on the web. Our visit was partly funded by Volunteers International and the International Association for Hospice and Palliative Care (IAHPC). Cho Ray is a 1200 bed city hospital in District 5 (Cholon) area of HCMC, a city of about 8 million people.

The course was run at the request of Dr. Hoang Hai, Director of the Training Dept. at Cho Ray because this hospital is currently building a cancer centre, which will boast two linear accelerators and a 10-bed palliative care unit. Dr Hai has had a long term interest in the development of palliative care at Cho Ray and has regularly attended Asian conferences on palliation. A staff member, Dr Thuan, has previously visited Australia for training in palliative care.

Twenty doctors and five nurses attended the course, including representatives from many different departments of Cho Ray. In particular, a general physician, renal physician, a neurologist, a neurosurgeon, a radiotherapist and an orthopaedic surgeon attended. The course commenced with an introduction to the philosophy of palliative care, and attention was paid to the traditional areas of pain and physical symptom control and emotional and psychological care.

The course ran for 5 days, and the course content included presentations from local speakers as well as us. Each morning began with a patient presentation from one ward area, and discussion about the patient followed. Teaching methods included short lectures, a series of pre-prepared translated case studies on symptom control of the common cancers and related problems in Vietnam – lung, cervix, breast, hepatocellular carcinoma, and HIV. Role play was used to demonstrate aspects of communication between doctor, patient and family, and these proved to be great fun and very instructive. In Vietnam it is not common to directly discuss the diagnosis with the patient, but after much discussion the participants were more comfortable with this idea, and several expressed their intention to change practice.

The particular problems we identified and were worked on in the course included access to and use of morphine. Changes to our planned teaching were needed because morphine is generally available only as 10mg ampoules for parenteral use. A long acting oral preparation, Skenan, is expensive and not readily available. Doctors outside hospitals cannot prescribe morphine, which makes discharge planning for patients requiring strong analgesics difficult. Transdermal fentanyl is likewise beyond the means of most, because patients must pay for their drugs. Many families face high costs when they travel from the countryside with a sick family member. The family must pay the patients costs for drugs and food in hospital as well as their own losses from work absence and expenses in the city.

We were also exposed to the reality of head injury in this city. The enormous volume of mixed city traffic in HCMC with cycle and motorcycles results in a large number of severe head injuries. These are made more frequent and severe by the almost total absence of helmets. Cho Ray is seen as the main provider of care for these patients. The severely injured patient gave us an opportunity to discuss the issues surrounding cessation of treatments and artificial hydration.

At the conclusion of the course I felt that it had been most successful. Within Cho Ray there is a great deal of general medical and nursing expertise and energy, and within the course a core of several doctors very actively interested in palliation. Plans have been made for maintaining contact by e-mail. In addition it is hoped that approval and funding can be found to assist the radiotherapist in his aim of travel to Australia for further training and experience in the day to day use of the linear accelerators being installed at Cho Ray. There is a desperate need for skills in this area, because there is currently only one Cobalt machine in HCMC available for the treatment of the poor, and this is currently out of service.

After working in Cho Ray, we traveled to Hue and visited the central hospital, where Elaine Magruder and others have previously set up an eight bed palliative care unit under the care of Dr. Phuong. Dr Phuong is a surgeon within the cancer centre, and is currently on leave in Belgium studying teaching methods. He has also visited Australia. We met Dr Cau, an oncologist, and two medical students who were working on a project on pain assessment. We also visited Dr. Bong, a Nun who is operating a medical clinic for the poor, and providing palliative care for many. She has also previously visited Australia.

Lyn spent time in Hue with the nurses, reinforcing and building on teaching that had been done by Australian nurses earlier in 2001. Lyn, David E, and Elaine then continued north to Ha Noi to Campus 2 of the Cancer Hospital. This was for further computer installation, and for more support and teaching of doctors and nurses in the use of a syringe driver in pain management and general Palliative Care principles. A syringe driver was donated for use in the Palliative Care unit at that hospital. Lyn was also able to participate in home visits to patients being cared for by their families.

We sincerely thank Elaine Magruder from Volunteers International and the IAHPC for their moral and financial support of our visit. Thanks also to Dr. Khiem Ngo for his extraordinary energy and translation, and to the staff of Cho Ray for their support. We are looking forward to returning to Cho Ray next year.

Submitted by: Dr. David Brumley & Lyn Edwards RN