Petr Herle, MD: 47 years of experience as a doctor today gives to the most fragile seniors at Sue Ryder

"I once realised that a person, even if they are a specialist - a doctor - has no right to judge another person's standard of living. We cannot say that a person's standard of living is already such that it is not worth treating. We must strive to the end for the best quality of human existence", says Peter Herle, MD, Court Doctor in Sue Ryder.

Mr. Herle, what led you to study medicine?
I didn't originally want to study medicine at all. I was interested in biology and zoology. I like botany - it's my big hobby I've been educated in all my life. But when I first started studying they were taking very few students for biology, and I found that I was more likely to get into medicine, which is quite close to biology. So I applied to medical school and to this day I don't regret it.

How did your collaboration with Sue Ryder begin?
When Sue Ryder was being established in 1998, I was approached by the head of health and social services with an offer of a doctor's office, which was being set up in Michelská dvůr. However, I had my own established practice just down the road, so I recommended MD Adriana Vokřálová, who accepted the offer.  And she and I then alternate - in the doctor´s office and at Sue Ryder. So I came into contact with clients and with the management of Sue Ryder from the beginning.

In 2016 I handed over the running of my practice to a colleague, which opened the door to working with Sue Ryder on a regular basis. I come here regularly once a week for Thursday appointments. And I come in at other times when I need to.

So more than working with the elderly, it was the proximity of Sue Ryder that drew you here?
I didn't have to take the job, but I was interested in it. I like medicine, I like my job and I like solving difficult problems. Seniors are complicated. Plus, it seems perfectly normal to me that if they need me somewhere, I'll help.

You're part of a multidisciplinary team at Sue Ryder, right?
Yes, I am. In the multidisciplinary team is created an important holistic view of the lives of the seniors who live at Sue Ryder. It is the intersection of the wishes and ideas of the client themselves, the perspective of myself as a doctor, nurses, psychologist, chaplain, caregivers and social workers. At the same time, further care, possible hospitalisation, end of life questions or social care needs are consulted with the client's family.

Your main partners in care are the nurses Sue Ryder?
That's right.

Can they call you whenever they don't know what to do?
Yes. We have an agreement that they can call me anytime if I'm not sleeping. The advantage is that I know the clients very well and I know the nurses, so I know what to expect. Who's how experienced, who I can trust with certain care. I know what they can handle on their own, so they don't have to call ambulance and send client to hospital. We do all this together, often on the weekend. But I don't mind. I'm retired now.

May I ask how old you are? I was thinking around 60.
I'm 72 now. I guess I deceive with my body. I guess this face runs in the family.

Isn't it difficult for you to be so close to the seniors at Sue Ryder so often?
...and see what's in store for me? (Laughter....)

Not at all. I've always thought that working in a facility like Sue Ryder is valuable for developing a doctor's knowledge and experience. What you see here, you don't see anywhere else.

In what sense is this experience so valuable?
Let me give you an example. A new client comes on board and you find out that they have been diagnosed with several chronic illnesses. It's called polymorbidity. The person complains of a lot of health problems and takes a number of medications. And you begin to investigate whether the cause of the health problem is the disease itself or whether it is the result of a drug interaction - 2 drugs may not tolerate each other, eliminate their effects, etc. Therefore, I have to assess the client's health condition comprehensively and sometimes it is a complete detective work. And that is tremendously interesting! The other very important thing is a comprehensive nursing social approach - working with the meaning of life, working with clients' families, end of life issues.

You accompany seniors at the end of their life at Sue Ryder. That's where the palliative approach often comes in. How does a client enter into palliative care?
Again, it is a holistic view of the client. Communication and trust is key here. I have a view and perspective on the situation as a doctor. Then there are the caregivers who spend the most time with the client and give information that is processed. The nurses are best able to assess the client's health progression - how it is getting worse or not and consult with me on what can still be done and what can no longer be done.

The whole process is managed by Věra Vodičková, the palliative care coordinator, who communicates with the families about the palliative approach and further development. And then there is input from other team members - psychologists, chaplains and social workers. In this way the multidisciplinary team works and I think it works in full harmony in Sue Ryder. One respects the opinion of the other, and when we see that there is basically nothing that medicine can achieve, we wonder whether it is time to start thinking about palliative care.

Can the family or the client themselves refuse a referral for a change from curative care to palliative care?
Usually this does not happen. As I said - the client enters palliative care based on the recommendation of the multidisciplinary team and based on my conversation with the client and then with the client's relatives. We usually come to a consensus.

However, it may be that we think that the client is already in such a state that they should be transferred to palliative care. We ask sensitively for his opinion and he says: "Look, not yet. I would still want to be treated if things get worse. I still want to go to hospital. I still want to resuscitate." Or the client's relatives will say, "Mom was good at my last visit and I don't think it is right time."

We totally respect this and will explain to the client and family all the issues involved in their expectations and further treatment, outlining what we can do for the client. But usually sooner or later the client himself or his family will come to the same decision.

Palliative care does not shorten the life of a person suffering from a terminal illness, but neither does it prolong it at any cost. How does this care differ from "non-palliative" care?
Palliative care does not aim to cure the client. It is most often discussed in the context of cancer. For example, cancer treatment may stop working. And then there is nothing left - all the possibilities of medicine have been exhausted. But this does not mean that such a person should die without help. Palliative medicine comes in and we suppress the unpleasant symptoms of the disease, but this does not lead to suppression of the disease itself - in this case, the tumour.

What do you deal with most often? Pain?
Pain, disturbances of consciousness, confusion, coughing, shortness of breath... These are all symptoms that need to be minimized for clients, even if we can cure them anymore. Fortunately, medicine today offers tremendous possibilities and we can alleviate or eliminate these symptoms altogether.

Do you also deal with psychological conditions?
I deal with clients' sleep problems, for example. As far as psychiatry is concerned, I obviously have some basic erudition on the subject, but I don't have that kind of ability in prescribing certain psychiatric medications.

A doctor - general practitioner can't prescribe all medications?
Not all psychiatric drugs. For example, there are certain types of antidepressants that I cannot prescribe. But there's also a Dr. Tereza Hraníčkoví at Sue Ryder and she's a great psychiatrist. I think that's what the management at Sue Ryder has done extremely well, to put together a team of professionals who work well and confidently together and look after the clients.

I'll come back to the decision to enter palliative care. Who is responsible for that?
I am responsible here because only the doctor can decide whether or not to resuscitate. Whether or not a client is going to be transported to the hospital if their health deteriorates.

I assume that this decision exists in writing.
Yes, this decision is always written in the client's file. In this part of my job, I'm actually sort of replacing the mobile hospice team Cesta domů that Sue Ryder works with. They do come in whenever we need to, but I know them and they know me and we trust each other. They know that when I'm here they can attend to other clients, of which they have many themselves.

As a result, we have only had 2 clients in shared care with Cesta domů in the last 6 years. The rest of the clients during their last days were accompanied by myself and my colleagues at Sue Ryder.

Do you need to expand your education in palliative care?
Back in 2000, I organised a course in palliative medicine at the IPVZ (Institute for the Training of Healthcare Professionals) because it was already clear that GPs needed to increase their knowledge in this area. Then I further explored this topic when I designed the course content. There it was also decided that a course in palliative medicine must be given to every general practitioner who goes for certification as a general practitioner. I have known the experts who worked and lectured in this field, including MUDr. Marie Svatošová, a leading figure in the Czech hospice movement.

So joining Sue Ryder was a logical extension of what I already knew and was prepared for. Of course, it still happens occasionally today that the Sue Ryder team will call the palliative team Cesta domů to come in. But these are usually when I am less available or on holiday. Or when there is a very complicated case and a second opinion is needed about the treatment.

Mr. Herle, what have your years at Sue Ryder brought you?
Satisfaction. It makes you feel like you're working for a good cause. I find that very fulfilling.

Are you sad when a client dies?
Some clients live here a long time. You develop a relationship with some of them and then you feel sorry when they die. I've had a few favorites of mine... But I come here once a week, sometimes more. I talk to them on the phone, but I don't see clients as often as nurses or caregivers. They're in much closer contact with them than I am, and it's harder for them. They witness the deterioration of the person's health, they see that there's not much they can do for the person and at the same time they know how nice the person is.

But we all understand that every life has the end. We're sorry to see Sue Ryder's clients go. But it warms me and the entire Sue Ryder team to know that we did our best for that client.

What do you think is the best medicine for a long quality life?
I have been concerned all my life with what will prolong my life. I think the most important thing is positive thinking - seeing the future with hope and optimism. We all have that in our heads and it's inherited. Then the relationship to exercise is also inherited. Movement prolongs life, so when you retire at 65, you can't put on your slippers, sit in front of the TV and wait to see what comes next.

So I think those are the two most important things - movement and good cheer. That good mood most of all, maybe even more than the movement, prolongs life. But optimism is inherited.

You think good mood is inherited?
I think it does. Whether one is smiling or continually angry. If on the question "How are you?" man regularly replies, "Bad!" If you ask me, I'll tell you: "I'm having such a great time in retirement. I've never had a better time in my life."

Very last question - what would you wish for the elderly care system in our country?
That's the simple answer - more beds and staff to care for elderly people. I am convinced that the entire elderly care system in our country is severely undersized. Today's young people want to go to work as long as possible and they do not have time to care for the elderly. However, services that are provided on an outpatient basis, such as home care, are not able to provide the comprehensive care that seniors with 24-hour supervision needs require. Therefore, more beds are needed.

It would be best if more rooms could fit into Sue Ryder. It is an inspiration for all in elderly care.

Text and photo: Radka Kulhánková

PS: Thank you from the bottom of our hearts for your help in helping us maintain and further develop dignified care and palliative access for Sue Ryder clients. And not only that - thanks to your support, students or other organisations that care for the elderly can also learn palliative care at Sue Ryder. Please donate and join our mission.