Sep 15, 2013

Foreign Family Caregiver

Like most middle class Malaysian families, I grew up with a family maid. We used to call them kakak, or sister in Malay. Like the African American ladies in "The Help" they cooked, cleaned, took care of the children, the elderly, and even buy groceries and manage the pantry. Throughout my childhood we had at least 5 kakaks from Indonesia. All of them worked for at least 2 years and returned home for good after their lease was done. Our last kakak was with us for the past 5 years from 2008 to February 2013. She subsequently returned to Bali, bought a store, and sold ice to hotels and tourists.
Growing up, we were extremely grateful to all our kakaks for shouldering all the housework and upkeep of our family - our sweat stained school uniforms, all the windowpanes in our airy home, breakfast, lunch, dinner, and endless guests and relatives frequenting our house. We spoke Malay but they eventually knew Mandarin from our daily family conversation.
After I started working in Taiwan, I had endless opportunities to work alongside lots of foreign caregivers of our patients. Unlike Malaysia, Taiwan has very strict regulations regarding foreign caregivers - they could only care for the elderly or severely disabled evaluated by specialist physicians approved by the Ministry of Health. As a result of a regulated cap, foreign caregivers in Taiwan usually have experience taking care of bedridden patients as well as the ability to speak and understand Mandarin.
At the end of one's life in bedridden state, these kakaks are their full time companions. Most other family members just pop in once in a while or may not even show up during the patient's hospitalization.
Taking care of a bedridden patient can be extremely depressing. Unlike babies which are tender and sweet, these patients might have nasty bedsores, pus-oozing wounds, foul-smelling phlegm to suction every 4 hours, and an endless list of medications to give at different times of the day. Imprisoned by their foreignness and round the clock demands, they maintain a minimal social life through text messaging or unlimited call plans. One could easily spot them chatting away on the phone or texting during their free time. Sometimes they got so engrossed they would ignore us during rounds. Their mastery of Mandarin varies and hence communication could get fiery when they aren't up to standards, especially in matters of hygiene.
On two occasions during the past month, however, their genuinity touched a cord in me. Our first kakak was caring for this bedridden old lady who was admitted for massive pleural effusion. On the night of her chest tube insertion, she accidentally removed the tube during one of her nightly delirious episodes. I went in to check if the patient is okay and found this angry kakak scolding the old lady for being impulsive and trying to slowly kill her by disrupting her sleep every 30 minutes.

3 days later, the old lady's consciousness took a turn for the worse. She was barely breathing and bloodwork finds severe hypercapnia partially corrected by positive pressure ventilation. Afraid of the inevitable, I called the family members for advanced directives and DNR. After the entire proceeding was over, I found the kakak quietly sobbing away along the corridor while firing away text messages.
"Are you okay?"
"It's my fault...I shouldn't have been so harsh on her."
"You took care of her for so long and did a very good job. It's hardly your fault. It's the natural way of life."
She went back into the old lady's room even more emotional than any of her family members.
The second kakak was a bubbly Indonesian girl who speaks very good Chinese. She had been taking care of Mr. Lin for 2 years and provided me with a detailed account of his present illness on admission (family members busy elsewhere, again). On his fourth hospitalization night, Mr. Lin accidentally choked while drinking some milk and was struggling for breath when I was called. After doing all the necessary workup and prescribing antibiotics while praying everything works out, I found the bubbly kakak in the same state as the previous kakak, as if all of them were programmed to tear up, cry, and text their friends about the conditions of their patients.
"Two years and he was doing very well..."
She was right. Mr. Lin had hardly any wounds, no bedsores, was clean every day I see him, and looks well-nourished.
"It's not your fault. It was an accident. You were great in taking care of him so well," I tried to comfort her.
While their emotionless family members went home to sleep in their snug beds, these kakaks are the ones who changed their granddad's diapers, patiently feeds 5 meals to their grandmother every day, cleans and bathes their parents in vegetative state, freeing up valuable time and energy for us to do the things we think are important. When they are hospitalized, they are the ones who slept on the minuscule sofa (convertible into a chair during the day), and had to tolerate the noisy and claustrophobic wards. When their patient is in critical condition, they joined in to pray, possibly to a different God, but for the same patient. At the end of the day, their daily keep is not just about money anymore. The bedridden granddad has became kakak's own parents.