Meet Dr Sarah Wenham, a keynote speaker at this month’s Palliative Care NSW’s conference in her home town of Broken Hill, NSW.

As a specialist palliative care physician, Dr Wenham serves 32,000 people across a region of 195,000 km², which shares borders with Queensland, South Australia and Victoria. She is clinical director of sub-acute and non-acute care for the Far West Local Health District.

Why did you focus your medical career on palliative care?

As an intern working in an acute hospital in the UK, I remember going on ward rounds and seeing dying patients just being left in a side room where they were largely ignored. The consultant and other doctors I worked with would stand at the doorway and say “They are for TLC (tender, loving care)”. They would write ‘For TLC’ in the patient’s notes and move on, feeling very uncomfortable with death and dying. Because they couldn’t cure the disease, they felt like they had failed.  TLC was a bit of a misnomer really, because that was the last thing we were giving them.

Dying patients hadn’t been properly assessed or managed during the working day. Because I was on-call, I would often be called to see patients who had uncontrolled symptoms or whose families were distressed. The important conversations hadn’t been had during the day either, so I found myself being the one to sit down to talk with patients and relatives about the fact that they were dying.

My consultants and colleagues would say that nothing else could be done, but I think there is always something we can do, even if it taking the time to just sit and be our patients and their families.

If patients were lucky, they were transferred from the acute hospital to the hospice.  Back then, there was no real provision for people to be supported to die at home. Fortunately things have improved significantly since then, but that was my introduction to how people died in an acute hospital.

I learned as an intern you can make a difference from the beginning, by learning good communication skills and by connecting with -- and really caring for -- patients as fellow human beings. That is what has driven me to train and specialise in palliative care.

I got my first hospice job in 2001 and have worked in palliative care ever since.  I worked with Hospital Africa in Uganda for three months, in Sydney for six months, and then did my specialist training in palliative medicine in the UK.

I worked as a community consultant in palliative care in Blackpool, UK, from 2010, before moving to Broken Hill in 2012 with my husband John, who is a GP with the Royal Flying Doctor Service.

What challenges come with providing palliative care in an area that is so isolated?

One of Broken Hill’s biggest strengths is that it is a strong community, but that is also the biggest personal challenge I find working here. I‘ve had to care for some very close colleagues, which stretches the professional boundaries I’d previously held. While I’ve become much more vulnerable as an individual, it has allowed me to take the care I can offer people to another level as well. It is a great privilege when the community trusts you as a professional, but with that comes a great responsibility to make sure we provide the best care that we can.

Being in a rural and remote area means we have to do things slightly differently. We have to be  inventive, ingenious and resourceful, but being isolated also means we have the flexibility to find local solutions.

Can you tell us about someone who has benefited from that flexibility?

We had a patient who wanted to stay out on his property until about a week before he died. He lived about 500km from Broken Hill.

We knew that as his condition deteriorated, he would need oxygen, suction, syringe drivers, injectable medications, an electric wheelchair, a recliner chair, and even a hospital bed. We planned well ahead of time, and sent equipment out to him on the mail truck.

One of the nurses and I flew to see him with the Royal Flying Doctor Service. We landed on the airstrip on the patient’s property.  We taught his wife how to give medications and set up a syringe driver. The nurse demonstrated on my arm to show her how to use a sub-cutaneous injection. It didn’t faze the wife at all. These people are all farmers and are used to doing this sort of stuff for their animals.

The nurse and I kept in touch with the patient and his family by phone, Skype and email.

He stayed on the property until a week before he died. Then he chose to come into Broken Hill because his elderly mother lives in town and he wanted to see her before he died.  We facilitated the Royal Flying Doctor Service to fly him from his station into hospital.

His only son’s partner was in the early stages of pregnancy at the time and they wanted to wait for a scan before telling the rest of the family. Because we have a small radiology department, we were able to arrange for her to have that scan early. That meant our patient was able to see a picture of his grandchild, and to tell his mother that she was going to be a great grandmother, which was pretty much the last thing he did before he died.

Our hospital colleagues are fabulous at working with us on things like that. We also have very supportive radiology department, which is usually able to get scans done quickly if we need them urgently. Our pharmacy department will provide the medications we need to keep people at home in remote areas or on their isolated properties. Our hospital and community colleagues are willing to bend over backwards to make those really special things happen.

Working rurally and remotely, I’ve really learned the importance of having a can-do attitude. We can always find a solution. It may not be perfect, but there’s always something we can do to make things a little bit better for people. We may not have all of the resources or support or access to every medication, but it’s about using what you do have to find a solution.

Tell us more about your team and how you manage to cover 195,000 km² of far western NSW.

At the moment we have the equivalent of four full-time palliative care staff in Broken Hill and two in Dareton, which is about three hours south.

We also support the primary health care nurses that staff the seven remote health facilities of the Far West Local Health District. We visit patients and their relatives when we need to. If we travel to a rural community or a remote property, that usually means we only get to see one patient during that whole day.  We know face to face contact and support for our isolated patients is essential, but we keep in touch with them in other ways too. We consult using telehealth and video conference. That makes it more time-efficient to see someone who lives in Ivanhoe, for instance, which is a small community of 90 patients about 350km from Broken Hill by unsealed road. Using these types of technologies allows us to prioritise and rationalise our time and resources.

We see more than 50% of people who die an expected death in our region, which is high compared to the rest of the state. We are a fully integrated service, so it doesn’t matter whether patients are at home, in hospital or a residential aged care facility, we can provide a service that provides real continuity of care. We are really proud that our care is patient-centred, based on patient preferences and priorities, and provided in the place they want to be cared for, with 98% of our patients dying in the place of their choice.

As a specialist palliative care team, we believe that the main reason for this is that we work seven days a week, providing a 24/7 on-call service for our patients. I’m also on call 24/7 to support our nursing staff. We try to be as flexible as we can - patients can deteriorate acutely or may develop unexpected needs that need to be addressed urgently. People out on properties often need to contact us late in the evening or early in the morning to fit in with their working day, or we need to have family meetings with relatives from out of town when they are visiting at weekends.

One advantage of working within a small health service is that we are able to find ways to access the resources we need to care for our patients. We have local fund that is resourced purely by community donations which has allowed us to equip a hospice suite within every in-patient facility. It also provides equipment for our patients to be cared for at home. This means that if a patient needs a recliner chair or a hospital bed at home, we can get it there that day.  It’s a resource that I haven’t seen anywhere else I’ve worked.

As we are a small team and we know can’t be everywhere or do everything, we focus on upskilling other people with palliative care knowledge and skills, so that they can also make a difference. We work with our local GPs, health-service nurses, hospital staff and staff at the residential aged care facility so that they are able to provide the best possible palliative care and end-of-life care that they can.

As the region’s only palliative care specialist, do ever you feel professionally isolated?

Yes and no. I work with an amazing team of nurses – they have become both my professional and personal support as friends and colleagues. However, sometimes I do miss the conversations that I could have if medical colleagues were sharing the same patients. I miss that most when I’m managing patients with really complex symptoms. In my previous job, I appreciated having peers to share difficult medical decisions with.

I sit on the Agency of Clinical Innovation’s palliative care executive committee, the Clinical Excellence Commission’s end of life advisory committee and the Therapeutic Guidelines palliative care expert writing group.  I am very grateful for the peer relationships I’ve been able to develop through these committees – people are incredibly generous with their time, support and advice. Being involved at a state and national level has also given me the opportunity to ensure our service is keeping abreast of all that is happening in the palliative care space, as well as be a voice for rural and remote populations.

Has four years been long enough for you to fall in love with Broken Hill?

Broken Hill is home to us a family now.  It is such a rugged, barren and dry place at times, but there is real beauty out here as well if you look for it.  It’s in the everyday things around you - personally and professionally you can find beauty even in the toughest things.

The environment and culture out here has really challenged me to look deeper and give a lot more of myself through what I do. I’ve learnt that it’s not just about what I do, but actually who I am has an immense impact on the care and therapy I can offer.

I hope that people who come to Broken Hill for the conference enjoy coming to this unique environment, this island in the desert, and that they find time to just ‘be’ and to reconnect with who they are both as individuals and as professionals.

GPs, nurses, allied health professionals and personal care attendants can obtain specialist palliative care advice and support from the Decision Assist phone advisory service: 1300 668 908.