International Palliative Care Network Lecture Series 2013

1. International Palliative Care NetworkLecture Series 2013 International Palliative Care Network Lecture Series 2013

2. Models of Care and Strategies to  Provide Early Palliative Care Delivery International Palliative Care Network Lecture Series 2013

3. Development of Palliative Care in Lebanon Presenters: Dr. Hibah Osman Ms. Loubna Batlouni International Palliative Care Network Lecture Series 2013

4. Balsam- Lebanese Center for Palliative Care Beirut, Lebanon International Palliative Care Network Lecture Series 2013

5. Hibah Osman Medical Director Blasam- Lebanese Center for Palliative Care h.osman@balsam-lb.org International Palliative Care Network Lecture Series 2013

6. About the Presenter Hibah Osman is a family physician and a palliative care specialist. She is founder of Balsam-Lebanese Center for Palliative Care and serves as its Medical Director. She recently received the Hospice and Palliative Medicine Certificate from the American Board of Family Medicine. She is in private practice and leads the palliative care team at the American University of Beirut Medical Center. International Palliative Care Network Lecture Series 2013

7. Loubna Batlouni Outreach Coordinator Blasam- Lebanese Center for Palliative Care l.batlouni@balsam-lb.org International Palliative Care Network Lecture Series 2013

8. About the Presenter Loubna Baltouni is the Outreach Coordinator at Balsam- Lebanese Center for Palliative Care. She is a public health professional with an interest in health promoting palliative care. She is responsible of awareness raising, advocacy, and capacity building activities at Balsam. International Palliative Care Network Lecture Series 2013

9. Conflict of Interest or Funding Source • None International Palliative Care Network Lecture Series 2013

10. Outline • Palliative Care Milestones in Lebanon • Evolution of Models of Care • Palliative care delivery in Lebanon: • Challenges • Facilitators • Introducing Balsam • The team • The services • Some figures • Provision of Home-based Palliative Care- Balsam’s experience: • Challenges at the healthcare provider level • Facilitators at the healthcare provider level • Challenges at the caregiver level • Facilitators at the caregiver level • Future of Palliative Care in Lebanon • Recognition of palliative care as a specialty • Advocacy activities of the National Committee • Acknowledgement International Palliative Care Network Lecture Series 2013

11. Lebanon • Area: 10452 km2 • Population: 4.5 million • Health system: • Highly Privatized • National Social Security Fund • Ministry of Public Health • Out of pocket expenditure International Palliative Care Network Lecture Series 2013

12. Palliative Care Milestones in Lebanon 1995: • Pain relief and Palliative Care identified as a priority during the World Health Organization National Cancer Control Workshop • Morphine quota: 0.5Kg • Patients registered to receive opioids: 95 1999: • A full day symposium on Palliative Care and Ethics organized by the Lebanese Cancer Society: • Recommendations submitted to the World Health Organization • Action plan submitted to the Ministry of Public Health International Palliative Care Network Lecture Series 2013

13. Palliative Care Milestones in Lebanon 2000: • Two-day workshop organized by the Lebanese Cancer Society to discuss the principles and barriers • Need to introduce pain relief and palliative care in undergraduate medical curricula identified 2001: • Nine fellows attended the “Education of Physicians on End-of-life Care” course in the United States and one week of bedside training • Morphine quota: 4.5Kg • Patients registered to receive opioids: 600 • Pain Relief and Palliative Care Group launched by the Lebanese Cancer Society International Palliative Care Network Lecture Series 2013

14. Palliative Care Milestones in Lebanon 2004: Legislative changes: • Physicians have the right to stop treatment if it is deemed “futile” by two physicians • ‘Do Not Resuscitate’ orders can be legally written in a patient’s chart • Morphine supply can be provided for a 4 week period (previously 2 weeks) 2009: • Opioids can be prescribed to cancer and non-cancer patients 2010: Non Governmental Organizations that offer home-based palliative care are established: • The Lebanese Center for Palliative Care – Balsam • The Home Hospice Association of Lebanon – Sanad International Palliative Care Network Lecture Series 2013

15. Palliative Care Milestones in Lebanon 2011: • The Lebanese National Committee for Pain Relief and Palliative Care was established • Standards for pain relief and palliative care • Strategies to engage professionals in the care process • Models for service delivery • Mechanisms to empower the patient and the family 2012: • A conference was held to share the work of the National Committee’s subcommittees • Education • Practice • Research • Policy International Palliative Care Network Lecture Series 2013

16. Palliative Care Milestones in Lebanon 2013: • An issue in the Lebanese Medical Journal will be dedicated to Palliative Care and will report on the recommendations of the National Committee for Pain and Palliative Care • Palliative medicine recognized by the Ministry of Public Health as a medical specialty • First hospital based palliative care service established in Lebanon at the American University of Beirut Medical Center International Palliative Care Network Lecture Series 2013

17. Evolution of models of care • Palliative care was not available in any setting in Lebanon • Non-governmental Organizations that offer home-based palliative carewere established (2010) • The American University of Beirut Medical Center is building a hospital-based palliative care team (2013) International Palliative Care Network Lecture Series 2013

18. Palliative care delivery in Lebanon Challenges: • Palliative care services not reimbursable by government nor by insurance companies • Organizations offer home based palliative care at no cost and are donor funded • Fear of covering home-based palliative care because they cannot be easily monitored • Laws do not facilitate advanced healthcare planning or goal setting, advanced directives are not legally binding • Difficulties related to opioids availability and prescription • Opioids can only be prescribed by oncologists and pain specialists • Formulations of opioids available in the market are extremely limited • Number of pharmacies that dispense opioids is limited (~30 pharmacies) • Patients go through a complicated process to obtain opioids (multiple signatures needed) • Lack of training among health professionals • Very few palliative care specialists in Lebanon International Palliative Care Network Lecture Series 2013

19. Palliative care delivery in Lebanon Facilitators: • Advocacy activities of the National Committee for Pain Relief and Palliative Care • Support and responsiveness of the Lebanese Ministry of Public Health International Palliative Care Network Lecture Series 2013

20. Introducing the “Lebanese Center for Palliative Care- Balsam” International Palliative Care Network Lecture Series 2013

21. The Lebanese Center for Palliative Care – Balsam is a non-governmental organization that works to relieve patient suffering and improve quality of life. Balsam provides holistic support to patients dealing with life-threatening illness by providing medical services as well as psychological, social, practical, and spiritual support within the family and home environment. International Palliative Care Network Lecture Series 2013

22. Balsam • Multidisciplinary Team: • Physician • Clinical psychologist • Clinical pharmacist • Nurses • Social worker • Home-based services • 24 hours a day 7 days a week • At no cost International Palliative Care Network Lecture Series 2013

23. Information about Balsam patients from September 2010 till December 2012 • 68 patients admitted (10 partial support, 58 full support) • 88% had a cancer diagnosis • 53 % of patients are females • 88% are Lebanese • 65 is the patient average age • age range is 20 to 90 years old. International Palliative Care Network Lecture Series 2013

24. Information about Balsam patients from September 2010 till December 2012 Patients admitted by month of referral Patient-days per year • Monthly increase in admission rate • Yearly Increase in patient-days • Demand goes up as public awareness about the importance of palliative care increases • Obvious need for palliative care in Lebanon but very few providers offer the service International Palliative Care Network Lecture Series 2013

25. Provision of home based palliative care services Challenges at the healthcare provider level: • Concerns about losing their patients • Concerns about losing income • Not convinced that the palliative care team could offer services they could not offer themselves • Limited understanding of palliative care International Palliative Care Network Lecture Series 2013

26. Provision of home based palliative care services Facilitators at the healthcare provider level: • Regular communication with treating physicians • Consistently involving treating physicians in major decisions • Restricting service to home-based care • Exposure to effective symptom management techniques increased trust in the palliative care approach • Having nurses from the hospital working with Balsam helped remind hospital providers about the availability of palliative services International Palliative Care Network Lecture Series 2013

27. Provision of home based palliative care services Challenges at the caregiver level: • Equate opting for palliative care to “giving up” • Unclear about what the palliative care team could offer them • Concerned about loosing their relationship with their treating physician International Palliative Care Network Lecture Series 2013

28. Provision of home based palliative care services Facilitators at the caregiver level: • Provision of equipment or practical support was the easiest way to gain entry. Trust was then built gradually. • Maintaining regular communication with their treating physician reassured patients International Palliative Care Network Lecture Series 2013

29. Future of Palliative Care in Lebanon The recognition of palliative care as a medical specialty will open the door to: • Hospital based palliative care services in medical centers • Community based palliative care services in primary health care centers • Education programs and training opportunities about palliative care and pain management for healthcare providers • Coverage of palliative care services by the government followed by private insurance companies • Palliative care physicians will be allowed to prescribe opioids International Palliative Care Network Lecture Series 2013

30. Future of Palliative Care in Lebanon The work of the National Committee for Pain and Palliative Care will open the door to: • Amendments of laws and policies restricting palliative care practice and pain management • The development of a national strategy International Palliative Care Network Lecture Series 2013

31. Acknowledgements • The Lebanese Ministry of Public Health • Minister Ali Hassan Khalil • Director General Dr. Walid Ammar • Members of the National Committee for Pain Relief and Palliative Care • Balsam donors and supporters • Individuals • Organizations International Palliative Care Network Lecture Series 2013