Samantha Grace Puckett Reflection – Palliative Care Training in Kenya

Samantha Grace Puckett was awarded a Center for Global Health Student & Trainee Travel Grant in the fall of 2023 to pursue a project with Living Room International Palliative Care Program in Eldoret, Kenya. View more photos of her project in this Flickr photo gallery.

When I think about my time at The Living Room Hospital and Kimbilio Hospice House, I'm struck by the same things I'm always struck by when I travel internationally and experience healthcare in a new setting vastly different from my training setting. The people in Kenya are the same people we see here in the United States. We are the same, both the people that we care for and the professionals who provide care. The physicians encounter many of the same struggles that we experience in the United States healthcare system. This is no different in Kenya or in palliative care, than it is many other places I have had the privilege to travel. For example, in Kenya, in palliative care, they encounter some of the same resistance that we experience in the United States. Namely, that we have a medical culture that does not accept palliative care. Also, the focus on miracles is much the same, the emotions experienced around death are the same. We are the same people.

The other thing that struck me while I was there was their ability and freedom to design a new system in medical care. The context of medical care often feels so restrictive in the United States, especially in our ability to imagine new solutions for old problems. They have been able to develop a way of treating patients with honor and dignity almost regardless of the price point while still being able to be financially solvent. Which is incredibly inspiring.
This was also educational for me in that it's the first time I've seen a bidirectional partnership at work. This is unique just like every other bidirectional partnership. For us, the bidirectionality doesn't necessarily include people traveling from overseas to the United States. Mostly because that is very expensive and may not ultimately help those travelling to the US significantly. I am of course hopeful that the friends I have made will be able to come to the United States eventually, but for something to be bidirectional it doesn't have to include physical travel both directions. I do not think, however, that just meeting virtually truly suffices to really build the relationships that are necessary for bidirectional partnerships to exist.

When I first got to Kenya, I wasn't completely sure what we were doing there. There wasn't a huge plan. We didn't have detailed plans for every day. And we didn't have any planned organized education to provide them. So, I worried that they wouldn't really get much out of it. I was sure that we could get something out of it just by observing the teams at the Hospice House and the hospital. I always feel like I learn something in that environment. But I wasn't sure if they were going to get anything out of it. I have learned to check my assumptions at the door about the need to have a very detailed plan and an organized structure and am much more open now just to the value that can be gained from conversation, and observation, and mostly, relationship. The exchange of knowledge and understanding is invaluable. Below are some reflections that we as a team collected with members of The Living Room Hospital Team. The hope is to use these for future educational endeavors to continue supporting our new friends, building this relationship, and ultimately increasing capacity for palliative care in Kenya.

Team reflections:

Together with the directors, clinical officers, medical officers, and family medicine specialist, we were able to identify several opportunities to apply practices from Kenya back to our context in the US and potential areas for improvement at The Living Room Hospital to be addressed during further virtual case-based discussions and educational interventions.

Practices to bring back to the United States

1. Seamless interdisciplinary team (IDT) Integration, especially during family meetings: We noted that the IDT at The Living Room Hospital does an excellent job of utilizing all members of the team during family meetings. The chaplain or social worker often begins the meeting and explains the purpose and hopeful outcomes of the meeting. They also address the spiritual needs of the family and patient from the very beginning in a culturally contextual way. For Kenya, this includes beginning and ending the meeting with prayer. During the first meeting, the family is always given the first opportunity to speak and share their experiences, followed by the medical team sharing the medical updates. Social workers and counselors will then also support the family members emotionally by acknowledging the difficulties of the situation and helping the family to navigate difficult decisions.
2. Highly Effective Use and Design of the Physical Environment: They utilize their space well, conducting all family meetings outside if possible. They have even built multiple areas in the gardens with this express intention. Not only family meetings, but even sometimes patient rounds were conducted outside. At Kimbilio Hospice, even patients who were bedbound were brought outside or into the public living spaces daily if this was possible, to facilitate an atmosphere of community and family, thus attending to the social needs of the patients.
3. Creative Funding Sources: Palliative care in general is difficult to obtain funding for as it typically does not make money for an organization, even if it does save that organization money. As a non-profit, the organization has developed creative funding models to supply funding to portions of their care which they feel are beneficial to their patients, but difficult to get insurance coverage for. For example, they have a funeral home which provides services to the broader community and the profits from this allow them to cover costs at Kimbilio Hospice House.
4. Meticulous Comfort Care (Hand feeding, wound care): We were struck by how well they do comfort care. They take their time and invest considerable resources to hand feed, provide meticulous wound care, and sit with patients. They do not factor in disposition or question if a patient is appropriate for the care setting. Rather, they are mission driven to provide care where care is needed. In many ways, the clarity of their mission and compassionate care delivered with the human touch results in better outcomes than the care model in the US.

We also identified a few areas for possible improvement that the team also agreed would be helpful.

1. Fine-tuning in Communication Training: Regarding the acute care setting, the staff would benefit from communication training. They had so many of the elements of good palliative care (symptom management, skilled prognostication), but they lacked the training on how, when, and with what wording to deliver bad news or communicate around serious illness. The team was receptive to learning communication skills around serious illness, but the cultural barriers around EOL care will still have to be addressed.
2. Shifting from General Medicine to Palliative Care and Back: Covering clinical, and medical officers, have a very difficult task as they receive patients for both palliative and non-palliative focuses, and at varying stages within the palliative care process. Some patients do not have a life-limiting illness at all. For example, the team cares for many straightforward, postoperative patients from routine surgeries, such as tonsillectomies and thyroidectomies. Some patients may still be pursuing curative treatment and may present with reversible illnesses, which may or may not be related to their primary diagnosis. Others still are referred to The Living Room Hospital only once their primary diagnosis has been deemed incurable. This places the team at The Living Room Hospital in a difficult position as they are required to constantly shift gears between Palliative/Comfort-focused care, and diagnostic and treatment focused care.
3. Streamlined Sign-out Processes: There is a high turnover of rounding providers from one day to the next; however, they seem to have a relatively minimal sign-out process. This leads to significant time spent trying to recall what plans were established the day before. This also leads to miscommunications between the team and the patient’s family and changes in the plan day to day as different physicians are covering.
4. Allowing for Time to Complete Follow-up Tasks: Due to the time it takes to round on all patients and the need for multiple family meetings in the afternoon, providers are often unable to go back to check on changes that were made in the morning. This means that no follow-up is happening on the effects of decisions made during rounds until the next day, potentially leaving patients unnecessarily in pain or in danger. Occasionally, changes that were decided upon during rounds (eg discontinuing antibiotics or increasing pain medications) are not made until the following day.
5. Selective Use of Antibiotics: Many of the patients were treated with antibiotics without discretion for where in the treatment course they find themselves or the possible side effects of these medications. There is space for more direction and guidance on when to use antibiotics including focuses on the goals of care and the likelihood that the causes of distress are infectious. As the common causes of illness in Kenya have shifted from infectious causes to noncommunicable diseases, a similar shift is required in treatment choices from treating everyone with antibiotics to approaching antibiotic use as one tool in a toolbox to be used as the appropriate situation arises.
6. More Detailed Pain Assessments: We had many good conversations on rounds about what type of pain each medication was being used to treat, so the staff are clearly comfortable with the indications for each type of pain medication, but they often did not get detailed pain histories from the patient to aid in choosing medications and to decide if the pain might indicate a new problem that ought to be addressed.
7. Increased Utilization of PRN medications: The hospital does not seem to have a system for patients to have “as needed” or PRN medication available to them, so often pain that is episodic in nature is not being treated as effectively.
8. Increased Utilization of POCUS: They have significant capabilities at The Living Room Hospital and via referrals to Moi University Hospital nearby; however, as is often the case in the US as well, decisions about when to use these tools are often unclear. For example, they can use POCUS, but many providers do not have training and, more importantly, there are not yet protocols or guidelines on when to use this tool.