Palliative care patient who receives all of her nourishment intravenously joins Hospital@Home program
Patient can enjoy the comforts of home, with support from a hospital care team
Last December, as Dr. Elizabeth MacNamara made her rounds at the JGH, she would check regularly on Krystyna Ludwik, a patient in Palliative Care, and invariably came away feeling that something was … off.
While at home, Krystyna Ludwik receives an intravenous infusion of total parenteral nutrition (TPN) from her husband, Grzegorz Pietrzynski. Due to her ovarian cancer, Ms. Ludwik can no longer eat and must receive all of her nourishment by TPN. (Click on this or any photo to enlarge it.)
The problem wasn’t Ms. Ludwik’s medical condition which, all things considered, was quite good.
In the three months since being hospitalized, she had responded to treatment for ovarian cancer and had made the transition to total parenteral nutrition (TPN), an intravenous substitute for eating.
Ms. Ludwik was also remarkably upbeat and energetic, intent on remaining as active as possible. Often, she would criss-cross the hospital on the arm of her husband, Grzegorz Pietrzynski, while pausing frequently to chat and joke with other patients and staff.
What bothered Dr. MacNamara was seeing a patient with such obvious physical capabilities confined to the hospital, instead of enjoying life in non-clinical surroundings.
To Dr. MacNamara, an Internist and former JGH Chief of Diagnostic Medicine, Ms. Ludwik appeared to be an ideal candidate for the Hospital@Home program, which would allow her to return home and continue to receive the same level of care as an in‑patient.
But there was an obstacle—a big one: The task of incorporating TPN into Hospital@Home was so complex and seemed so daunting that no one at the JGH had thought to attempt it. For that matter, nothing comparable had ever been tried in Quebec.
For TPN infusions to be performed properly at home, a capable caregiver would have to be trained to perform many painstaking steps, while taking strict precautions to prevent infection.
Nevertheless, Dr. MacNamara was undeterred.
Known for her assertiveness in seeing to the needs of patients, she brought together members of staff from various disciplines and urged them to find a way to send Ms. Ludwik home under the watchful eyes of the care team of Hospital@Home.
Finally, in mid-February, Ms. Ludwik got her wish: She was able to leave the hospital, secure in the knowledge that her husband had been well trained to administer the daily TPN infusions.
At the same time, she was assured by staff that the door to the JGH was always open, in case she needed to return for help of any kind.
Since then, Ms. Ludwik has been able to spend her days relaxing in familiar, comfortable surroundings, going on the occasional outing (notably, to the Biodome), and preparing treats in her kitchen with her daughter and grandchildren whenever they drive in from Ottawa.
What is total parenteral nutrition (TPN)?
When disease, injury or other circumstances prevent someone’s digestive system from absorbing nutrients, that person must stop eating and, instead, rely for nourishment on TPN, which bypasses the digestive system.
TPN contains all of the essentials—proteins, carbohydrates, fats, vitamins, minerals and electrolytes—in a concentrated liquid. It is infused into the bloodstream through an intravenous catheter, usually placed in a large vein in the arm or chest.
“Parenteral”, derived from the Greek, means “beside (or beyond) the intestine.”
“What I’m able to do depends on how I’m feeling from one day to the next, but so far, so good,” she said in mid-May. “I didn’t go out much in winter, but I hope to do more, now that the weather is better.”
“We’re so grateful to Dr. MacNamara and everyone who made this happen,” added Mr. Pietrzynski. “It’s hard to believe how many people have backed us up—doctors in the Department of Obstetrics and Gynecology, as well as nurses, pharmacists, nutritionists, and even the drivers who make the deliveries to our home and pick up the samples.
During a trip to Montreal from her home in Ottawa, Magdalena Labelle (left) helps her mother, Krystyna Ludwik, with the cooking.
“Without them, life would have been so much more difficult. Krystyna is still with us thanks to all of them.”
In general, Ms. Ludwik speaks with a JGH nurse on the phone each morning, followed in the evening by a video consultation on a tablet provided by the hospital. As well, her vital signs are monitored on an ongoing basis by portable devices.
On most weekdays, Dr. MacNamara checks in briefly by phone. And once a week, a nurse from CLSC de Côte-des-Neiges visits in person to change the dressing on the intravenous line through which Ms. Ludwik receives her TPN.
In addition, a nurse on the Hospital@Home team is available by phone 24/7 to answer questions, offer advice, discuss any concerns or take charge if a problem arises.
“Ms. Ludwik also lets us know if she’s leaving the house for any reason,” notes Michelle Kosikowski, Interim Chief of Service for Virtual Care. “We’re always aware of her whereabouts and we make sure she has everything she needs.”
Of key importance in making this initiative work is the fact that Mr. Pietrzynski, a retired chemist, feels comfortable handling the TPN equipment and materials. “He was very eager to learn and take an active role,” says Ms. Kosikowski.
Extensive training was provided by Katie Chan, a Nurse Educator in the Hospital@Home program, who certified Mr. Pietrzynski in all the necessary aspects of administering TPN.
This included setting up and connecting the plastic bag of TPN liquid, ensuring the proper functioning of the line through which the nutrients flow, and taking the necessary measures to prevent infection.
Though the preparations were extensive and the learning curve was steep, the outcome was well worth it, says Kim Gartshore, Coordinator of the Command Centre, Virtual Care and Alternatives to Hospitalization.
“This is all part of our philosophy of putting the needs of the patient first,” she explains. “We align ourselves with whatever we believe to be worthwhile, safe and practical for the patient, even if it sometimes means charting a course into unknown territory.”
A joint effort pays off
While acknowledging her own role in enabling Krystyna Ludwik to receive TPN in the Hospital@Home program, Dr. Elizabeth MacNamara credits many members of JGH staff for their crucial collaboration. Among them:
- Dr. Susie Lau, Ms. Ludwik’s gyne-oncologic surgeon
- Dr. Harvey Chang, a palliative care specialist
- Kim Gartshore, Coordinator of the Command Centre, Virtual Care and Alternatives to Hospitalization
- Michelle Kosikowski, Interim Chief of Service for Virtual Care
- Katie Chan, Nurse Educator in the Hospital@Home program
- Nutritionist Cathy Kalifantis
- Members of the Pharmacy team
- Staff at CLSC de Côte-des-Neiges
The linking of TPN with Hospital@Home exemplifies the general approach to care embraced by CIUSSS West-Central Montreal.
During a trip to Montreal from her home in Ottawa, Magdalena Labelle (left) helps her mother, Krystyna Ludwik, with the cooking.
Known as Care Everywhere, it states that members of staff must continually strive to achieve the right outcomes by providing the right care at the right time by the right person in the location that is the safest, most appropriate and most convenient for users.
“This is the best of all possible worlds, it truly is,” Dr. MacNamara says. “The family feels happy and secure, and a hospital bed has been freed up for another patient. It’s very rewarding to see something like this turn out so well. The Jewish has been exceptional in making it possible for all of this to happen.”
“We’ve been blessed to be followed by such a wonderful team,” says Magdalena Labelle, Ms. Ludwik’s daughter. “Dr. MacNamara moved mountains for my mom, who continues to live a very good life, despite the end-stage cancer.
“Honestly, we often forget about her medically complex situation. This is patient-centred palliative care at its purest.”
For Dr. MacNamara, the take-away is clear: “What I want patients and staff alike to know is, don’t give up!”
Teamwork at its finest! Many members of JGH staff collaborated to have Krystyna Ludwik admitted to the Hospital@Home program with TPN. Among them were (from left) Catherine Kalfantis, a Nutritionist with the TPN team; Dr. Elizabeth MacNamara, Internist; Katie Chan, Nurse Educator in the Hospital@Home program; and Pharmacist Long Thanh Nguyen.
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