Practical Pointers for Caring for the Sick at Home

Practical Pointers for Caring for the Sick at Home

All the passages below are taken from the book “Wish I Knew! Caring for the Sick at Home” by Susie Kong and Tisa Ng. It was published in 2004.

1. Tube Feeding

Susie Says:

A feeding tube is used when an invalid has problems with taking food orally. There are many reasons why people are put on tube feeding. The more common causes are stroke, pneumonia and surgery of the alimentary tract.

When a person has difficulty in swallowing, some food particles or liquid may go into the lungs instead of the stomach, resulting in lung infections.

If someone, especially an elderly person, keeps coughing or chokes easily when eating or drinking, this may indicate a developing problem with swallowing. Consult a doctor early, as delays may lead to lung infections and other complications.

There is nothing fearsome about the feeding tube, although it may not look attractive for someone to have a tube sticking out of the nose. The feeding tube is generally inserted through the nose, into the oesophagus and finally to the stomach. This is to ensure that the person with swallowing difficulties gets sufficient nutrition without having to take food and liquid through the mouth.

A timetable of feeds is usually recommended when the invalid is discharged from the hospital. This is to ensure that the invalid gets the necessary nutrition at regular intervals. The nutritional feeds come in a liquid form and are very well-balanced. The hospital's dietitian may recommend a protein supplement to be added to the feeds; otherwise, there is no need to give other food supplements.

It is a good practice to follow the scheduled time of the feeds, but do not be unduly worried if the invalid misses a feed because the tube is dislodged or pulled out and you have to wait for the nurse to come and reinsert the tube. Missing a feed is not critical: it is like a healthy person missing a meal.

Common sense goes a long way in dealing with invalids. One of the most useful things caregivers can do is to put themselves in the patient's place and try to imagine what it would be like.

Even when a maid or other helper is given the responsibility of dealing with the invalid, it is important for family members to be aware of what is going on in order to provide a good level of supervision, and to make decisions for intervention when necessary.

Let's face it - removing feeding tubes and inserting new ones can cause discomfort. This should be minimised through good maintenance and care.

When putting in a new tube is unavoidable, the process is easier for both patient and healthcare professional if the patient is relaxed and comfortable. Nervousness and resistance cause muscles to be tensed and can lead to trauma, and should be avoided.
The presence of someone who is familiar and trusted, talking calmly to the patient or just holding his or her hand, can make a world of difference.

Nervousness or unease on the part of family members can filter through easily to the invalid and cause unnecessary anxiety. This is the last thing the invalid needs.

Being observant of the patient's responses is also important, especially when speech or movement is impaired. It is hard to say or show what is wrong. For example, more restlessness than usual can be a sign of discomfort or distress and the cause has to be found.

The thing to remember in dealing with milk feeds and feeding tubes is that the caregiver is dealing with a person, not just with instruments and materials.

Tips on Feeding Tubes

Feeding tubes come in a variety of materials. Plastic tubes can last up to two weeks after they are put in place, while the more expensive silicon tubes can last up to two months. The right choice depends on several factors, including proper maintenance and the individual's response. If the invalid often pulls the tube out, resulting in frequent replacement, there is no point in investing in the longer-lasting silicon tubes. However, if the problem arises most commonly from kinking in the stomach, then the slightly stiffer silicon material may be an advantage since the plastic tubes are more pliant and prone to kinking.

There are two principal types of feeding tubes. The Ryles tube extends about the length of the forearm beyond the entry point at the patient's nostril. It has a single opening. An adaptor is required for the small syringe used in pre-feed testing, and the opening fits the catheter tipped 60-m1 syringe, used for feeding. The flexi-flo tube is a little shorter beyond the inserted portion and comes with two openings: a smaller one for administering the pre-feeding test and a bigger opening for feeding and medicines.

Both types of tubes have markings to show the correct position and whether they are properly in place. The Ryles tube has markings of one, two, three and four lines. For most adults, the three-line mark should be just visible at the nostril. The flexi-flo tube also has a black marking for the same purpose, which should also be just visible at the nostril, or slightly inside. Any significant variation - it is too far out, or has disappeared altogether - means that professional help should be called in to check or change the tube before anything else is done.

The tubes come in different sizes. For comfort, the most common size is 12Fr. The sizes of the Ryles tubes are colour-coded at the opening: black for size 10Fr, white for size 12Fr and green for size 14Fr.

Tips on Aspiration

The tube must be checked before each administration of any fluids or medication, to confirm that the tube is in place in the stomach and has not been dislodged between feeds. There are different methods of checking the tube. The most common way is to extract some fluids from the stomach and test with a small piece of blue litmus paper. The colour of the litmus paper should turn from blue to pink. The stomach produces acid and the change in colour of the litmus paper is an indication that the tube is in the stomach.

Some of the most common problems associated with feeding tubes arise from over-aspiration when drawing up the stomach's fluid contents to check for acidity. Too much pressure can lead to the tubes sucking in the soft lining of the stomach, preventing any fluid from being brought up for examination. When the stomach is empty, over aspiration can cause trauma to the stomach lining, resulting in traces of blood being drawn up. The air test is a useful alternative, although it requires a little training to perform with confidence.

To administer the air test, place a hand on the abdomen above the stomach, and then push a little air, about 10 ml, quickly through the tube with the small syringe. You should hear a gentle "pouf" as the air is expelled from the tube, and you will be able to feel the air under your hand at the same time. If you cannot feel any air entry or if you meet resistance when pushing in the air, it is advisable to get a professional to check.

It is essential to use the correct syringes for aspiration and for feeding. Always use a 20-m1 syringe for aspiration and a 60-m1 syringe for feeding. If the 60-m1 feeding syringe is used for aspiration, the pressure caused by the greater volume could cause damage to the stomach lining.

Common Problems

Feeding tubes can sometimes become curled up at the back of the throat. This can be checked visually by opening the mouth wide enough to see into the back of the throat, to ensure that it is straight and correctly in place. If the tube is curled up, it will have to be replaced.

Feeding tubes can also become kinked inside the stomach when it is empty. This is beyond the caregiver's control, and when that happens, there is no choice but to replace the tube. Kinking can occur when the patient is moved from a reclining to a sitting position for the feeds, especially for patients with relatively short upper bodies, or whose posture has been affected by their illness.

Sediments from medication and deposits from milk curds can cause clogging of the feeding tubes. The most effective way to prevent this is to ensure that the tube is adequately flushed immediately after anything has been introduced.

Feeding

Since milk flow is dependent on gravity, it is important to hold the feeding syringe at the correct level to achieve an appropriate rate of flow. Too low, and the flow becomes sluggish. Too high, and the rush may be more than the patient can take. As a guide, the feed should be held at about the patient's eye level when sitting up. Never feed the patient in a prone position. The backflow could come up the throat and get into the lungs, causing infection and other complications.

Although there are prescribed amounts of milk feed that have to be given to the patient, this can be varied from time to time depending on the patient's needs, changes in environment, and metabolism. Observation and common sense are reliable guides. Under normal circumstances, a complete feed of about 250 ml should take between ten to fifteen minutes. Any major deviation could be a sign that some adjustment is required.

Care of Tubes

Feeding tubes come with stoppers to protect them when not in use. The stoppers themselves should be kept clean. Always replace them when not using the tube. This should be done gently, so as not to pull at the tube. Occasionally, the stoppers in the flexi-flo tube may get very tight - this could be caused by a bit of a vacuum being created in the tube when the stomach is empty. If this happens, dip the stoppers in hot water to make them easier to open.

The tube is anchored with a piece of micropore tape at the nose. All that is really needed is to ensure the tube does not cause discomfort, and that it does not get tangled in bedclothes and other objects around the patient's head.

Since the human face secretes natural oils and additional moisture when it is hot, it is entirely possible that adhesive tapes can come off over time, or not stick securely. Rather than add more tape or attempt to press it down, wipe the area, make sure it is clean and dry, and replace the tape daily.

It is useless to have tape on the face if the tape is not secured to the tube itself. To make sure of this, loop the tape around the tube at the nostril before fixing the end to the side of the nose. However, no amount of tape can hold the tube in place if a patient is determined to loosen it. Therefore, the most effective thing to do is to see that the patient is as comfortable as possible, and accepts the presence of the tube and any slight discomfort it may cause.

Some invalids may have a feeding tube inserted directly into the stomach instead of through the nostril due to certain medical conditions, like a growth in the nose or throat. The decision to insert a stomach (gastrostomy) tube is usually discussed with the family, as this procedure requires a minor operation.

Feeding through a stomach tube is the same as feeding through a naso-gastric tube. The entry site of the tube should be cleaned daily and protected with a small piece of gauze to prevent infection. [40-46]

2. Catheters

Susie Says:

Catheters become necessary when a patient's bladder control is impaired, resulting in incontinence. Incontinence can refer to involuntary loss of urine when someone coughs or sneezes, inability to hold urine long enough to reach the toilet, or dribbling and leakage of small amounts of urine. This condition is common in elderly persons. Other common causes include surgery of the genito-urinary organ, gynaecological procedures and some major surgery.

In some older females, incontinence is often the result of stretching of the pelvic floor muscles during childbirth. The condition in older men can be due to enlargement of the prostates. The reason many elderly people do not like travelling long distances is because they fear they will not be able to control their bladder during the journey and would feel embarrassed to wet their pants.

Adult diapers can be used in mild cases of incontinence.

When control is seriously impaired, a catheter can be used for both men and women. For men, there is also the uro-sheath.

A catheter is a small thin tube, about 40 cm long, with two small holes at the tip end and two openings at the other end. This tube is inserted into the bladder through the urethra to drain out the urine. At the tip end of the catheter, there is a small, deflated balloon. When the catheter is inserted into the bladder, the balloon is inflated with a small amount of water to keep it from slipping out. The catheter is connected to a urine bag through a long connecting tube.

The uro-sheath is less intrusive since it is worn outside the organ, like a condom. This is slipped on, and then held in place with double-sided tape. It is important that the tape should be between the sheath and the skin, and not taped outside the sheath onto the penis. It is also important that the correct size is used. If it is too large, it will be difficult to hold in place, even with the tape, and the sheath can simply fall off. If it is too small, the pressure can cause the member to be engorged. Read the instructions carefully.

If incontinence is not treated, it can often lead to urinary infections, and in some cases, damage to the kidneys.

A catheter can get blocked with deposits of salts and proteins excreted by the kidneys. When a catheter is blocked, the urine cannot flow and the invalid will end up with a distended bladder that can be very painful. Urine left too long in the bladder can also result in urinary tract infections and damaged kidneys.

Tips on Catheters

Catheters are narrow and therefore prone to blockage when deposits of salts or protein particles gather in the narrow space. Constant flow helps to prevent these deposits by keeping the catheter flushed. This requires sufficient liquid intake. Generally, older people do not like drinking water, so it is important to remind them to drink plenty of liquid if they have catheters.

When pressure gathers due to blockage, it is possible that the accumulated urine can spurt out from around the catheter. Sometimes, when the bladder is over-distended, the neck of the bladder may go into spasms when the catheter is removed.

When this happens, the insertion of a new catheter can be painful and difficult. The best way to avoid this is to have the procedure done before this condition has arisen.

At times, there may be a little bleeding resulting from the trauma of changing catheters, and traces of blood can appear in the urine when the flow resumes after a new catheter is inserted.

When the flow is established, traces of blood in the urine could indicate an infection of the urinary tract. This should be treated with antibiotics, which must be prescribed by a doctor.

Leakage or urine seeping outside the tube indicates a blockage or other failure, and action should be taken as soon as possible. One clue as to whether the catheter is blocked is if the amount of urine coming out is much less than the usual amount. Call in a professional as soon as possible. Do not wait till there is no flow.

Types of Catheters

Catheters come in different materials, and they are intended to last for different periods. The 100% silicon catheter is the costliest and can last up to two months, if there is no blockage. Siliconised catheters can be used for up to one month, and latex catheters are intended for two weeks' use.

It is not necessarily a case of "the more expensive the better". Blockage can occur any time, regardless of the material used. If the urine is cloudy-looking with a lot of sediments, the catheter can get blocked in two weeks even if it is supposed to be a long-term catheter.

Adequate flushing is necessary, whichever the type of catheter used. This requires adequate liquid intake, which helps to prevent accumulation of salts and other sediments that can cause blockage.

Urine Bags

The urine is drained through the catheter to a connecting tube into a urine bag. This allows a filled urine bag to be emptied and replaced without disturbing the catheter. The connecting tube is usually protected with a blue or green cap at the connector. The cap must be removed when changing the urine bag to allow the urine to flow through. The urine bag should be changed at least once a week.

The simplest way to monitor urine flow is to observe the rate at which the urine bag is filled.

A significant reduction in the rate of flow requires attention. It is often the first sign of blockage in the catheter, which can occur when there is insufficient liquid intake, especially when the patient has limited movement.

It is also possible to monitor the condition of the patient by observing the appearance of the urine through the transparent material. Traces of blood could be an indication of infection. Protein deposits or sediments can cause cloudiness.

It is worth remembering that the urine needs to flow from the catheter to the bag. Therefore the connecting tube should be kept free of tangles and unnecessary loops, and the liquid should be allowed to flow downwards, working with gravity. There is nothing to be gained in opposing the laws of nature!

Wearing appropriate clothing is important when the invalid is on a catheter. Avoid wearing long tight pants, because it is difficult to put the urine bag and long connecting tube through the leg of the pants without accidentally disconnecting it. Sarongs or short pants are better options.

Faecal Incontinence

Faecal incontinence is another problem often experienced by the elderly invalid, either in the form of diarrhoea or constipation.

Diarrhoea is the frequent passing of loose or watery stools. Prolonged diarrhoea can lead to dehydration and should be treated immediately.

There are many causes of diarrhoea. Sometimes, medication like antibiotics, iron preparations or sedatives may lead to diarrhoea. Invalids who are on tube feeds may be sensitive to certain brands of milk and may suffer from diarrhoea during the initial period. If it does not settle after 3-4 days, consult your doctor or dietitian to change the brand of milk.

Constipation is a condition caused by infrequent bowel movements of hard faeces that are difficult to pass. When hard faeces and partially block the lower portion of the colon, it promotes mucous production, and a foul-smelling brown liquid may leak out. This is sometimes mistaken for normal bowel movement.

Elderly and bedridden invalids often suffer from chronic constipation because of reduced activity, inadequate fluid intake, inappropriate diet and certain medication. This condition can be painful and may affect the invalid's physical and psychological well-being and should be prevented.

Eating the right type of food, drinking plenty of fluids and doing a bit of exercise may prevent the invalid from getting constipation. This may sound simple but it is easier said than done. Most elderly people have problems taking a high-fibre diet because they have difficulty in chewing, while many do not like drinking water and few are willing to exercise.

It is sometimes necessary to give the invalid some laxatives to soften the stool. These can be given at night. Laxatives in syrup form are available at pharmacies and Chinese medical halls. Occasionally, if the constipation is really bad, an enema may be required. [72-76]

3. Bedsores

Susie Says:

Pressure sores or bedsores can develop when the invalid is seated or lying in the same position for long periods. Blood circulation to certain areas is slowed down and the tissue in that region of the body slowly dies. It usually starts with redness, then turns black and finally becomes rotten and smelly.

Pressure sores are painful and can be prevented. If the invalid is bedridden and cannot move independently, the caregiver must help to turn the invalid every two hours: right side, on the back, then left side.

It is important that family members are involved in the care of the invalid and do not delegate everything to the maids. Often, maids are too afraid to tell their bosses or ask for help even when they encounter problems.

Putting on diapers for invalids is convenient and prevents the bed from getting wet. However, they should be changed regularly, at least three to four times a day, as the warmth and moisture from the urine on the skin can cause bedsores. Clean the covered area with wet wipes each time the diaper is changed.

Lying or sitting in the same position for a long period of time impedes blood supply to particular areas. Give specific instructions to the maid to report any changes in the skin, for example, broken skin, redness or black patches. Ideally, a member of the family should check the invalid's skin condition at least once a day for broken skin or redness. Bedsores can be prevented if action is taken early to address the problem. If you are not sure, you may request the attending home care nurse to have a look at it.

As our weather tends to be humid, it is important that the room where the invalid sleeps is well ventilated at all times. Do not pile too many blankets on the invalid as the warmth and moisture from perspiration can cause the skin to break easily.

The bedlinen should be kept dry and clean without any creases. Wet linen should be changed immediately to prevent the body from being soaked in urine.

Infected bedsores produce a nasty smell similar to that of rotting meat. Be vigilant to any smell in the room that is not normal.

Changing Bedsheets

Not only do bedbound invalids have to be turned, they need clean beds too. Here's how to change the bedsheets for an invalid's bed.

Tips

Some invalids can be very heavy and it is difficult for one person to do the turning and positioning without dragging. Avoid friction between the skin and bed surfaces during turning. It is useful to place an old sheet or sarong under the body of the invalid. Two people can lift one side of the sheet or sarong, and then roll the invalid. To keep the invalid in position, place a pillow at the back for better support and another between the legs.

Pressure-relieving mattresses are available on the market. These mattresses are specially designed to take away the pressure on the body when the invalid is lying in bed. They are usually filled with air or water; some are made of thick foam. But although having the mattress is helpful, the invalid must still be turned every two hours.

Be vigilant and check on the skin condition daily, especially if the invalid is a diabetic. Look out for broken skin around the bony parts of the body, for example, scapula, back, hips, ankles or heels. If any redness appears, get the doctor or visiting nurse to have a look at it. Do not wait till it turns black, or worse still, become rotten and smelly. Once a bedsore has developed, treating the wound is a long process and can be very costly. [108-111]

4. Safety Precautions

Susie Says:

Falls among the elderly are one of the most common accidents that happen at home. The likelihood of falling increases with age, and women fall three times more than men.

The various factors that contribute to such falls are impaired vision, changes in gait and balance, medical problems, medication and environmental hazards.

Ageing affects the eyes' ability to adapt quickly to changes in lighting levels. Many old people suffer from glaucoma and cataracts. These conditions can affect visual fields and colour perception. Keep eyeglasses clean and ensure that they are in good working condition.

As a person ages, posture tends to worsen due to degenerative changes in the spine, loss of bone mass, and decreased muscle strength and flexibility, particularly in the back and legs. The change in the centre of gravity and balance increases the risk of falls, often resulting in fractures, which restrict mobility and further weaken the muscles.

Medical conditions and medication may pose another significant risk of falls. Dosage may have to be adjusted. Discuss with the attending doctor if the elderly person feels giddy after taking the drugs.

Many falls occur in the bathroom. Wet, slippery floors, uneven surfaces, curbs and steps and poor lighting are hazards that contribute to falls.

Many elderly people suffer from more than one medical condition, like high blood pressure, heart problems, diabetes and arthritis, and need to take several types of medication.

Names of medicines are usually long, and the packing and tablets may look similar. The labels are often very small and it is difficult enough for an educated young person to read and remember all the instructions, let alone an old person, or a maid. The instructions for medicines prescribed by doctors are in English; however, the majority of our elderly do not read or write the language, nor do most foreign maids. The family must translate the instructions into a language that they can understand and follow.

There are good reasons why some medicines are taken at different times of the day, some before food and some after food. All instructions must be followed exactly.

Some medicines may cause side effects like vomiting, rashes or diarrhoea. It is important to check with the doctor if there are side effects before continuing with the medicine.

Because invalids often have impaired ability to heal themselves, especially if there is a history of diabetes, even the smallest wounds should receive immediate and careful attention.

Keep all skin surfaces clean and thoroughly dried after washing. Areas where it tends to crease, especially the groin and joints, require special attention and must be well dried.

Elderly invalids with a history of diabetes must pay extra attention to their toes and nails. Any cracks or cuts may lead to infections with formation of pus. This is because the blood circulation to the feet, being the most extreme parts of the body, may be poor. Any broken skin, if not treated at once, may get infected and become gangrenous. In other words, the tissue dies and the toes turn black. The poison in the blood will circulate to the rest of the body and the health of the invalid will be further compromised.

Tips

Things like throw rugs, electric cords and small objects can cause the elderly to trip and fall. Loose items on the floor should be kept to a minimum. Tape down any electric or telephone cords. Keep all passageways clear and allow sufficient width if a walker or a wheelchair is used.

Furniture should be solid and stable and of a suitable height. It is difficult for the elderly person to sit down or get up if the chairs are too low and the cushions too soft.

The height of the bed used by the elderly person is an important consideration. It should not be too high or too low, so as to allow the elderly to get in and out of bed without the risk of falling. Place a table lamp beside the bed and use a nightlight.

If the room does not have an en-suite bathroom, it is advisable to place a commode chair next to the bed at night. Elderly people often need to go to the toilet during the night and may lose their orientation when they get up from the bed.

Consider installing grab-rails in the toilet and shower area, and nonslip floor tiles in the bathroom. Some can be installed with minimum fuss, while others can be laid over existing surfaces. Elderly people, especially those who use walking sticks or walkers, often have problems maneuvering small curbs and steps. Where possible, remove them, or replace the tiles with a darker colour to highlight them.

Install adequate lighting and place items like soap and shampoo where they can be reached easily. Many elderly people have stiff joints and may have problems squatting. Replace squatting toilets with sitting toilets, or place a commode chair over the squatting toilet.

It is advisable to install a sliding door or a door that opens outwards, to allow more space in the bathroom.

Different medicines are prescribed for different conditions and must be taken according to instructions. As many liquids and tablets look similar, it is important that the labels are kept on the original plastic bags or bottles. If you are not sure, check with the doctor or pharmacist.

If it is necessary to transfer pills to a box, make sure names, dosages and timings are written clearly. Give instructions to the person responsible for administering the medicine, and supervise until that person fully understands what to do.

All medicines should be kept out of reach of children. Some medicines are sensitive to light and need to be stored in dark containers, otherwise they may lose their effectiveness. Keep them in a cupboard, not by the bedside or left lying around the house.

Never use medicines that are expired, or prescribed for somebody else. You should flush all expired or leftover medicines down the toilet bowl to prevent other people, especially children, from eating them.

If there are any side effects like rashes, giddiness, swelling or vomiting, stop the medicines immediately and seek advice from the doctor who prescribed them.

To prevent the feet or toes from getting infected, wash the feet daily with lukewarm water and mild soap and dry them thoroughly. Apply a moisturiser to the feet and heels to keep the skin soft.

Toe nails in the elderly tend to become thickened and brittle and can be uncomfortable. Cut them straight across and gently file the rough edges to prevent ingrown nails. If the elderly person is mobile and can move around, ensure properly fitted shoes are worn to protect the toes.

People in Singapore have a habit of going barefoot at home. It is advisable that the elderly wear at least a pair of slippers when walking around the house, to prevent injury to the toes if they accidentally knock into something hard, like legs of furniture or children's toys left lying on the floor.

Any cuts or injuries must be attended to immediately. These can easily get infected, resulting in complications that sometimes require amputation.[90-94]

5. Caring for Caregivers

Susie Says:

It is easy to forget that the caregiver is also a whole, multi-dimensional person, with his or her own complex feelings, needs and aspirations, and a life beyond the primary role of looking after the invalid. Concern for the patient and an exclusive focus on the responsibilities of the caregiver can often lead to neglect of the latter's own requirements.

The immediate family may be the first line of defence, the first ones on call when needed. This is natural. It is worth remembering that the family could also be of immense help to the caregiver in taking over from time to time, so that he or she can pursue other activities or enjoy the company of a wider circle of friends.

It is the invalid who cannot lead a normal life. The caregiver should not be subjected to the same restrictions.

A caregiver's needs may change over time. This is expected in a living, evolving person. So, there are times of special anxiety about the invalid when all else is secondary, and other times - usually when the invalid has been stable for a period - when the caregiver could do with some respite. Sensitivity to these changing needs and accommodating them can be the best forms of support for a caregiver.

Because the invalid is the centre of everyone's attention, caregivers often feel as though they are not entitled to any special consideration, and that if they receive either financial or logistical aid from other family members, it is already good enough. In fact, the caregiver is carrying the bulk of everyone's burden, for and on behalf of the whole family. Therefore, beyond any assistance in coping with the invalid, the caregiver's needs must also be addressed by the whole family.

It is worth remembering that a family, especially under the extra stress of coping with the needs of an invalid, is more than just a set of logistical arrangements. Just handling everything that needs to be done is not enough.

Tips

It is your time, not your life, which needs to revolve around the invalid's schedule. You are not indispensable. Let someone take over once in a while. Take time out for yourself. Involve other family members so that you can take a break from your daily caregiving routine, even if only for a few hours.

You will be able to cope better if you have occasional relief from your duties. Take a short vacation to recharge. Make alternative arrangements if it is inconvenient for other family members to take over. There are facilities like nursing homes or community hospitals that provide short-stay respite care.

Communication is key. Do not expect even close family members to anticipate your needs. Tell them.

Do not cut yourself off permanently from the world. Make time and space for activities unrelated to your duties with the invalid. Go out and have a meal or watch a movie with friends; it is important for you to continue having a social life. This will help you cope better in the eventuality of loss.

Have a chat with a friend, or with the visiting nurse. There are many family service centres located throughout Singapore that provide counselling services and family support. Check with your local family service centre if they have support groups. Through these groups, you can share experiences and may find answers to similar problems you encounter.
Many invalids are taken care of at home by maids. Remember that maids too need a break, and it is advisable that family members take their turn at least once a day. Relieving the maids from their duties also provides an opportunity for family members to spend time with the invalid. [28-29]

6. Death and Dying

Susie Says:

Being prepared is helpful in everything, even death.

Families can go to extreme lengths to keep patients alive, even when quality of life is severely impaired. This is sometimes a response to the emotional needs of the family rather than the best interests of the patient. The issues are complex. No outsider can fully understand, or take the decision away from those involved. However, a clear understanding of the motivations guiding these decisions can be helpful in choosing the best course for all - including the patient.

When there is a sick elderly person or someone with a terminal illness at home, the family must learn to accept the eventuality of death. Most terminally ill elderly people know that they are dying and accept death with resignation. The person may want to talk about joys and sorrows, or even the funeral; allow him or her to do so.

For long-term caregivers, whose lives have been adjusted around an invalid's needs, the demise of the invalid can create a vacuum. A period of disorientation is common and it will take time for the caregiver to pick up the strands of his or her own life. This is easier when the caregiver has not been cut off from other family and social support. Where the responsibility for caregiving has resulted in a high degree of isolation, the adjustment is likely to be much more difficult.

Tips

When a person dies in hospital, the doctor-in-charge will prepare the death certificate, and the bereaved family will then be able to claim the body from the mortuary. However, it is useful to be aware of some procedures such as reporting the death, deciding on the funeral and obtaining the necessary permits for the wake, cremation or burial.

In the event that a sick invalid collapses at home, the first thing to do is to call 995 for an ambulance. When it arrives, the medics will check on the status of the patient. If the invalid is alive, the medics usually advise that the invalid be taken to hospital for further management. But if the invalid dies before the ambulance gets there, the medics will inform the nearest police station, and the police will visit the house to ensure that no foul play has taken place. While waiting for the police, the family should try to contact the family doctor to come over to certify the cause of death.

When someone dies at home, the family doctor or a doctor who has recently attended to the deceased must certify the cause of death before any funeral arrangements can be carried out. Many elderly people unfortunately do not have their own family doctors, so when death occurs at home, especially at night, it is difficult to find a doctor who can certify the cause of death. Sometimes the casket companies, at the request of the family, may offer the services of a doctor for convenience. Remember: this is illegal. It is advisable that if you have a sick elderly person at home, you should get a doctor from your neighbourhood to attend to the invalid. Discuss with the doctor whether he would be prepared to certify the cause of death should this person die, and find out how to contact him if the clinic is closed.

When death occurs at home, the family must report it at the nearest neighbourhood police post. Bring the deceased's identity card or passport and death certificate. If the police are satisfied that the invalid has died from natural causes, they will issue a permit for burial or cremation.

If there is no doctor to certify the cause of death, the police may request that the police investigator go to the house and examine the body. A police hearse will be activated to remove the body to the mortuary at the Singapore General Hospital. An autopsy may be carried out there to determine the cause of death. If the deceased has been hospitalised before, and the hospital is certain that the cause of death is due to his medical condition, then an autopsy may not be necessary. The family will be advised to claim the body from the mortuary the next day.

After the police report has been made, the bereaved family can proceed to engage the services of a casket company to make all the necessary arrangements for the wake and funeral. This can be done by phone - the list of casket companies is found in the Singapore Yellow Pages.[123-125]

Resources

Home Nursing Services

These organisations provide nursing services to homebound elderly. Most patients would have been referred to one of them on discharge from hospital. Services are provided mainly by voluntary welfare organisations and patients can apply for subsidies from the Government based on their family income levels. We have also included a few private providers and hospitals.

Alexandra Hospital Home Nursing Centre 64792468

378 Alexandra Road

Alexandra Hospital S(159964)

Ang Mo Kio Home Nursing Centre 64506293

17 Ang Mo Kio Avenue 9 #02-01

Ang Mo Kio Community Hospital S(569766)

Ang Mo Kio Hospital Home Care Services 64506273

17 Ang Mo Kio Avenue 9 #02-01

Ang Mo Kio Community Hospital S(569766)

Bedok Home Nursing Centre 62412195

Blk 212 Bedok North Street 1 #03-147

Bedok Polyclinic S(450212)

Bukit Batok Home Nursing Centre 64251879

50 Bukit Batok West Avenue 3

Bukit Batok Polyclinic S(659164)

Care for the Elderly Foundation 67417444

461 Sims Avenue S(387541)

Changi General Hospital Home Nursing Centre 68501740

2 Simei Street 3 Changi General Hospital S(529889)

Geylang Home Nursing Centre 67457285

21 Geylang East Central S(389707)

Grace Home Care Services 62265307

Blk 1 Tanjong Pagar Plaza #03-50 S(082001)

Home Nursing Foundation 62525677

93 Toa Payoh Central

Toa Payoh Central Community Club

#07-01 S(319194)

Hougang Home Nursing Centre 63871230

89 Hougang Avenue 4 S(538829)

Institute of Health Home Nursing Centre 63274717

3 Second Hospital Avenue S(168937)

Jurong Home Nursing Centre 65609902

190 Jurong East Avenue 1 #03-00

Jurong Polyclinic S(609788)

NUH Home Nursing Centre 67725535

5 Lower Kent Ridge Road

National University Hospital S(119074)

Ren Ci Domiciliary Care 63580777

50 Jalan Tan Tock Seng S(308438)

Singapore General Hospital Home Nursing Centre 63265291

Singapore General Hospital Outram Road S(169608)

St Luke's Community Care for the Elderly 65632281

2 Bukit Batok Street 11 S(659674)

Tan Tock Seng Hospital Home Nursing Centre 62511586

11 Jalan Tan Tock Seng

Tan Tock Seng Hospital S(308433)

Toa Payoh Home Nursing Centre 62525677

93 Toa Payoh Central S(319194)

TOUCH Community Services (TOUCH Home Care) 62586797

Blk 173 Toa Payoh Lorong 1 #01-1264 S(310173)

Tsao Foundation (Hua Mei Mobile Clinic) 64716007

378 Alexandra Road #02-01/03

Community Services Complex

Alexandra Hospital S(159964)

Woodlands Home Nursing Centre 63670812

10 Woodlands Street 31 S(738579)

Private Providers

Econ Home Care Services 64478788

20 Jalan Afifi #06-02 62554333

CISCO Centre S(409179)

SharYim Health Services Pte Ltd 62554333

1013 Braddell Hill #25-06 S(579721)

Sister Choy Health Services 63388811

35 Selegie Rd #09-26 67321555

Parklane Shopping Mall S(188307)

Sue Private Nurses Agency 67321555

304 Orchard Rd #04-06

Lucky Plaza S(238863)

Hospices

Assisi Home Lt Hospice 63476446

820 Thomson Road

Mount Alvernia Hospital S(574623)

Bright Vision Hospital 62485755

5 Lorong Napiri S(547530)

Dover Park Hospice 63566417

10 Jalan Tan Tock Seng S(308436)

Hospice Care Association 62512561

12 Jalan Tan Tock Seng S(308437)

Methodist Hospice Fellowship 64784712

70 Barker Road #05-01 S(309936)

Metta Hospice Care 67872212

Blk 296 Tampines Street 22 #01-526 S(520296)

Singapore Cancer Society Home Hospice Care 62219578

15 Enggor Street #04-01/04

Realty Centre S(07971 6)

St Joseph's Home Ft Hospice 62680482

921 Jurong Road S(649694)

Hospitals

Adam Road Hospital 64667777

19 Adam Road S(289891)

Alexandra Hospital 64722000

378 Alexandra Road S(159964)

Ang Mo Kio Community Hospital 64538033

17 Ang Mo Kio Avenue 9 #02-01 S(569766)

Changi General Hospital 67888833

2 Simei Street 3 S(529889)

East Shore Hospital 63447588

321 Joo Chiat Place S(427990)

Gleneagles Hospital 64737222

6A Napier Road S(258500)

KK Women's and Children's Hospital 62934044

100 Bukit Timah Road S(229899)

Mount Alvernia Hospital 63476688

820 Thomson Road S(574623)

Mount Elizabeth Hospital 67372666

3 Mount Elizabeth S(258510)

National Cancer Centre 64368000

11 Hospital Drive S(169610)

National Heart Centre 64367800

17 Third Hospital Avenue S(168752)

National Neuroscience Institute 62564755

11 Jalan Tan Tock Seng S(308433)

National University Hospital 67795555

5 Lower Kent Ridge Road S(119074)

Raffles Hospital 63111111

585 North Bridge Road S(188770)

Ren Ci Hospital Et Medicare Centre 63580777

50 Jalan Tan Tock Seng S(308438)

Singapore General Hospital 62223322

Singapore General Hospital Outram Road S(169608)

St Andrew's Community Hospital 62419956

1 Elliot Road S(458686)

St Luke's Hospital for the Elderly 65632281

2 Bukit Batok Street 11 S(659674)

Tan Tock Seng Hospital 62566011

11 Jalan Tan Tock Seng S(308433)

Thomson Medical Centre 62502222

339 Thomson Road #B1-00 S(307677)

Woodbridge Hospital 63892000

10 Buangkok View S(539747)

Home Care Equipment and Supplies

Home care aids, equipment and supplies are available in most retail pharmacies and hospital pharmacies. Some companies provide aids and equipment on a rental basis, and home deliveries can also be arranged.

Bendemeer Medical Marketing Et Nursing Services 62932307

Blk 43 Bendemeer Road #01-1032 S(330043)

DNR Wheels Pte Ltd 62544070

21 Kim Keat Road #01-03 S(328805)

Equip Medical Pte Ltd 65623008

81 Toh Guan Road East #03-01 S(608606)

JDH Marketing (Singapore) Pte Ltd 68501868

279 Jalan Ahmad Ibrahim #03-01 S(639938)

Lifeline Corporation Pte Ltd 62892062

85 Playfair Road #06-02

Tong Yuan Industrial Building S(368000)

Medicare (S) Pte Ltd 67345150

20 Kramat Lane #04-07

United House S(228773)

Nightingale Nursing Et Medical Services 63245826

1 Kampong Bahru Road S(169339)

Pharmex Marketing 68410636

18 Jalan Masjid #B1-03

Kembangan Plaza S(418944)

Rehab Mart 62531629

12 Boon Teck Road S(329586)

Respite Care

Caregivers may sometimes need to take a short break to get recharged, but worry about having no one to take care of the invalid at home. Respite care arrangements can be made for a short stay in a nursing home or community hospital. Information on nursing homes is available in the Singtel Yellow Pages. Listed below are community hospitals that accept patients for respite care.

Ang Mo Kio Community Hospital 64538033

17 Ang Mo Kio Avenue 9 #02-01 S(569766)

Bright Vision Hospital 62485755

5 Lorong Napiri S(547530)

Ren Ci Hospital Et Medicare Centre 63580777

50 Jalan Tan Tock Seng S(308438)

St Andrew's Community Hospital 62419956

1 Elliot Road S(458686)

St Luke's Community Hospital for the Elderly 65632281

2 Bukit Batok Street 11 S(659674)

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