Palliative Care and Pain Suppression in Thailand

[connda]

On 8/29/2017 at 1:49 PM, Sheryl said:

Singapore has well developed hospice services both in-patient and in the home.

 

But if you are going to travel away from home could just as well be in a hospital in Thailand. End-of-life care in the better private hospitals, if you have a palliative care specialist as your primary doctor, are OK. The gap is for hospice type care in the home.

So if I can't afford a better private hospital, then dying without adequate palliative care is in the cards?  This is why some expats opt out to exit life on their own accord.  It totally sucks when it has to be a financial decision - do I exit in minimal pain and leave my wife financially destitute, or just exit so she is  the recipient of the estate and not some hospital's finance department.  The morphine is not expensive - just unavailable at the right dosages to keep you out of morbid pain.  It should not be that way.  We treat our dogs better than that.  Says a lot of Thailand and their compassionate culture.  Don't get me wrong - I'm Buddhist and have been for decades.  But compassion means taking the steps to keep others from suffering.  I'm not seeing it here.
So that is why I'm asking about hospices outside of Thailand.  I have insurance that will cover hospice care.  I'm not sure they will cover end-of-life care in a "better private hospital."   

[NancyL]

16 minutes ago, connda said:

So if I can't afford a better private hospital, then dying without adequate palliative care is in the cards?  This is why some expats opt out to exit life on their own accord.  It totally sucks when it has to be a financial decision - do I exit in minimal pain and leave my wife financially destitute, or just exit so she is  the recipient of the estate and not some hospital's finance department.  The morphine is not expensive - just unavailable at the right dosages to keep you out of morbid pain.  It should not be that way.  We treat our dogs better than that.  Says a lot of Thailand and their compassionate culture.  Don't get me wrong - I'm Buddhist and have been for decades.  But compassion means taking the steps to keep others from suffering.  I'm not seeing it here.
So that is why I'm asking about hospices outside of Thailand.  I have insurance that will cover hospice care.  I'm not sure they will cover end-of-life care in a "better private hospital."   

Connda, pallative care units in Thailand usually are located within private hospitals.  So if your insurance will cover hospice care, why won't it cover end-of-life care in a private hospital?

[Sheryl]

They do give morphine in the govt hospitals. And plenty of people die in them. But nurse:patient ratios are poor and the overall level of palliative care not up to what one would want...though certainly better than nothing. To day

 

End of life care is not as expensive as other things (e.g. surgery etc) in a private hospital.

 

As mentioned, oral morphine and fentanyl patches can be gotten outpatient. You would need to be admitted only at the point where you could no longer take oral medication so stay would usually not be very long.

[al007]

21 minutes ago, Sheryl said:

They do give morphine in the govt hospitals. And plenty of people die in them. But nurse:patient ratios are poor and the overall level of palliative care not up to what one would want...though certainly better than nothing. To day

 

End of life care is not as expensive as other things (e.g. surgery etc) in a private hospital.

 

As mentioned, oral morphine and fentanyl patches can be gotten outpatient. You would need to be admitted only at the point where you could no longer take oral medication so stay would usually not be very long.

I started this thread

 

there is a lot of misinformation that has  been posted, DT would call it fake news

 

i have confidential information from very good doctors that tell a different story, I will willingly share on a PM basis 

 

I am rather fed up with the politics of TV

[al007]

30 minutes ago, Sheryl said:

They do give morphine in the govt hospitals. And plenty of people die in them. But nurse:patient ratios are poor and the overall level of palliative care not up to what one would want..

You would need to be admitted only at the point where you could no longer take oral medication so stay would usually not be very long.

Fake new scare news

 

At the stage you are admitted and on IV pain suppression you know little of whats going on so nurse patient ratio etc irrelevant

 

Do not be sacred by so called experts

[al007]

 

 

In post 32 Nancy quoted as follows

 

 So if your insurance will cover hospice care, why won't it cover end-of-life care in a private hospital?

 

Well there is a lot of misunderstanding around

Insurance companies are large businesses for the purpose of making money

 

They write to contract and all the small print

 

The less they pay out the more money they make

 

They will always take your money and only dispute at the time of claim

 

So to make the statement why won't they cover end of life in a hospital very obvious the policy does not include that

They only pay according to the contract they wrote, nat according to what you might like

 

 

In post 19 Nancy quoted

 Everyone, no matter how old, can obtain accident insurance.

 

This is on the thread on palliative care, and if anyone believes this type of policy might payout for Palliative care, that is fake news and very mistaken

I believe its inclusion without warning could persuade people to spend money they do not really have and expect to be covered for palliative care, to be mislead

Of course if at the time you need palliative care and are knocked off the motor bike then hospital costs might be paid, but in reality at that stage of your life you are unlikely to be on the motor bike

 

Generally be very careful and read all the small print in depth before buying ANY insurance, and if in doubt ask the insurance company to clarify further in writing, in that case, the letter will be enforceable legally

 

Insurance companies are here for their benefit not ours, pay premiums for years, get old the insurance company then increases the premium to unaffordable levels, and when challenged say we did not withdraw cover, offered market rates and the insured chose not to renew, his problem not ours

 

Americans should at least understand this last bit , it happens in the USA all the time, Obama care was trying to change this, but in Thailand that would not help you

[Sheryl]

 
 
In post 32 Nancy quoted as follows
 
 So if your insurance will cover hospice care, why won't it cover end-of-life care in a private hospital?
 
Well there is a lot of misunderstanding around
Insurance companies are large businesses for the purpose of making money
 
They write to contract and all the small print
 
The less they pay out the more money they make
 
They will always take your money and only dispute at the time of claim
 
So to make the statement why won't they cover end of life in a hospital very obvious the policy does not include that
They only pay according to the contract they wrote, nat according to what you might like......

He specifically stated his policy does cover hospice care.

Hence Nancy's question.

[NancyL]

14 hours ago, al007 said:

Fake new scare news

 

At the stage you are admitted and on IV pain suppression you know little of whats going on so nurse patient ratio etc irrelevant

 

Do not be sacred by so called experts

Sheryl has seen much more of end-of-life situations here than anyone on this thread.  I have seen situations where people were admitted to hospital, clearly suffering in pain from cancer, but because the cancer hadn't been "staged" with appropriate screenings done to determine the spread with a prognosis about just how long the patient had to live, morphine was denied.  As Sheryl has said, it's important to seek treatment early and have a palliative care specialist who is your primary care physician.  

[al007]

1 hour ago, Sheryl said:

 

He specifically stated his policy does cover hospice care.

Hence Nancy's question.

 

Correct, I think maybe you miss my point, insurance companies pay out according to the contract

 

The contract says hospice not hospital

 

Of course it is worth challenging it but unlikely in my view as a retired professional who among many things had in the past responsibility for very large group medical schemes as well as PHI and disability insurance

 

Insurance companies  and the underwriters are not charities and often not nice people

 

At the time of taking out the policy if the question had been asked will you pay for hospice care in a hospital and there was a written answer confirming  then he probably ok

 

Even on this thread there is a difference in meaning maybe in English like the Queens English, being my language and American English

 

Palliative care in a hospital is not the same as a hospice, I can only talk for the UK where hospices are far cheaper than full blown hospitals

[al007]

1 hour ago, NancyL said:

.  As Sheryl has said, it's important to seek treatment early and have a palliative care specialist who is your primary care physician.  

I only talk of my own personal experiences

 

With all my problems for me it is neither sensible nor appropriate for my primary care physician to be a palliative care specialist at this time

 

This week I have had long discussions with my primary oncologist, I actually have two, on the question of pain when dying

 

For me that man is my number one carer

He trained at John Hopkins, he is about 40, in his prime and not past his sell buy date

 

(A friend with prostate problems this week saw a urologist at a private hospital in BKK, and that man was past his sell by date and gave some very suspect opinions, age of consultant for me is critical)

 

My Oncologist agrees Thailand lags USA and UK in pain suppression but comments among the younger doctors things are changing a lot

He has categorically assured my wife and myself, he can and will arrange for pain mitigation whilst at home even though 500kms from BKK, and with a little manoeuvring this will be until the very end

 

HE HAS SAID DO NOT WORRY HE WILL TAKE CARE OF IT ALL

 

I trust him and my personal problem is being taken care of

 

At the moment I do not know if I have 6mths or 15 yrs to go, next week will clarify more

 

I am a very open person and will willingly discuss by PM even things we are prohibited from discussing here on open forum, my wish is to learn and help others and avoid controversy, and remain honest wth my opinions

[Sheryl]

Hospice is a type of care. It can be given in a facility that only does that, or in a hospital, or in a long term care facility, or at home though the first and last of these options are not currently found in Thailand.

 

Hospice care in a hospital ia a clearly defined type of care.

I have not seen an insurance policy that covers hospice services but would not cover it if given in a hospital. And I have read through an awful lot of insurance policies.

 

 

[NancyL]

2 minutes ago, Sheryl said:

Hospice is a type of care. It can be given in a facility that only does that, or in a hospital, or in a long term care facility, or at home though the first and last of these options are not currently found in Thailand.

 

Hospice care in a hospital ia a clearly defined type of care.

I have not seen an insurance policy that covers hospice services but would not cover it if given in a hospital. And I have read through an awful lot of insurance policies.

 

 

Yes, "hospice" is not a place, but rather a type of care.  When my father was in a U.S. nursing home, at some point it was suggested that he was a candidate for hospice.  He didn't have cancer, but a variety of ailments where it was obvious his "systems" were shutting down, he had lost his appetite and didn't have long to live.  We thought that meant they were recommending that he "go to hospice".  No, it meant that hospice would come to him.  No more sticks several times a day to check his blood sugar so they could give him very small doses of insulin.  No more force feeding thru a nasal tube.  Someone from hospice was with him in the room 24/7, just sitting with him, talk to him if he want and usually just sitting, knitting.  He said it gave him comfort to listen to the knitting needles, because his mother used to knit at night and he remembered hearing the sound of knitting needles as a child when he was drifting off to sleep.  

[al007]

 

2 hours ago, Sheryl said:

I have not seen an insurance policy that covers hospice services but would not cover it if given in a hospital.

Well I guess you now have

 

I would fully agree with the insurer

[al007]

Listening to Sheryl and Nancy, I feel injustice is maybe being done

 

You are two powerful ladies with a wealth of experience, so you say

 

Sheryl has reviewed an awful lot of policies, to quote the lady

 

The kind and charitable thing for you two ladies is to assist the poster wth these problems, get his authority and then negotiate on his behalf with the insurer

 

From what you both say it will be a piece of cake

 

You will then  have done a very charitable act and made the man very happy and relieved

 

I will also eat humble pie and say I was wrong, and give US$250 to a charity of your choice

 

Just a thought from a man maybe dying of cancer

[Scott]

One inflammatory post has been removed.   Continue and suspensions will be issued.  

 

The thread is about giving information.   Scoring points isn't going to cut it and continuing to address posters in a disrespectful manner isn't going to cut it.  

 

[Sheryl]

53 minutes ago, al007 said:

Listening to Sheryl and Nancy, I feel injustice is maybe being done

 

You are two powerful ladies with a wealth of experience, so you say

 

Sheryl has reviewed an awful lot of policies, to quote the lady

 

The kind and charitable thing for you two ladies is to assist the poster wth these problems, get his authority and then negotiate on his behalf with the insurer

 

From what you both say it will be a piece of cake

 

You will then  have done a very charitable act and made the man very happy and relieved

 

I will also eat humble pie and say I was wrong, and give US$250 to a charity of your choice

 

Just a thought from a man maybe dying of cancer

You seem to be misunderstanding the poster's situation.

 

His insurer has not said or done anything.  And he is not currently in need of palliative care. So there is nothing to be negotiated.

 

He simply remarked that his policy covers hospice but that he did not think it would suffice for palliative care in a private hospital, looking towards the future.

 

If he wants clarification the first thing for him to do would be to check the exact wording of his policy, including any definitions, and then if necessary contact the insurer for clarification about the hospice benefit.

 

Thai-issued policies generally state "hospice and palliative care". 

 

 

 

[al007]

On 31/08/2017 at 6:18 PM, connda said:

 I have insurance that will cover hospice care.  I'm not sure they will cover end-of-life care in a "better private hospital."   

Lets try and help connda get an answer we have talked all around this

 

A copy of the policy document is required

Name of insurer and domicile, if UK you would have access to the insurance ombudsman, very pro the policyholder

 

The countries laws that are applicable to the contract, i.e. UK law USA Law California Law Thailand Law

 

Read carefully all definitions esp re palliative and hospice care, and anything vaguely related to end of life

 

Read carefully all exclusions

 

Read financial levels of cove

 

read precasting clauses

 

Reread slowly the whole policy document

 

Meet with the agent who sold the policy

 

At this stage write to the insurance company for clarification, and keep the reply with the policy document

 

Now and not later is the time to clarify matters not when you are drugged on morphine

 

WE are already on PM contact and if you wish via that section I would willingly give you my opinion, if you send me a copy of the policy document but unless very simple still suggest you get a second opinion

 

 

[al007]

10 hours ago, Sheryl said:

His insurer has not said or done anything.  And he is not currently in need of palliative care. So there is nothing to be negotiated

Incorrect and misleading statement may I gently suggest Sheryl

 

Now is the time to negotiate with the Insurer and clarify the position, that negotiation could result in clarification of the wording, or a change of cover for additional consideration

 

It would appear my English is not understood by Americans

 

In the English language in the UK to negotiate is not about solely payment of claims

[Pilotman]

My wife's brother in law in Udon  is in the last stages of liver cancer and in pain.  The  hospitals can do nothing for him and even discharged him last week.  What a tragic situation for him and others in that state. 

[al007]

3 hours ago, Pilotman said:

My wife's brother in law in Udon  is in the last stages of liver cancer and in pain.  The  hospitals can do nothing for him and even discharged him last week.  What a tragic situation for him and others in that state. 

 

So very sad

 

One observation are we certain we know all the facts, occasionally they get twisted

 

When you say UDON, do you mean UdonThani, and if so was it the cancer hospital, on the main road from the south going into town

 

I have had consultations at the cancer hospital  near Udon Thani and found a very large range of ability and care

 

If I had a family member in this situation I would visit the hospital and try and get the CEO, and initially try nice honest sweet talking

 

If that failed I would return with a solicitor, I would not give up easily

 

I find what you describe as horrendous, it is not a situation of can not prescribe pain killers it is simply WILL NOT

 

We also know the chief Executive of KhonKaen, I would go there also I would leave no stone unturned

 

It is very sad the pain this leaves the man in and also the pain and stress it causes the family

 

Hospitals have management levels above the hospital itself, I would be there as well

 

Personally I find what you describe as barbaric and totally unacceptable

 

I will at least pray, sometimes  maybe the last resort but it can also help. and I believe has helped me

 

If you need to talk please PM me, I will give you my phone number

 

Mcmillan in the UK have a help line and can be got on Skype, it is not only the cancer victim that needs help but the immediate family, these people will talk even if you are outside the UK, I have used them a lot on my own problems

[Sheryl]

3 hours ago, Pilotman said:

My wife's brother in law in Udon  is in the last stages of liver cancer and in pain.  The  hospitals can do nothing for him and even discharged him last week.  What a tragic situation for him and others in that state. 

 

Chances are they sent him home with some sort of pain killer but it is not proving adequate. They need to bring him back to the hospital and explain that his pain is unrelieved, and be fairly assertive about it.  When the hospital  said they could do nothing for him,  they meant that his condition is not curable. But they can certainly increase the pain medication -- however, it is necessary to tell them it is not proving adequate. Otherwise, as far as they know, it is working.

 

If it is not possible to relieve his pain with oral medication they can admit him for IV morphine. But again, they have to be told what the situation is.

 

I have found Thais to be very, very reluctant to be assertive with doctors or tell them when a treatment or medication is not working.  You should tell them that the hospital can give better pain relief and that they must go back to the hospital and tell them the medication provided is not doing the trick. They will be given something else/more; if that also does not work, then again they may have to go back, but if they persevere, they will be able to get him what he needs to be comfortable. (It may require being in hospital until he dies). Make sure however that they understand that pain control is all that is possible, not cure.

 

If the pain is severe, or if he is to weak to sit up, they should not feel obliged to go through the usual outpatient channel and wait -- they should go directly to the ER, and be firm that they want better pain control. They can and should do this even at night or on a weekend.  (In fact, odds of getting re-admitteed are best if they go in at night or on a weekend).

 

In my experience the above will work 90-95% of the time, though it sometimes takes more than one repeat visit.  If it does not then, assuming he is being treated under the "30 baht" (gold card) scheme, they should complain to the NHSO hotline 1330 (https://www.nhso.go.th/eng/Site/Default.aspx)

 

 

[al007]

On 23/08/2017 at 4:08 PM, al007 said:

I have seen Thais dying here in many cases in great pain and it distresses and worries me greatly, I have said to families this is unnecessary let me get and pay for a doctor but generally had to back off

I said this over a week ago when I started this thread

 

Sheryl has just confirmed the Thai personality, is to suffer and not complain, and they treat doctors often like Gods, this thinking unfortunately makes it more difficult to assist

 

So there is an element of the pain that is of their own making, and regardless of my views we must respect the Thai Culture

 

Sometimes we will fail despite our efforts, we need to be firm and let them see our concern is because of love

[Pilotman]

2 hours ago, Sheryl said:

 

Chances are they sent him home with some sort of pain killer but it is not proving adequate. They need to bring him back to the hospital and explain that his pain is unrelieved, and be fairly assertive about it.  When the hospital  said they could do nothing for him,  they meant that his condition is not curable. But they can certainly increase the pain medication -- however, it is necessary to tell them it is not proving adequate. Otherwise, as far as they know, it is working.

 

If it is not possible to relieve his pain with oral medication they can admit him for IV morphine. But again, they have to be told what the situation is.

 

I have found Thais to be very, very reluctant to be assertive with doctors or tell them when a treatment or medication is not working.  You should tell them that the hospital can give better pain relief and that they must go back to the hospital and tell them the medication provided is not doing the trick. They will be given something else/more; if that also does not work, then again they may have to go back, but if they persevere, they will be able to get him what he needs to be comfortable. (It may require being in hospital until he dies). Make sure however that they understand that pain control is all that is possible, not cure.

 

If the pain is severe, or if he is to weak to sit up, they should not feel obliged to go through the usual outpatient channel and wait -- they should go directly to the ER, and be firm that they want better pain control. They can and should do this even at night or on a weekend.  (In fact, odds of getting re-admitteed are best if they go in at night or on a weekend).

 

In my experience the above will work 90-95% of the time, though it sometimes takes more than one repeat visit.  If it does not then, assuming he is being treated under the "30 baht" (gold card) scheme, they should complain to the NHSO hotline 1330 (https://www.nhso.go.th/eng/Site/Default.aspx)

 

 

He was on his way back this morning so I hope they have listened to me (and your post) and he gets the IV he clearly needs. 

[Pilotman]

2 hours ago, al007 said:

 

So very sad

 

One observation are we certain we know all the facts, occasionally they get twisted

 

When you say UDON, do you mean UdonThani, and if so was it the cancer hospital, on the main road from the south going into town

 

I have had consultations at the cancer hospital  near Udon Thani and found a very large range of ability and care

 

If I had a family member in this situation I would visit the hospital and try and get the CEO, and initially try nice honest sweet talking

 

If that failed I would return with a solicitor, I would not give up easily

 

I find what you describe as horrendous, it is not a situation of can not prescribe pain killers it is simply WILL NOT

 

We also know the chief Executive of KhonKaen, I would go there also I would leave no stone unturned

 

It is very sad the pain this leaves the man in and also the pain and stress it causes the family

 

Hospitals have management levels above the hospital itself, I would be there as well

 

Personally I find what you describe as barbaric and totally unacceptable

 

I will at least pray, sometimes  maybe the last resort but it can also help. and I believe has helped me

 

If you need to talk please PM me, I will give you my phone number

 

Mcmillan in the UK have a help line and can be got on Skype, it is not only the cancer victim that needs help but the immediate family, these people will talk even if you are outside the UK, I have used them a lot on my own problems

Thanks for that.  he is now on his was to Udon Thani from the village which is close to Non Sang. the local  facility is barely a cottage hospital or clinic and they are next to useless..Trouble is, in Udon last time, the doctor wanted to take a biopsy  and the brother in law said no, why i'm not sure.  He said on the phone to me that he was afraid of dying, and so refused, which is an odd thing to say in his circumstances.  I am 600kls away but I hope that on his return to the hospital today , he just does what the doctor wants and then gets some pain meds that actually do the trick, one way or the other.  

[Sheryl]

A local district hospital would often not have the staff or supplies to provide what he needs. Provincial hospital is the right choice.

[al007]

1 minute ago, Pilotman said:

Thanks for that.  he is now on his was to Udon Thani from the village which is close to Non Sang. the local  facility is barely a cottage hospital or clinic and they are next to useless..Trouble is, in Udon last time, the doctor wanted to take a biopsy  and the brother in law said no, why i'm not sure.  He said on the phone to me that he was afraid of dying, and so refused, which is an odd thing to say in his circumstances.  I am 600kls away but I hope that on his return to the hospital today , he just does what the doctor wants and then gets some pain meds that actually do the trick, one way or the other.  

Do not forget the cancer hospital just south of Udon, maybe his local clinic if pushed will give him referral there

 

The people I have met there have been very caring and very helpful

 

I do not know how you explain this I am not afraid of dying just the pain bit

[Sheryl]

If he has not even had a biopsy there is some possibility that what he has, is not liver cancer at all. Amoebic abscesses and chronic abscesses due to liver fluke can sometimes look a lot like liver cancer clinically (though can usually be differentiated by ultrasound).

 

[Pilotman]

17 hours ago, Sheryl said:

If he has not even had a biopsy there is some possibility that what he has, is not liver cancer at all. Amoebic abscesses and chronic abscesses due to liver fluke can sometimes look a lot like liver cancer clinically (though can usually be differentiated by ultrasound).

 

I didn't know that.  he has had an ultra sound and the Drs seem quite sure that it is Cancer, but I will bring that up.  he is back home now after having fluid drained and in slightly  less pain. 

[connda]

On 9/1/2017 at 10:20 PM, Sheryl said:

You seem to be misunderstanding the poster's situation.

 

His insurer has not said or done anything.  And he is not currently in need of palliative care. So there is nothing to be negotiated.

 

He simply remarked that his policy covers hospice but that he did not think it would suffice for palliative care in a private hospital, looking towards the future.

 

If he wants clarification the first thing for him to do would be to check the exact wording of his policy, including any definitions, and then if necessary contact the insurer for clarification about the hospice benefit.

 

Thai-issued policies generally state "hospice and palliative care". 

 

 

 

If I ever reach the point where I need hospice care, long before that point I will have contacted the insurance company in order to specifically understand what is covered.  Also, even though I currently only have Medicare Part A, obtaining hospice care in the US is always another option.  However, Medicare seems to be a nightmare.  I've tried to understand it, but it's confusing and gives me a headache attempting to do so.  But I believe that hospice care is available if you only have Medicare Part A, at least that is how I'm reading this.
https://www.agingcare.com/articles/medicare-coverage-hospice-care-142914.htm

[Sheryl]

That is my readong also.

 

If your concern about your insurance is that the schedule of benefits says something like "Stay in hospice of palliative care (X amount)" this does not mean that palliative care is covered only in a hospice.  Rather, that separate listing is there to show that they will reimburse care in a stand-alone hospice facility, since (1)otherwise care is limited to hospitals and (2) reimbursement cap  for a hospice would be less than for a hospital as charges are usually lower. . In-hospital palliative care would be covered under the hospitalization benefits. In-home palliative care would be covered by home nursing benefit of your policy includes one.