Transferring Palliative Care Expertise

1. Transferring Palliative Care Expertise Ian Magrath, UICC WCC, August 2008 www.inctr.org

2. 56 million people die every year 40 million are in developing countries About 30 million need palliative care Only a small number receive it The Problem Sternsvald & Clark, 1999

3. India 0.0769 (2001) Tanzania 0.0259 U.S. 45.0822 Egypt 0.0651 Nepal 0.0010 Saudi Arabia 0.5323 89% consumed in Europe and the USA

4. Overall Strategy • To establish regional palliative care centers that both provide care (institutional and home) while: • Training and educating palliative care specialists and non-specialists health workers • Spawning regional satellites • Engaging with policy makers re: opioid availability • Working with and promoting the development of local NGOs for palliative care • Undertaking relevant research in palliative care, e.g, optimal assessment of outcomes, obstacles to opioid use • Interdigitating with other INCTR elements re: development of training tools, accreditation and use of IT technology

5. Regional Program Development Expert Visit Long term assignments Local Director Workshops Training Courses Accreditation Training Care Research Satellites may be hospitals or community based programs Regional coordination essential

6. Assess, Plan, Act • Assess current facilities for the delivery of palliative care, and existing elements of relevant civil society • Identify appropriate location for the establishment of a first palliative care center for care and training • Train local staff via expert visits and use of established programs (e.g., MNJ for Asian region, Hospice Uganda in E. Africa) • Assess obstacles to opioid use and develop strategies to overcome them

7. INCTR Country Projects • Nepal - Kathmandu Valley, initiated 2003: Drs Shrestha, Vaidya • India - Hyderabad (MNJ) initiated 2006: Dr Gayatri Palat • Tanzania - Dar es Salaam (ORCI), initiated 2007: Drs Ngoma, Msemo • Brazil - Sao Paulo (Santa Marcelina Hospital), initiated 2008; Dr Epelman

8. Requirements for Success • Local leader trained in palliative care • Major hospice or cancer center • Strategic plan for expanding palliative care services within the institute and beyond • Institution of sensitization workshops, and training programs at various levels (general nurses and doctors to palliative care specialists; social workers, managers • Rapport with policy makers re: opioid availability • Collaboration with local NGOs • External and local funding

9. Visits by Palliative Care Experts INCTR’s PAX team includes palliative care physicians, a nurse and social workers. Most volunteer, Director, Dr Brown, mix of volunteer and INCTR support for developing the program

10. INCTR’s PAX Team • Dr Stuart Brown, PC physician, Director • Dr Fraser Black, PC physician, Co-Director • Virginia Le Baron, PC nurse • Douglas Ennels, PC Social Worker • PC Experts: Robin Love, Peter Kirk • Dr Aziza Shad, Sabine Perrier-Bonnet

11. Workshops, Seminars, Courses Basics of palliative care for doctors, nurses, social workers Longer courses – months to a year, for oncologists and palliative care specialists

12. AMCC Actions from 2003 • 16 missions in 9 Francophone African countries from 2003 to 2008 • Sensitization workshops, train the trainers, and basic palliative care (in some cases included in general programs in cancer): • 282 doctors, 301 nurses, 8 midwives • 2 PC workshops held in Aortic meetings in Senegal (2005) and South Africa (2007) for 54 and 80 participants respectively

13. Stimulating Civil Society • Relations established with an existing Pain and Palliative Care society in Nepal • A group of physicians and business men has agreed to work to further develop palliative care in Nepal

14. Facilitating Discussions on National Medication Policy and Availability

15. Development of Guidelines Symptom Control Available via INCTR’s website and in printed versions

16. Implement Web-Based Teaching and Support (Future Plans) Telemedicine system in Brussels

17. Visit to class X students at Diamond Jubilee Public School to discuss palliative care Public education should start early School Visits

18. Interview with “The Hindi” a major national newspaper Presentation at World End-of-Life Care Conference, 26th to 30th of September, 2006, at Montreal. Public Relations Palliative clinic for terminally ill to be set up. The Institute, which has been offering palliative care for terminal cases for the last three years, has recently received support from the International Network for Cancer Treatment and Research (INCTR). Along with the American Cancer Society, the Network has also provided grants and a consultant for the Institute.

19. MNJ Statistics - Outcome Total of over 7000 patients provided with palliative care

20. Morphine Consumption for the period from Jan, 2006 to June, 2007 600 500 400 Total in Grams 300 Morphine in Grams 200 100 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Months MNJ Statistics – Outcome 790 gms in 2005; 5260 gms in 2007

21. Summary • While palliative care programs of various levels of efficiency exist in many countries, these are grossly inadequate for the needs • INCTR’s approach to training and education is to work in long term collaboration with developing countries • It is important to establish centers/units that can provide both palliative care and training in a sustainable manner • Palliative care units can improve existing capacity through the creation of additional centers in the same or other regions associated that can also function as training centers • They also function as the regional focus for the promotion of palliative care (and improving access to opioids) with government, academia and civil society • Sensitization and training workshops in palliative care in the absence of establishing centers can also be successful, but outcome measures (best = patients treated) more difficult