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The importance of palliative care in the future

In the modern age, and thanks to technological and medical advances, the life expectancy of people across the world has shot up. Living into one’s sixties is no longer a miracle that is the exception to the rule, but has become the norm for most people.

The WHO estimates that one in six people will be 60 or older in 2030, with the elderly population increasing from 1 billion in 2020 to 2.1 billion in 2050. While we can expect further improvements in medicine and medical care over the next few years, it is safe to say that the pressure on and need for palliative care services is likely to increase as a growing elderly population reaches the stage in their lives when the need for hospice care arises.

In South Africa, the average life expectancy for men stands at 62,5 years, whilst women are expected to live up to 68,5 years. Our own elderly population consists of 5.43 million people out of a total population of 59.62 million, with this number expected to rise. The elderly population also makes up most of the mortalities in the country, as most causes of death are from non-communicable diseases like heart disease or strokes, which mostly manifest at later ages.

Palliative care is tasked with providing holistic care to patients that suffer from life-limiting illnesses. Many patients who receive palliative care suffer from diseases that are typically developed in old age, such as dementia, disability due to a stroke, and chronic obstructive pulmonary disease. Geriatric syndromes, so called because of the complex and multiple underlying factors that cause them (like frailty, falls and delirium, for example) may also lead to older people requiring assistance and care. We have already seen this trend abroad: In the US, just over 1.6 million patients received hospice care in 2019 – that number was 1.34 million in 2009.

Of course, palliative care is not only for older patients. Even so, a bigger elderly population will require more specialised medical care, and this includes palliative and hospice care.

The holistic and comprehensive nature of palliative care makes it a necessary option for people older than 60 who require medical care for a life-limiting illness, along with spiritual and emotional support for themselves and their families. As the years go by, we will all become older and frailer, which is why palliative care will become even more important in the future.

If you or a family member need palliative care services, please feel free to contact HospiceWits by sending an email to info@hospicewits.co.za, or by calling 011 483 9102/3.

What conditions may palliative care be useful for?

Palliative and hospice care can be beneficial to patients with life-limiting illnesses, and is also of great value to the patient’s family. Palliative care entails a host of different services, which are administered by a multidisciplinary team of professionals, including doctors, a pharmacy team, nurses, nursing assistants and a psychosocial team. Improving quality of life is at the core of what HospiceWits and all other palliative care providers do.

Often, though, people aren’t sure what kind of conditions might benefit from palliative care. The WHO estimates that only 14% of people who need palliative care actually receive it – here are some illnesses of which the symptoms can warrant hospice care.

ALS

Amyotrophic Lateral Sclerosis, also known as Lou Gehrig’s Disease, is a progressive disease that affects voluntary muscle action. As muscle action is lost, palliative care can be beneficial to help the patient with basic tasks that they might not be able to complete themselves, in addition to helping to alleviate other symptoms like discomfort, pain, anxiety or depression.

Dementia

Dementia is an incurable type of illness affecting brain degeneration, memory loss and behavioural changes that are not associated with normal aging. Palliative care can help patients with anxiety, depression, pain, stress and, most importantly, managing a patient’s behaviour and communication, which may get worse as the disease progresses. Alzheimer’s dementia is the most studied, however, there are various types of dementia such as Parkinson’s (affecting the muscles), Lewy body dementia, vascular dementia, Korsakoff’s syndrome (alcohol-related) and HIV-induced dementia. 

Cancer

More than 100 different types of cancer can develop in the body. Working with the oncologist, palliative care providers can help to aid patients who suffer symptoms like pain, fatigue, nausea, vomiting, depression, anxiety, diarrhoea, constipation, shortness of breath and confusion.

Chronic obstructive pulmonary disease

Shortness of breath, coughing, pain, weight loss, low oxygen in the blood and a risk of lung infections all characterise this disease, which damages the lungs. Palliative care can help the patient and their family with things like talk therapy, massage and relaxation techniques, as well as setting goals about how to stay healthy during the progression of the disease.  The palliative care team can also provide interventions such as oxygen therapy to assist with the quality of life of the patient, and to make them as comfortable as possible.

Congestive cardiac failure

This chronic condition renders the heart unable to pump blood properly. Palliative care specialists teach the patient how to sit, stand, and lie down in order to improve breathing, among the standard help with things like anxiety and depression. The palliative care team can also prescribe medications to assist with managing cardiac-related symptoms such as irregular heartbeat, hypertension and breathlessness.

COVID-19

Because this disease is relatively new, the long-term serious side effects that result from COVID-19 are still unknown. Symptom management and compassionate support are part and parcel of palliative care for this illness.

Eosinophil Associated Disease

EAD can lead to inflammation and damage to the tissues in the areas of the body that are affected by the disease. Palliative care takes the symptoms of the patient into account, depending on what parts of the body are affected.

HIV/AIDS

Although medication for HIV has come a long way and people who have been diagnosed with it can expect to live long and happy lives with the correct treatment regime, the advanced stage of the virus (AIDS) does come with a long list of symptoms which may include fatigue, pain, shortness of breath, anxiety, depression, vomiting, nausea and diarrhoea, all of which can be better managed with the help of the palliative care team.

Huntington’s Disease

Huntington’s Disease affects the nervous system and brain. The progression of the disease has both physical and mental characteristics, which can be better managed when palliative care professionals are involved in treatment.

Kidney disease

Diabetes, high blood pressure, anaemia, nerve damage, weak bones and poor nutritional health can all come to the fore as a result of kidney disease. Chronic kidney disease requires specialised care, and palliative care can also be of value in this regard.

Liver disease

Cirrhosis of the liver leads to the scar tissue forming on this vital organ, impeding its important work – filtering out toxic substances from the blood, among others. End-stage liver disease, also referred to as chronic liver failure, will lead to fatigue, jaundice, swelling of the abdomen and legs, weight loss and appetite loss, itchy skin, nausea and hiccups. These symptoms can be managed with the help of a palliative care service provider.

Multiple sclerosis

MS affects the central nervous system and is either a progressive or relapsing disease. Palliative care treatments for MS include techniques and medications to relieve muscle spasms and manage pain, in addition to calming the nerves and easing the depression that is another common symptom of this disease.

Pulmonary fibrosis

Pulmonary fibrosis leads to scarring of the lungs, which can make breathing more laborious. Medications and treatments like oxygen therapy can be beneficial to patients, whilst palliative care may help the patient to match their choice of treatment to their goals and needs.

Sickle cell anaemia

The red blood cells in the body are affected by sickle cell anaemia, which then leads to poor blood flow, inflammation and pain. Palliative care providers can assist in managing the symptoms of this chronic disease.

Stroke

An interruption of blood flow to the brain is what leads to a stroke, and the consequences of this are often paralysis or weakness on one side of the body, along with other symptoms like headaches, loss of balance, memory problems, inappropriate behaviour, and trouble with speaking or understanding speech. When it comes to a stroke, palliative care is recommended sooner rather than later, in order to effectively combine the medical interventions with other therapies to treat other common symptoms like anger or depression.

Palliative care has been invaluable to millions of people around the world. HospiceWits is proud to be a trusted palliative and hospice care provider in Soweto and the greater Johannesburg area. To learn more about the services we offer, click here.

Here are 5 excellent reasons to support HospiceWits shops

HospiceWits shops form a central part of the fundraising efforts of this NPO. Located in Orange Grove, Parkmore and Kensington, with an additional shop at the Rosebank Market, these shops are filled to the brim with a treasure trove of goods, ranging from household appliances and antiques to second-hand books and knick-knacks of all kinds.

If you were still wondering why paying a visit to HospiceWits shops is worth it, here are five excellent reasons to drop by.

Find unique items

If you prefer thrift shopping for clothing, HospiceWits shops are wonderful for finding one-of-a-kind items that will add to your vintage wardrobe. Because thrift shopping is akin to a treasure hunt of sorts, you just never know what nuggets of gold you’ll find.

Purchase high-quality goods at low prices

Bargains are a dime a dozen at HospiceWits shops. Whether you’re in search of household goods, clothing, home décor, shoes, furniture, accessories, games or books, these are all available at discount prices. It’s worth looking for the things on your shopping list at HospiceWits before visiting a traditional retailer to purchase them – you’ll find you’re saving a ton of money by buying second-hand.

Find your next DIY project

Upcycling and reimagining old goods are all the rage today, and there are loads of things in HospiceWits shops that simply need some TLC to come to their right again. Avid DIYers would do well to scour any of our shops for ugly duckling items that are just begging to be turned into graceful and stylish swans after a good spit, polish and a bit of paint.

Help the planet by reducing waste

If going green is a priority in your life, you can do your bit for Mother Earth by shopping at HospiceWits charity shops. The manufacturing, production, packaging and distribution associated with new clothing utilises an immense amount of energy, whereas disposing of unwanted clothing puts strain on landfills that are already packed to the brim. The same is true of the production of many other items that we purchase from traditional retailers every day. Buying second-hand relieves some of this environmental pressure, and is truly the way of the future.

Support the community

Supporting the local community is at the heart of shopping at HospiceWits shops. HospiceWits charity shops exist solely to serve the community they are located in, and profit isn’t the main focus, as is the case with more traditional retailers. Over the past 30 and 43 years respectively, HospiceWits has been a proud service provider to the Soweto and greater Johannesburg areas. Every single purchase contributes to fundraising efforts, which ensure that this NPO can continue doing this important work for decades to come.

Offering care and support to our patients and to their families is our singular mission, and we simply cannot do it without the loyal support of the public.

HospiceWits shops are happy to receive any donations of pre-loved and gently-used goods. Please drop off unwanted household items, clothing, books and other goods at our charity shops, located at the addresses listed below.

Parkmore HospiceWits shop

Corner of 11th Street and Elizabeth Avenue

011 883 7242

Orange Grove HospiceWits shop

199 Louis Botha Avenue

011 728 1052

Kensington HospiceWits shop

163 Queen Street

011 615 3343

Rosebank Market HospiceWits shop

15A Cradock Avenue

Rosebank Mall

011 728 1052

Should you wish to have items collected, HospiceWits is happy to do so. Please contact our depot to arrange a collection by phoning 011 728 1052 or 011 728 0737.

Polofields Crossing Book Fair yields great funding for HospiceWits

Literature buffs were once again treated to the swathe of books on offer from 27 to 29 May 2022, as Polofields Crossing held its third Book Fair in aid of HospiceWits in a book tent outside PAUL Bakery and Restaurant.

The proceeds from the Book Fair benefited HospiceWits as we continue to provide quality palliative care services to our patients in Soweto and greater Johannesburg.

The winter Book Fair saw the addition of a children’s book tent, where young readers were able to listen to author Siyavuya Mabece speak about her anti-bullying book, Enough! Stop Bullying!. The 10-year-old writer was joined by Catherine Jarvis, who spoke about her award-winning young adult novel The Swim Team on Saturday, 28 May.

In all, the 2022 Polofields Crossing Winter Book Fair garnered over R50 000 in book sales, all of which will be used to support HospiceWits in the work we do.

HospiceWits would like to extend our warmest gratitude to Polofields Crossing and all its tenants for making this another Book Fair to remember. As an NPO, we are solely reliant upon public and corporate donations. With the Book Fair, these two entities came together in a beautiful way.

We also extend a hearty “thank you” to all the book lovers of Joburg, who came out in their numbers to support this fundraising initiative.

HospiceWits looks forward to collaborating with Polofields Crossing for future Book Fairs. If you missed this one, do not worry – we cannot wait to welcome you to the next Polofields Crossing Book Fair.

Keep an eye on our Facebook page to find out when it will be held, and to stay on top of the latest news from HospiceWits.

The HospiceWits Shops contribute to our Fundraising efforts

Our HospiceWits shops, located at 4 different sites in Johannesburg, are key components of our fundraising efforts and are a mainstay that not only help us offer care and support to our patients but also gives shoppers the opportunity to find a host of products at bargain prices.

Located in Parkmore, Kensington, Orange Grove and at the Rosebank Flea Market, HospiceWits shops stock pre-loved goods, ranging from household appliances to books, furniture, antiques and collectables, toys and children’s clothes and much more. As a registered NPO, HospiceWits relies on the generosity of the public for fundraising, and the sales generated from our charity shops around Johannesburg form a cornerstone of these efforts.

All funds raised at our shops contribute to the significant overheads that an NPO such as ours incurs on a monthly basis.

Recently, the Orange Grove Groover community alerted us to allegations of theft and corruption at the HospiceWits charity shop in Orange Grove. HospiceWits takes note of these allegations with great concern, and would like to thank everyone that has brought these matters to our attention.

HospiceWits would like to assure our community that we are taking measures to investigate them thoroughly, and will where necessary, implement procedures to ensure this kind of activity ceases immediately

It is our intention to always serve the community in which we work, and that not only means doing what we do best – providing support and care to our patients with a life threatening illness and to their families – but also ensuring a pleasant customer service experience for our customers, who are our greatest supporters and enable our nursing team to do their daily work.

HospiceWits thanks the public for its continued support over many years. Without our community, we would not be able to keep on providing palliative care services to patients in need in the greater Johannesburg and Soweto areas.

Should you have any concerns about our shops, please don’t hesitate to send an email to info@hospicewits.co.za.

Polofields Crossing and HospiceWits join forces for third Book Fair this May

The pen is mightier than the sword, states the old adage, and HospiceWits is proud to again join forces with the Polofields Crossing shopping centre to let the spotlight fall on the power of literature at the third Polofields Crossing Book Fair.

Held as a fundraising event for HospiceWits – all proceeds will be used to ensure HospiceWits is able to continue offering palliative care services in Johannesburg and Soweto – the winter edition of the Polofields Crossing Book Fair promises an offering that will warm the hearts of all Joburg’s book lovers.

Taking place from 27 to 29 May between 09:00 and 17:00, the location of this third Book Fair will change slightly, with the main book tent moving to the parking area close to PAUL Bakery and Restaurant at Polofields Crossing.

The winter fair also sees the addition of a book tent dedicated entirely to children’s literature. This expansion of the Book Fair aims to promote reading among perhaps the most important readers of all – the youth.

The kiddies’ book tent won’t just feature a large selection of books for children, but will also give avid little readers the opportunity to listen to young author and anti-bullying activist, Siyavuya Mabece. Mabece’s book Enough! Stop Bullying! addresses a problem that is still far too widespread among the children of our nation. She will be joined by Catherine Jarvis, whose young adult novel The Swim Team won a gold award when the Sanlam Prizes for Youth Literature were presented last year.

Young lovers of the written word are invited to join Mabece and Jarvis in the kiddies’ book tent at 10:00 on Saturday, 28 May, and browse through the selection of children’s literature in the tent between 09:00 and 17:00 on Saturday.

As always, HospiceWits welcomes book donations during the Polofields Crossing Book fair, but also invites book lovers to show their support by donating pre-loved books prior to the festival. Book collections will be done at SuperSpar at Polofields Crossing, SuperSpar Olivedale and Robindale SPAR, as well as at Curro Waterfall. Polofields Crossing and HospiceWits are grateful to the pupils of Curro School, who will also be volunteering their services at the Book Fair on Saturday, 28 May.  

If all the book hunting makes you hungry, don’t forget to indulge in boerie and prego rolls, hot beverages and pancakes, which will be sold by SuperSpar Polofields. Kismet Spices at Polofields Crossing will join in the fun with a display at the Book Fair, and will also be running a competition that lets attendees stand the chance to win great prizes, while adding to their book collection.

HospiceWits extends our heartfelt thanks to Polofields Crossing for again playing host to this popular event, which immeasurably contributes to our annual fundraising efforts. If you’ve always wanted to drop by and support the Polofields Crossing Book Fair, now is the time. After all, nothing takes the bite out of the winter cold like a good book. We look forward to seeing you there from 27 to 29 May!  

‘Rest house for travellers’: What does hospice care entail?

The word “hospice” has its roots in the Latin hospitium, which refers to hospitality, “a place of lodging” or a “guest house”. Whilst it’s easy to see the connections with caring in the etymology of the word, many people still aren’t sure what exactly hospice care entails.

To make things a little clearer, here is what hospice care offers to patients and their families.

Holistic care for patients with life-limiting illness

Taking an interdisciplinary approach, hospice care, also referred to as palliative care, offers holistic care to patients with life-limiting illness, and to their families.

Employing a range of healthcare practitioners, hospice care is given either at a palliative care facility, like HospiceWits’ in-patient unit, or at the patient’s home through the services of the homecare nurses.  

The interdisciplinary team providing care to the patient and their family consists of physicians, nurses, nursing assistants, psychologists and counsellors, and therapists. Medical professionals tend to the needs of the patient with regards to their illness, whilst mental health professionals assist the patient with their psychological needs, and also offer counselling to the patient’s family throughout the patient’s illness, and bereavement counselling when the patient has passed away.

This multi-pronged approach makes hospice care an excellent option for patients who are diagnosed with a life-limiting illness, walking the full journey with the patient until the final stages of their lives. Palliation addresses the patient’s holistic needs, while also making sure that their family is prepared for whatever the future may hold.

The care offered by the HospiceWits interdisciplinary team primarily includes, but is not limited to:

– Pain management and symptom control by trained doctors and nurses.

– Counselling and support to patients and their families by psychologists, social workers and counsellors.

– Grief, loss and bereavement counselling.

The palliative care services offered by hospices are highly regarded by the myriads of people who have received hospice care themselves, or have seen the value of hospice care for their families.

If we think of ourselves as travellers through life, the origins of the word “hospice” ring particularly true. When receiving hospice care, patients are given a nurturing and caring space in their lives to take rest and live the balance of their lives to the full, pain-free and with dignity.

HospiceWits is proud to be a provider of palliative care services to patients in Johannesburg and Soweto. If you need more information about the services we offer, feel free to contact HospiceWits here, and to follow our Facebook page for regular updates.

More about Dame Cicely Saunders, founder of the hospice movement

When thinking about how much palliative care has become a part of our lives, it’s difficult to imagine that it has only existed in its current form for 55 years. The remarkable woman who started the very first formal hospice care facility was Dame Cicely Saunders. She established St Christopher’s Hospice in South London, being moved to do so after having lost two people dear to her heart to terminal disease.

Dame Saunders is widely considered the founder of the modern hospice movement, and did groundbreaking work in the field of palliative care.

Nurse, social worker and physician

Dame Saunders initially studied to be a nurse, completing her nursing training at the Nightingale School of Nursing. Little would Dame Cicely Saunders know that she, too, would be amongst the most well known female medical professionals in history. After a back injury, Saunders completed a degree in social work in 1945, and realised at the age of 33 that if she really wanted to change the concept of pain management, she would have to become a qualified doctor. This combination of skills would prove invaluable later.

The life of Dame Saunders was changed by one of her dying patients, a Polish-Jewish refugee who had a life-threatening cancer. He talked about death and the care of the dying, telling her what he and people like him needed. It was this experience that planted the seed of offering holistic care that addresses the complete needs of the patient.

After losing a second partner, Antoni Michniewicz, while researching pain control, and also losing her father shortly after that, Saunders fell into what she referred to as “pathological grieving” – although Michniewicz’s death taught her that “as the body becomes weaker, so the spirit becomes stronger”.

Dame Cicely Saunders was the first person to introduce the term “total pain” into the medical vocabulary. It refers to the physical, emotional, social and spiritual distress a patient may experience, and forms the bedrock of what hospice care caters for.

St Christopher’s Hospice opened its doors in 1967, and was the first of hundreds of thousands of similar palliative care providers established to offer holistic care to patients around the world.

Dame Cicely Saunders died of breast cancer at St Christopher’s Hospice in 2005, after devoting her life to the development of holistic care to those with life-limiting illnesses, and significantly contributing to the field of medical ethics. The principles laid down by Saunders are still the principles according to which hospice care is provided today, and this trailblazer’s legacy is immeasurable.

HospiceWits is proud to offer palliative care services to patients in and around Johannesburg. To learn more about our hospice care, click here.

HospiceWits’ interdisciplinary team and palliative care

HospiceWits takes an interdisciplinary approach to palliative care for people with life-limiting illness, incorporating various experts in this field to ensure that the patients in our care receive holistic treatment that isn’t only limited to meeting their medical needs.

Our team is made up of a number of expert medical caregivers, who all work in unison to provide top-quality care to our patients and to their families.

When you opt for palliative care from HospiceWits, these are the people that you or your loved one will have access to.

General practitioners or physicians

As you might expect, medical doctors will be in charge of the medical care of the patient who is receiving palliative care from HospiceWits. A GP or physician will communicate with the rest of the care team regarding the patient’s medical condition, and will convey this information to the loved ones and relatives of the patient. Physicians will make treatment recommendations and assess the side effects and benefits of particular treatments, as well as explaining what outcome is likely if no treatment regime is followed. Doctors make decisions with regards to tests, the prescription of medication, and other relevant forms of treatment.

Nurses

The relatives of a patient that is receiving palliative care from HospiceWits are likely to regularly communicate with the nurses tasked with their loved one’s care. HospiceWits nurses administer the medical care a patient needs according to the recommendations made by the GP or physician, in addition to offering direct care to the patient. Nurses often serve in a supervisory role to nursing assistants and other members of the care team.

Nursing assistants

As the name suggests, nursing assistants help in the nursing care of the patient – this includes monitoring a patient’s vital signs and regularly checking their blood pressure, temperature and pulse, and then relaying this information to primary healthcare workers.

Social workers and counsellors

Psychosocial care is a primary pillar of the service HospiceWits provides, and a social worker and counsellors are indispensable to patients and to their families in this regard. In order to relieve the mental distress that many patients and their loved ones experience, these mental health experts employ a variety of techniques and counselling methods.

Therapists

Depending on the care a patient needs, specialised therapists such as occupational therapists or physiotherapists are sometimes a part of the care team.

Volunteers

HospiceWits is grateful to the many volunteers that offer their time in service of the patients in our care. Volunteers assist HospiceWits in a myriad of ways, including offering companionship to the patient, running errands for the patient and their family, and assisting the primary care team in terms of direct patient care.

Each member of the HospiceWits interdisciplinary team is essential in providing the exemplary service that this organisation has become known for over the years. To learn more about how to access palliative care services from HospiceWits, click here.

Dementia: These are the early signs to look out for

One of the conditions affecting patients who receive palliative care from HospiceWits is dementia. This catchall term describes a number of conditions, both progressive and terminal, which include Alzheimer’s disease (this is the most common form of dementia), frontotemporal dementia, vascular dementia, Lewy body dementia, Korsakoff syndrome and/or a combination of these conditions.

While many people consider dementia a normal part of aging, it is important to mention that this group of conditions do not form a part of the normal cognitive decline that older people experience, as it is a disease of the brain that affects cognitive functioning and decline in short-term memory, and often causes irreversible loss of neurons.

It is important to recognise the early signs and symptoms of dementia, not only because these might present far earlier than one might expect, but also because an early diagnosis of dementia ensures that a patient can plan for the future and receive the medical and non-medical interventions that may reduce the speed of the progression of the disease.

Keep an eye out for the following signs and symptoms. Should you notice them in yourself or in a loved one, make it a priority to speak to a medical professional about what the treatment path should be going forward.

Early signs of dementia, versus normal cognitive decline in older individuals

Even if dementia is often considered a normal part of growing old, there are significant differences between signs of dementia, and normal signs of aging.

For example, age-related changes might lead a person to make a bad decision once every often, whilst dementia symptoms include regular poor judgement and decision-making. As people grow older, they might forget to pay a bill once in a blue moon, but the total inability to manage a budget if one was once able to do so might be a sign of cognitive decline related to dementia.

Similarly, forgetting the day or date (and then perhaps remembering it later) is quite normal for older people – people who are in the early stages of dementia will often lose track of the date or season without recalling the fact later.

Sometimes forgetting a word is normal for most people, regardless of their age, while people with dementia will struggle to have a proper conversation or follow a conversation with other people or on the TV or radio, often confusing words and the structure of a sentence. Even if we all sometimes misplace objects, people who are starting to show signs of dementia will do this very regularly, and will exhibit an inability to retrace their steps in order to find said objects.

Other signs to look out for include:

  • Forgetting the names of close friends or everyday objects.
  • Feeling confused (even in places a person is familiar with) or getting lost on journeys that are familiar to a person.
  • Pronounced changes in mood or behaviour.
  • Noticing that other people notice or comment on a person’s memory loss.

How to prevent the onset of dementia

While dementia often has a strong genetic link (in other words, if a close relative has the disease, there is a chance that there may be a family history which affects a person’s susceptibility to also being diagnosed with it in their life), there are certain lifestyle changes that may reduce someone’s chances of getting dementia. Following a healthy, balanced diet and maintaining a healthy weight can be beneficial, as can regular exercise and keeping the blood pressure at a healthy level. Cutting down on drinking alcohol and quitting smoking is also always advisable.

Should you require assistance with a loved one who requires palliative care due to dementia, please contact HospiceWits. Our interdisciplinary team takes a holistic approach to palliative care, which can be of great support to a dementia patient and their relatives.