"It's easy to see the equipment that has been thoughtfully installed in the ward. But we feel even more proud of the efforts we make in looking after the patients." Dr. Wang Ying-wei, director of the Heart Lotus Ward, expects that Tzu Chi Hospital will enlarge the scope of palliative care service. "I hope the way we look after terminally ill patients, which is different from ordinary medical care, will spread to the whole world."

People who have visited or heard a brief introduction of the Heart Lotus Ward in Tzu Chi Hospital always say that the facilities are real nice. One visitor even said, "I would like to stay in this ward too."

"It's easy to see the equipment that has been thoughtfully installed in the ward. But we feel even more proud of the efforts we make in looking after the patients." Dr. Wang Ying-wei is full of confidence that the palliative care work will get better and better.

Recalling the process of setting up the palliative care ward, Dr. Wang said that eight years ago, when all the physicians in the department of family medicine proposed the idea to Master Cheng Yen, she remarked that Chinese traditionally think that a person should pass away at home with family members around. Therefore, she encouraged the doctors to start by providing home care for the terminally ill.

Four years ago, Tzu Chi Hospital staff members who were concerned about palliative care organized classes on palliative care and spiritual care. In 1990, Mackay Memorial Hospital established the first palliative care ward in Taiwan. The time had arrived for Tzu Chi Hospital to prepare the same so that our home care and palliative care could be combined.

The hospital sent people to Japan to visit palliative care organizations. At the same time, they studied relevant information collected from abroad. However, Dr. Wang remarked that while they could refer to other facilities for the necessary hardware, the "software" had to be carefully planned by themselves to bring about a more indigenous development of palliative care. They had to consider local customs and habits surrounding eating and medication and traditional views of illness and death. In other words, they had to develop ways of treatment which could be accepted by local patients.

"When I came back from Japan, my mother-in-law was seriously ill," remembers Dr. Wang. "It made our family members experience the worry and despair that patients' relatives normally go through. She passed away not long after. Her illness and death, as well as the funeral arrangements, were a good opportunity for me to learn. It seemed that she guided me on the road of palliative care before she passed away." If he had only played the role of physician, he would not have understood the feelings of relatives of terminally ill patients.

The team members do their best to provide good, friendly care to the patients. They feel that a patient is not just a bed number. Nurses and volunteers work in shifts, but each one must look specifically after one patient so that he receives consistent care. In other words, a nurse is responsible for a particular patient all the time, not just when that nurse is on duty. The nurse must understand all the problems of the specific patient. If something happens, she can immediately discuss with others how to handle it properly.

"Any method is good if it is beneficial to the patient. We do a lot of brainstorming in our discussions. Any seemingly impossible idea can be brought out and will not be criticized because it might lead to another possible solution." Dr. Wang is the "idea king," and he also encourages others to create ideas. For instance, they use a beautician's face steamer to provide heat treatment for patients' feet. Chinese herbal medicine tastes very bitter, so staff members make the medicine into a jelly which tastes much better. Fragrant oil therapy can help patients sleep better, especially those with insomnia. Each patient who checks out from the Heart Lotus Ward is given a Patient/Friend Card and a medical kit, which even includes a bell which the patient can ring to call family members.

Each morning when the nurses change shifts, the doctors are there to listen to suggestions from the nurses, patients and their families. In order to enhance the interaction between team members and patients, they attach a chart on each case history to trace the results of their suggestions. Sometimes patients have problems which can't be easily solved, such as control of symptoms, interpersonal conflicts, complaints from their families, etc., which put pressure on medical team members. At such times, only the support of the team can reduce the pressure.

Team members do much more work in the Heart Lotus Ward than they would do in an ordinary ward. That includes things to be handled after the death of a patient and assistance to their families to reduce their grief. Therefore, the psychological burden of the team members is much heavier. All the patients in the Heart Lotus Ward will pass away soon. It seems that the medical team can have no sense of accomplishment. However, the principle of palliative care is to help patients get through the last period of life with dignity and to assist their families to cope with their emotions. That is their sense of accomplishment. After all, palliative care stresses care, not cure.

The National Health Administration made a suggestion that the team make an assessment of the quality of palliative care. Team members joked that they had an unofficial criterion-they could rate the quality based on whether patients' family members would come back to the Heart Lotus Ward to visit after the patients were gone.

Dr. Wang smiled and said that more than half of the families come back after the first week of the patients' death. They bring fruit or cakes to the nursing station to show their appreciation. Some of them promise to come back to do volunteer work, and some ask whether they can donate money. We can see that they trust and support the services in the ward. This is a response to the spirit of palliative care: patients pass away in peace, comfort, and dignity, and their families adjust themselves gradually through the grief period.

On the first anniversary of the ward, Dr. Wang encouraged team members by saying that they had to have the courage to accept failure and overcome difficulties. Teamwork doesn't mean just doing things well. They must constantly learn how to do things even better, and they must always encourage each other.

In addition, Dr. Wang expects to strengthen spiritual care so that religious professionals can take good care of patients with different religious beliefs. He thinks that in the last period of life, patients need spiritual guidance in their own religions to walk through the valley of death. Spiritual care is a special field in which doctors and nurses can help very little.

Regarding the development of palliative care, Dr. Wang thinks that Tzu Chi Hospital will enlarge its service area in Taiwan. Being always optimistic, Dr. Wang said with a smile, "I hope the way we look after terminally ill patients, which is different from ordinary medical care, will spread to the whole world."

Patient/Friend Card

There was a patient from Taichung. When his situation stabilized, he went back home. One day his condition suddenly deteriorated. His family sent him to a hospital nearby, where doctors performed CPR in an attempt to revive him. The procedure was too much for the patient and he died. His family members were extremely sad. When the team members in the Heart Lotus Ward heard about this, they also felt upset.

Usually when a patient is admitted into the Heart Lotus Ward, his family has to sign an agreement that no CPR will be done when the patient is in critical condition. But for patients who temporarily go back home, it is difficult to keep this agreement. Whether because of the attitude of the patient's family or because of poor cooperation in the medical system, patients often have to undergo unnecessary torture before their death.

In view of this, a special Patient/Friend Card was designed. It states that the bearer is receiving palliative care, and that if a critical situation happens, the Heart Lotus Ward of Tzu Chi Hospital should be contacted. The card measures 8.5 x 7.5 cm, so that it can be carried together with the national health insurance card. In a critical situation, an emergency unit will know that no CPR is needed.