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Palliative Care Oct 2006

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					INCTR Palliative Care
    Programme




                        INCTR
The Problem

                56 million people die
                 every year
                40 million of these in
                 developing countries
                About 30 million
                 need palliative care
                Only small number
                 receive it

Sternsvald & Clark, 1999            INCTR
Overall Strategy of PCP (PAX)
 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
   – Engaging with the local government with respect to opioid
     availability and the development of a plan to make palliative
     care widely available in the region
   – Promoting the development of local NGOs for palliative care
   – Undertake relevant research in palliative care, e.g, optimal
     assessment of outcomes, obstacles to opioid use
   – Work closely with other INCTR elements and INCTR
     partners in expanding the program via additional educational
     tools (clinical care guidelines, telemedicine)

                                                              INCTR
INCTR is Ideally Placed to Promote the
Development of Palliative Care in Nepal




  NNCTR/INCTR sponsored cervical screening
  program at Scheer Memorial Hospital, Banepa

                                                INCTR
Nepal Network for Cancer Treatment
       & Research (NNCTR)




            Headquarters, Banepa
                                   INCTR
                    India
 U.S.              0.0769   Tanzania
45.0822            (2001)    0.0259

                       Egypt
                       0.0651
                                  Nepal
          Saudi
                                  0.0010
          Arabia
          0.5323




                                           INCTR
Since 2002




             INCTR
Scheer Memorial Hospital
             150-bed general
              hospital
             New palliative care
              unit 2004
             10 to 15 beds




                                INCTR
Bhaktapur Cancer Care Centre




               5 beds for palliative
                care
               Outpatient pain
                clinic

                                   INCTR
Hospice Nepal




                INCTR
Kanti Children’s Hospital
              4-bed unit opened in
               2004




                                INCTR
INCTR’s Role




               INCTR
Education &
 Training



              INCTR
      Facilitating Discussions on National
       Medication Policy and Availability
 WHO Foundation Measures for
   Implementing Cancer Pain
      Relief Programmes




                    Drug
Education           availability




      Government policy

                                             INCTR
Professional
 Resources


               INCTR
                                         This is a draft version and not for general distribution.
home Since the material in this handbook is abbreviated it should be interpreted in the context of other materials and textbooks.
                                       Clinical judgment should be exercised at all times.




                                                                 Anorexia and Cachexia
                                                                 Constipation
                                                                 Cough
                                                                 Delirium and Hallucinations
                                                                 Dyspnea
                                                                 Malignant Bowel Obstruction
                                                                 Malignant Ulcers and Wounds
                                                                 Nausea and Vomiting
                                                                 Pain
                                                                 Respiratory Secretions at the End of Life
                                                                 Seizures
                                                                 Signs and Symptoms at the End of Life
                                                                 APPENDIX 1:
                                                                  Breakthrough Doses of Morphine
                                                                 APPENDIX 2:
                                                                   WHO Pain Ladder
                                                                 APPENDIX 3:
                                                                    Abbreviations




                                                                                                                                    INCTR
Funding for Vehicle
 for Home Care


                  INCTR
Future Plans/Goals:
       Nepal




                      INCTR
1.   Improve Quality of Care in Present
     Facilities




                                          INCTR
2.   10 Palliative Care Beds in New 75-Bed
     Unit at Bhaktapur Cancer Care Centre




                                      INCTR
3.   Paediatric Palliative Care

                         5 palliative care
                          beds for children at
                          Scheer Memorial
                          Hospital, Banepa




                                           INCTR
4.   Home Hospice Programme

                    Expand Home
                     Hospice Programme
                     administered
                     through Hospice
                     Nepal, Patan




                                   INCTR
5.   Implement Web-Based Teaching and
     Support




      Telemedicine system at NCI Liaison Office, Brussels
                                                            INCTR
6.   Outreach to Rural Areas

                      Specialist visits
                      Education of
                       healthcare
                       professionals
                      Public health
                       education, including
                       cancer awareness



                                         INCTR
7. Improve Opioid Availability


                               India
                              0.0769   Tanzania
      U.S.
                              (2001)    0.0259
     45.0822
                                  Egypt
                                  0.0651
                                             Nepal
                     Saudi
                                             0.0010
                     Arabia
                     0.5323




                                                      INCTR
8.   Expansion of Programme to Other
     Regions of Nepal
                              B.P. Koirala Memorial Cancer
                              Hospital, Bharatpur




         Hospice, Bharatpur

                                                    INCTR
INCTR/ACS/Pallium Programme
 Initiated with funding from ACS
 Goal: to establish palliative care centers in
  India which can both deliver care (institutional
  and home), and provide a center of
  excellence for:
   – Training of palliative care specialists
   – Liaison with local government re: issues such as
     opioid use and training of non-specialist doctors
     and nurses
   – Development of civil society relevant to palliative
     care
   – Outreach into other institutions and rural regions
                                                       INCTR
         Project Initiation
 Appointment of Program Director (Dr.
  Gayatri Palat) in July 2006 at MNJ
  Institute of Oncology and Regional
  Cancer Center, Hyderabad, Andhra
  Pradesh
 Assessment of palliative care needs


                                         INCTR
          Andhra Pradesh
 Population 75,727,000 (census 2001)
  with 23 districts.
 An estimated 200,000 people suffering
  from cancer.
 An estimated 2,350 people suffering
  from AIDS
 No formal palliative care in the state –
  an estimated 1% have access – via
  MNH IO
                                         INCTR
   MNJ Institute of Oncology
 Founded in 1955 in Hyderabad with
  donations from philanthropists, notably Mehdi
  Nawaz Jung Bahadur, after whom the 250
  bed hospital is named
 Designated as a regional cancer center by
  the Government of India in 1996
 Presently attached to the NT Rama Rao
  University of the Health Sciences, AP
 Has telemedicine facility and digital library

                                            INCTR
              Existing Facility
 Department of Pain and Palliative Care exists at MNJ
  IO but no dedicated beds
 120 patients seen in month of July with 15
  admissions for palliation
 Dr Durga Prasad nominally in charge – 6 weeks
  training from Dr. Rajgopal, 1 month at MD Anderson,
  Train the trainer course run by Pallium
 Has other duties (radiotherapy), and “runs”
  department in his spare time
 Director of Institute very supportive of developing the
  program along the lines proposed by INCTR

                                                      INCTR
             Dr Gayatri Palat
 Was Associate Professor, Department of Pain and
  Palliative Medicine at the Amrita institute of Medical
  sciences, Kochi, Kerala
 Initial trainee in anaesthesiology from 1996-1999
  (Medical College, Calicut, Kerala)
 Worked in Pain and Palliative Care Society with Dr
  Rajgopal in the WHO Demonstration Project MC,
  Calicut from 2000 – 2004, rising from registrar to
  Associate Professor (with Dr Rajgopal)
 From 2004-2006, Associate Professor in Pain and
  Palliative Medicine at Amrita Institute of Medical
  Sciences, Kochi (with Dr Rajgopal)

                                                       INCTR
                Progress - July
 Productive meetings with met with Director of MNJ
  IO, Dr Prasad, local NGOs
 Director agreed to
   – I month rotations for radiotherapy trainees through PPC dept
   – Initiation of training program for palliative care nurses
   – Meeting with Dean of Medical Education for the state to
     discuss state-wide palliative care training for undergraduates
     in all medical faculties
   – Appointment of Dr Palat as Associate Professor
   – Appointment of secretary to department
   – Expansion of present palliative care facilities
 Initiation of assessment of opioid availability in P
                                                               INCTR
                Initiation of Care




Pediatric consultation for child




                                   Smiling patient after oral morphine

                                                                 INCTR
      More Tangible Progress
 Appointment of two nurses to department
 Society “Pain and Palliative Care Society” being
  formed to work closely with the department at NMJ
  OI
 Initiation of radiotherapy rotation and upgrade to 6
  weeks “certification course”
 Initiation of palliative care “Journal Club”
 Development of research project, ‘Symptom
  Prevalence in Patients with Head and Neck
  Malignancy, a Prospective Survey’
 Meetings with Dean and Government officials
                                                     INCTR
      Initiation of Home Care
 First patient: elderly
  patient with Ca
  rectum




                                INCTR
             School Visit
 Visit to class X
  students at Diamond
  Jubilee Public
  School to discuss
  palliative care




                            INCTR
            Public Relations
 Interview with “The Hindi” a major national newspaper
 Presentation at World End-of-Life Care Conference,
  26th to 30th of September, 2006, at Montreal.

                  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.


                                                                 INCTR
                Tanzania

 Second meeting at
  ORCI to discuss an
  INCTR palliative
  care program
  August 2006 as
  component of PACT
  program




                           INCTR

				
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