International Association for Hospice and Palliative Care 

Subject: IAHPC Newsroom
2004; Volume 5, No 8, August

Dear Members and Colleagues:

The complete IAHPC Online Newsletter has been uploaded to our website at:

Table of Contents:

1. Message from the Chair
2. Message from the Executive Director
3. Article of the Month: “An Eicosapentaenoic Acid Supplement versus Megestrol Acetate Versus Both for Patients with Cancer-associated Wasting: A North Central Cancer Treatment Group and National Cancer Institute of Canada Collaborative Effort”
4. Book Reviews by Dr. Woodruff
5. Travelling Fellowship Report : Moldova
6. Travelling Fellowship Report: Siberia
7. Regional Reports: Africa, Cuba and UK
8. Pediatric Newsletter from Australia
9. Webmaster’s Corner
10. Editor’s Notes: Updates, Meetings and Courses


Eduardo Bruera, MD
William Farr, PhD, MD

1. Message from the Chair
Eduardo Bruera, MD (USA)

I am delighted to announce to our readers and the palliative care community that the IAHPC Board has recently elected Dr. Kathleen Foley as the next IAHPC Chairperson, starting January 2005, after my term as the second Chair of IAHPC ends.

Dr. Foley has a distinguished career as an attending neurologist in the pain and palliative care service at Memorial Sloan-Kettering Cancer Center in New York City. She is a professor of neurology, neuroscience, and clinical pharmacology at Cornell University Medical College and is universally recognized as the foremost pioneer in the development of the field of cancer pain management. She participated in the initial efforts that resulted in the establishment of the World Health Organization efforts in cancer pain relief, most of the initial efforts in the development of palliative care in North America and Europe, and in recent years she has served as the Director of the Project on Death in American since its inception in 1994. This project has been successful in completely changing the approach to end-of-life care in the United States. In addition, Dr. Foley has an extensive experience in international programs. She has traveled widely and has contributed to most international efforts for the development of cancer pain and palliative care around the world.

We are sure that under her leadership, IAHPC will continue its growth as the global palliative care organization, helping individuals, programs and institutions around the world.

I am also glad to announce that the Board has recently reappointed Liliana De Lima in her role as the Executive Director of IAHPC for an additional three years. Liliana has done a wonderful job in directing the organization and we look forward to her continuation with us.

Until next month,
Eduardo Bruera, MD

2. Message from the Executive Director
Liliana De Lima, MHA (USA)

As Eduardo mentioned in his announcement this month, the IAHPC Board has elected Dr Kathleen Foley as our next Chair, starting January 2005. Dr. Foley has enormous leadership and has played an important role in the development of palliative care around the world. I look forward to her Chairmanship and her future role with the organization.

I am also very grateful with the Board of Directors for my reappointment as Executive Director of the organization. These past four years have been a wonderful learning experience for me as we have established liaisons with individuals and programs around the globe, supported program and allocated grants for several purposes. Please remember that our ability to keep helping depends on our capacity to raise funds and donations, and that we will exist as long as those who are capable of supporting us continue to do so.

I have two additional important announcements: First, Ocean Road Cancer Institute in Daar es Salam, Tanzania has been elected as a winner of an IAHPC Faculty Development Program grant. Dr Msemo Diwani has been selected as the candidate to work as a full time palliative care physician in Ocean Road Institute and as palliative care professor in the Department of Radiotherapy and Oncology of Muhimbili University College of Health Sciences situated at the Ocean Road cancer Institute. Ocean Road Cancer Institute is the only institution which provides oral morphine to patients in Tanzania and we hope that this will be an important opportunity to make an important change in the medical and nursing students in the country.

We are also happy to announce that IAHPC has been invited to chair a panel on pediatric palliative care in the 24th Congress of the International Pediatric Association in Cancun, Mexico, on August 18-21. Our panel is called "Pediatric Palliative Care Issues in Developing and Developed Nations: Program, Development and International Resources". Liliana and Doctors Veronica Dussel from Argentina and Prof. Sverre O. Lie, from Norway will participate in the panel. We believe this is a great opportunity for IAHPC and an important step in bringing forward the pediatric palliative issues into an international congress.

Additional information about this congress and registration can be found at URL:

We look forward to seeing some of our readers there.

A small new pediatric palliative care unit being set up in China requires short/long term volunteers to help. If you are interested in helping, please contact Dr Joyce Hill [email protected]

Until next month,
Liliana De Lima, MHA

3. Article of the Month
Carla Ripamonti, MD (Italy)

An Eicosapentaenoic Acid Supplement versus Megestrol Acetate Versus Both for Patients with Cancer-associated Wasting: A North Central Cancer Treatment Group and National Cancer Institute of Canada Collaborative Effort

Author(s): Jatoi A, Rowland K, Loprinzi CL, Sloan JA, Dakhil SR, MacDonald N et al.

Abstract: J Clinical Oncology 2004; 22: 2469-2476

Eicosapentaenoic Acid (EPA) is an essential omega-3 fatty acid highly present in certain species of fish. Published studies showed that EPA administration in patients with cancer-associated wasting brought about weight stability as well as weight gain, an increase in appetite and an increase in survival. From data of translational studies, EPA seems to suppress some mediators of cancer-associated wasting such as interleukin-6 and a proteolysis-inducing factor (inducing protein degradation).

Jatoi et al. carried out a double-blind, placebo-controlled trial which compared three treatment arms: an EPA nutritional supplement (1.9 g bid) plus placebo; megestrol acetate (MA) 600 mg/day plus an isocaloric, isonitrogenous placebo twice a day; and both agents. The aim of this multi-centre trial was to evaluate which therapy improved weigh, appetite, quality of life and survival.

MA was included in the study because it proved to increase appetite and non fluid weight in cancer patients, a nutritional supplement was included because one study showed that a combination of this caloric supplementation to EPA lead to weight gain.

Patients with brain tumors, brain metastases, potentially hormone-sensitive tumors, ascites or oedema, GI problems, heart failure, history of thromboembolism and those with a life-expectancy < of 3 month were excluded from this study, in addition to patients treated with steroids, progestinics and other appetite stimulants.

For the inclusion in the study, patients were required to have a 2-month weight loss of at least 5 lb (2.3 Kg) and they had to perceive loss of weight and/or appetite as a problem. A total of 421 patients were considered assessable.

Regarding WEIGHT, the percentage of patients treated with MA alone who reached the 10% weight gain above baseline (primary end point) was higher than that of patients treated with EPA supplement (18% vs 6% p=.004). Combination therapy resulted in weight gain of >= 10% in 11% of patients (p=.17 across all arms).

APPETITE measured by the North Central Cancer Treatment Group (NCCTG) questionnaire was unable to detect any difference among the three therapeutic arms. Differently, using the Functional Assessment of Anorexia/Cachexia (FAACT) questionnaire (version 4), appetite stimulation was reported to be higher in MA alone arms and in EPA-MA arm compared with the EPA supplement alone arm (p=.004).

Regarding global QUALITY OF LIFE and SURVIVAL no significant difference among the groups was found.

TOXICITY among the study arms was comparable. However, male patients in the arms including MA reported greater rates of impotence (which was however not evaluated at basal time).

Why I chose this article

Lack of appetite and loss of weight are present in most advanced and terminal cancer patients. Whilst we know MA'’s value in stimulating appetite and weight increase, data relative to EPA's role are still wanting. Bruera recently studied the efficacy of fish oil in 60 patients with advanced cancer and demonstrated its inefficiency. Jatoi's RCT results are an additional confirmation, i.e. EPA supplement does not give any significant improvement as far as weight, survival or quality of life are concerned when compared with Megestrol Acetate.


Carla Ripamonti, MD
Member of the Board of Directors, IAHPC

4. Book Reviews
Roger Woodruff, MD (Australia)

Principles and Evidence for Practice

Sheila Payne, Jane Seymour and Christine Ingleton (Eds)
Open University Press, 2004. ISBN 0-335-21243-3. 791 pp. RRP £29.99, $US42.95

This new textbook aims to draw together the principles and evidence that underpin palliative care nursing. It is organized in a novel fashion, following the trajectory of the illness, rather than the traditional physical, psychological, social and spiritual approach. The book is divided into four parts - Encountering illness, Transitions into the terminal phase, Loss and bereavement, and Contemporary issues, the last covering nursing education, research and practice. Each Part is prefaced by an editorial Overview that provides useful orientation, but the twenty pages spent listing what the authors say in the chapters that follow seemed unnecessary.

This book focuses on those facing death and emphasizes the nurses’ role in their care. There are some excellent chapters on access to palliative care, dealing with families, grief and bereavement and other topics. Some other chapters I found a little long-winded. There are also issues where the clinical evidence base has been overlooked. For example, in the two separate discussions on artificial hydration for the dying, the theories are presented but no reference made to the observational studies, never mind the randomized control trial, which suggest it is of no benefit.

The discussion on euthanasia is disappointing. The author describes a “conceptual mist”, which I found to be a blinding smog. [John Keown’s “Euthanasia”, recently reviewed here, provides an erudite and crystal-clear description]. There is repeated reference to Kuhse’s work that has been publicly discredited (incidentally, by the authors of two other chapters in this book), and very little discussion of what the Dutch and Oregonians have shown us. Only on page 14, in the final paragraph, is it noted that some Dutch patients were euthanized without request or consent. But as these cases fall outside the Dutch laws, they don’t warrant discussion. And the numbers of patients involved is “marginal”. A thousand patients a year? Please!

My quibbles aside, this is a very impressive book that provides in-depth discussions on a range of issues that are less fully addressed in other palliative care books. It will be of great value to nurses practising palliative care or studying it at a postgraduate level. For me, it was a little too long on theory and short on clinical facts, so it complements but does not replace the ³treatment manual² type of book. And we need both.

THE STARTLED HEART: Ghazal Variations on Loss

Eve Joseph
Oolichan Books, 2004. 57 pp. ISBN 0-88982-191-7. RRP $CAN 15.95. Available from [email protected]

Ghazal? Not in my O.E.D. But Google found it at poetrynet.

So what is a Ghazal? It is a poem of 5 to 15 couplets, written in a particular form, according to traditions originating in ancient Urdu and Persian.

Now that we’ve cleared that up, we can talk about the book. This is a wonderful collection of 45 ghazals that are a celebration of life, and death, written by a counselling psychologist who works at the Victoria Hospice in Vancouver, British Columbia. Her professional experience and insight made the poems, for me, feel authentic and real.

If you like poetry, or you want something to help you think about what you do everyday, buy this little volume.

The way the man dying of leukemia, said:

“Death has been here three nights
And tonight I think we’ll sleep together.”


Richard B. Patt and Susan S. Lang
Oxford University Press 2004. 446pp. ISBN019-513501-6 . RRP $US 35.00, £17.90

This book is the thoroughly revised and updated version of the 1994 book “You Don¹t Have To Suffer” by the same authors. It is a well-written and comprehensive handbook for cancer patients and their caregivers.

The first section deals with cancer pain - what it is, what causes it, and how it should be assessed. The fourth chapter in this section empowers patients and their families to actively participate in the management of pain and provides checklists of what to ask the doctor and what to expect. The second section gives detailed descriptions of analgesics, adjuvant drugs and there is a chapter on anesthetic procedures. The third section provides help in dealing with common symptoms and side effects and there is a chapter on mind-body approaches to easing pain. The last two chapters on “Dealing with Feelings” and “If Death Approaches” will be particularly valuable for caregivers and clearly explains what to expect and what you can do about it.

There are appendices that include where to find more information, the foreign (non-USA) names for the common drugs, instructions for relaxation exercises, and detailed information about advanced care planning.

This will be an invaluable resource for people caring for patients with cancer and pain, particularly if they are being managed at home. The information is well set-out and clearly explained, and there is a glossary of medical terms included.

A global challenge

M. R. Rajagopal, David Mazza and Arthur G. Lipman (Eds)
Haworth Medical Press, 2003. 249 pp. ISBN 0-7890-1556-0. RRP $US27.00

Two-thirds of those in need of palliative care live in developing countries that have less than ten percent of the world’s resources in terms of health care personnel, drugs and equipment. I have to admit I would have thought that the needs were even greater and the resources less. As Jan Stjernsward says in his introduction, this book offers a banquet of papers that describe pioneering work on the front lines of pain and palliative care service planning and implementation in developing countries. There are papers describing the development of programs in India, Chile, Argentina, Saudi Arabia, Hong Kong, Malaysia, Uganda, Papua New Guinea, and Kenya. There are also chapters on ethics, spiritual care, education and research in the context of developing countries. The book is enhanced by having a thoughtful two-page editorial commentary after each of the papers.

The importance of the IAHPC program of Travelling Fellowships is acknowledged in an editorial commentary following David Allbrook¹s report from Kenya and Nell Muirden’s report from Papua New Guinea, although two of the other authors in this book were IAHPC Travelling Fellows and a third was a Travelling Scholar.

The enormity of the problems described in this book are daunting, but it is interesting to read because it is written by highly motivated people who are out there trying to do something about it.

KINDNESSES. A Journey Through the Seasons of Grief - Poems, Prayers and Joyous Observations

Terry Walton
Rosalie Ink Publications, 2001. 66pp. ISBN 0-971-1869-0-1. RRP $US 12.95

This is a well-written and beautifully presented little book that would be a most useful present for a friend or family member who is grieving.

I quote the comments of two other reviewers, which aptly describe this book.

“With tenderness and delicacy, Kindnesses exposes the raw wound of loss to the healing light of truth and memory. Terry Walton’s voice is singular and so very attentive to the small things that help the mourner heal.” Rabbi Jeffrey K. Salkin

“I love the connection with flowers and plants, the enhanced feelings of renewal and rebirth.” Hospice Patients Services Director.

Roger Woodruff
Director of Palliative Care, Austin Health, Melbourne, Australia

5. IAHPC Travelling Fellowship Reports

Professor Jacek Luczak


After three physicians from Hospice Angelus in Moldova finished their training in Poznan’s Hospice Palium Palliative Care Resource & Training Center, Professor Luczak visited the Republic of Moldova (RM) for the first time in May 2003. During his stay he met several palliative and hospice care individuals as well as delegates of Ministry of Health. Encouraged by Dr Irina Baikalov, the director of Second Breath Hospice in Balti to visit Moldova again, Professor Luczak applied and received an IAHPC Traveling Fellowship grant.

Aims of the visit:

To identify the current epidemiological situation, the Palliative Care needs and determine the current status of hospice programs and share experiences and knowledge on PC principles, policy, education, cancer pain management and morphine availability

To gather PC leaders, professionals including oncologists, AIDS specialist, nurses and volunteers with the delegates of Ministry of Health and the Agency for Drug Control to discuss the urgent problems and obstacles in developing palliative care in RM.


First, a visit to Hospice “Zubresti-North Carolina” and then a home visit to an 83 year old patient with breast cancer. The Hospice director presented a summary of the development of the Hospice and the project of the creation a 20 bed Hospice with the financial support from North Carolina, USA. The hospice is planned to open in October 2004 as the first inpatient unit in Moldova.

Visit to Balti, where a meeting with the team from the “Second Breath” took place. Due to a limitation on the amount allowed for prescription (10 ampoules per week), patients from Balti can’t receive the necessary dosage of morphine. Some commercial preparations of potent analgesics are available, but too expensive. In addition, family members are obliged to take back to the policlinic the empty ampoules of used morphine!

Visit to the Medical University in Chisinau
Here a meeting took place with Ion Ababii, the Rector of the University, Mr. Vovc, the chief of the International Relations Department, and Mr. Chicu, the vice director of the University. As a result of this meeting, an additional one took place at the University with several professors and academic teachers from interested in PC.

Visit to the Oncological Institute
A meeting was organized with the vice-director of the Institute, Dr. Cernat who gave an overview about the activities of the Oncological Institute and the importance of oncologists in PC.

Meeting in Soros Foundation Moldova Center (SFM).
Professor Luczak met with the director of the Public Health Program, Valeriu Sava and the assistant of the PC program Angelina Ursu. There was also a discussion about the right to die in dignity and in peace.

Meeting with Mr. Gherman, Minister of Health of Moldova.
Professor Luczak was accompanied by Polish Ambassador Piotr Marciniak and his deputy, Igor Bugai and the interpreter. Mr. Gherman was accompanied by the vice-minister, Mr. Vovc and Rodica, the responsible person for International Relations.

Professor Luczak spoke about the visits to the existing Hospices in Moldova, the importance of changing the restrictive policy of opioid prescription in Moldova and the effectiveness of oral Morphine. Mr. Gherman agreed on the importance of PC. Also, he talked about making oral morphine available in Moldova, and in setting up a Palliative Care Task Force Group attached to the MOH. He also emphasized the importance of HIV/AIDS infected people and the care they receive and role of nurse initiatives and nursing education.

June 17-18, the seminar “Palliative Care” took place in Chisinau.
The meeting was planned for 30 participants but 45 participants registered, including medical students! Workshops were an important part of the Seminar. The workshop on dying focused on the unmasked face of dying and death and included with the sharing of a very painful experience by a young bereaving widower.

Participants of a workshop on opioid availability and PC policy development, lead by Maria Ivancov, worked out the recommendation and steps in developing of palliative care.

Important steps in developing PC in Republic of Moldova

1. Accepting a unique approach of cancer pain management and PC in RM according to the WHO guidelines.
2. “A Green Path” and a “quantum satis” to the oral opioids for the dying patients.
3. Changing restrictive policy legislation -simplifying the drug prescriptions methods

opioid prescription

increasing the dosage and the quantity of opioids

the right of who can prescribe the opioid

4. Introducing new oral immediate release form of opioids – oral morphine solution preparing by pharmacist from powder (registration, import of free of charge substance from Polfa Kutno with support of Polish Embassy
5. Change PC policy and assure financial support of the Hospice movements in Moldova and access to the Insurance (sickness fund)
6. Access to the international meetings on palliative care and cancer pain management
7. Creating a Chair of Palliative Medicine at the Medical University from Chisinau.
8. Promote training program in palliative care

Education in PC

1. Elaborating nationally agreed upon guidelines of cancer pain management and PC
2. Elaborating methodological recommendations for the medical workers and patients/relatives
3. Including the PC program in the Educational Curricula
4. Introducing PC programs in the curricula of the Chairs for Doctors’ Perfection
5. Rising Public awareness on cancer pain management and important role of hospice and palliative care services especially in end of life care

PC Policy Development

1. Recognizing palliative medicine and PC as a separate compartment of medicine
2. Introducing PC in the State Health System
3. Introducing the PC services in the unique program of medical insurance
4. Allowing NGOs to implement PC services
5. Introducing PC in the National Program of Combating Cancer
6. Development of PC according the WHO recommendations
7. Preparing medical, social workers on PC and team work.
8. Supporting the initiatives of civil society in PC

Improving opioid availability

1. Allowing the GP who takes care of the patient to prescribe opioids
2. Making oral morphine available– an important recommendation by WHO
3. Eliminating the requirement of having the patient’s relatives return the empty ampoules of morphine
4. Allowing to prescribe up to 10g of oral morphine or the equivalent of injectable morphine-4 g
5. Simplifying the prescription process
6. Changing the legislation on regulation allowing every physician to prescribe opioids

Evaluation of the Seminar:

This was the first time in Moldova that a Seminar in PC was organized with the participation of an international expert, the Polish Embassy, professors from Medical State University, Ministry of Health, Oncological Institute, representatives from Medical colleges from Moldova, Drug Control Committee, NGOs and people who deal with PC/Hospice in Moldova.

The participants of the Seminar showed a great interest in studying the problems and development of PC in Moldova. As a group discussion the participants elaborated some recommendations on development of PC in Moldova, it was a task that was a beginning of their joint collaboration.

The Resolution/Recommendations of the Seminar were given to the Ministry of Health through the Polish Embassy. The event was featured in the National mass media – TV, radio, newspapers, as it was organized a Press Conference at the end of Seminar.

Due to the restricted policies the dying patients rarely die in hospitals, the majority die at home in great sufferings. About 87% from these categories die at home without an adequate care.

In RM there 3 nongovernmental Hospices (Chisinau, Balti, Zubresti) and other nursing initiatives having the aim to alleviate suffering and improve the quality of life of the dying were founded. These organizations offer palliative care to the patients free of charge. The services which are offered by professionals in PC are not included in the National Program of Medical Insurance. It is a matter of urgency to change the governmental policies that need to contain PC/Hospice in the National Program of Medical Insurance financially covered by CNAM.

The support and the collaboration with the Ministry of Health is very important and should be done through the Council in PC composed by representatives from the Ministry of Health and interested people who will be able to reach the above mentioned objectives.

Prof. Luczak’s last day ended with visit to Hospice Angelus Moldova. He met the team, discussed their achievements (rising number of patients cared, lots of training and education also abroad (St Christopher’ Hospice, International Seminars in Palliative Care in Gdansk, Poland) and their project to set up an training center at the hospice (they taught GP and family nurses in PC and would like to extend the program).

Author’s Comments:

As someone involved in supporting development of hospice/palliative care in Moldova, I found this grant by IAHPC an important step forward.

The main goals of the visit were realized, but there are still many things to do to improve the care of dying. Activities of the hospice leaders must be supported by the government, the prescription policy must be changed, and implementation of oral morphine is urgently needed.

Formation of the Palliative Care Task Force Group as an advising body attached to the Ministry of Health and cooperation with the University of Medical Sciences can be helpful in further development.

We recently made arrangements to provide a doctor and a nurse from hospice Zubresti with training in our hospice (Poznan, Poland) this July and an oncologist from Chisinau Oncological Institute in November. In the future, cooperation with our Moldovan colleagues we will be continuously supported by Polish Embassy.

The full text of this Travelling Fellow’s report is available on our website at URL:

IAHPC Travelling Fellowship Report

IAHPC report on Teaching Project to Siberia
Maureen A Gill, RN and Julia C Wootton, MD : April 2004

Project Background

In April 2003 a new 24 bed hospice opened in Prokopjvesk a large mining town in the Kuzbass region of Siberia, FSU. The town was a prime location for such a care development, having been identified by the regional cancer figures for several years previously as having the highest incidence of the disease in the population.

The new hospice was in the planning stages for six years, having been the vision of one Nadya Adamova, Chief Nurse at one of the city’s nursing homes for the marginalized. She had attended lectures on Palliative Care given by Maureen Gill and a visiting Palliative care team to Kemerovo Regional Hospice in 1998. With the help of the Chief of the local health Administration in Propkopyvesk, Dr.Nikolay Zinevsky, and in corroboration with Maureen Gill, the vision of a hospice for the city became a reality.

At the hospice opening ceremony, Dr Zinevsky apprehensive about the lack of training in the speciality for hospice staff approached Maureen Gill.
This group had simply been allocated jobs at the unit following the conversion of their old place of work (a gynaecological hospital) into the hospice building. Education in the philosophy and practice of Palliative Care was therefore paramount! Personal support in this area of work was also essential for staff!

Visit to Prokopyvesk

Our main aim was to provide staff with a basis of knowledge in Palliative Care by offering stimulating and high quality lectures. This information needed to be based on frameworks that could be adapted to the Russian culture and take into account the lack of many medicines and services. Lectures were delivered in the hospice itself. Whilst the room was adequate for the numbers attending on any given day, there was a lack of any aids to teaching. The lack of equipment meant long periods for students to listen to only translated material and could not have helped to hold their interest. Staff present varied in number depending on their manager being able to release them from the workplace at any given time but generally varied from 15-50. As well as the staff from the hospice, hospitals and nursing homes were represented. The meetings were multi- disciplinary and this is a step forward in Russia where it has been previously difficult to reach doctors and nurses in the same group.

We were particularly pleased that as time passed, students felt confident enough to be more and more interactive and the more formal lectures began to take on a more relaxed atmosphere. Many had only previously experienced a more didactic method of teaching and time is needed to change this and to allow individuals to realise they are not being judged or tested by tutors, and that their opinions are valued.

Some began to stay behind after lectures for more informal discussions on all aspects of Palliative Care.

We had prepared a full programme for students, but because of the time taken to interpret as well as other matters, time was the curtailing factor.
We were given the opportunity to visit the patients in the hospice and talk with them. As we had only one interpreter it was not possible to take students with us on this occasion, which, for the learners, could have been a valuable learning curve. To have been invited to talk with patients and observe the day to day working of the hospice was however another stride forward as far as foreign visitors are concerned and marked a new feeling of openness and sharing with our Russian nursing and medical colleagues.

Valuable discussions with Dr Nikolay Zinevsky and the Chief Dr. of the hospice Dr. Vladimir Zhebenkov took place often at mealtimes and at the end of the working day. Our hosts were extremely generous and most hospitable. We hope these deliberations will prove fruitful in the future development of the hospice as well as more broadly the furthering of Palliative Care in the region under the leadership of Dr Zinvesky, a man of great insight.

We took the opportunity to visit the city of Kemerovo during our stay at the kind invitation of Dr. Olga Berezikova, the Director. Although Maureen Gill had previously played a part in teaching at this hospice, it had changed its location and had been under the responsibility of a different Director. It was decided to accept this invitation in order to re-establish good working relationships with this unit. Fortunately we were also given several opportunities to teach and exchange ideas with staff and again Dr. Berezikova was most hospitable and hopes for future collaboration in teaching of Palliative care for her staff and other interested parties. She arranged a meeting for us with the Deputy Chief of her Health Administration, who voiced his hope that we may consider a new partnership for future cooperation.

Whilst in Kemerovo we were also invited to visit the City Hospice and have discussions with staff working there. Many doors were opened for us and this was most encouraging.

Evaluation of the Project

Maureen Gill had prepared a simple evaluation form for the students. It became evident; however, that staff had not previously used this methodology. Some did attempt to complete the evaluation forms. Themes emerged from both these documents and the verbal opinions of the participants. These are:

Topics were of real interest and relevance to day-to-day work at the hospice.
Communication skills were especially mentioned on more than one occasion.
Psychological support lectures were mentioned as extremely helpful.
A friendly atmosphere was deemed significant and its part in learning.
Many group members mentioned, “Putting the new information/skills into practice”
One evaluation asked for more to have been given on “medicinal care”
No other suggestions were made for other topics to have been covered.

Verbal feedback was positive and there was a real feeling of hunger for knowledge, genuine interest in all that was being discussed. We felt that students were impressed that we valued their contributions and we tried to support and praise them for the impressive work they are doing at the cutting edge of Palliative Care in their country.

The Way Forward.

The way forward should be carefully considered at this time. Maureen Gill has been involved with developments in Palliative Care in this region for seven years now and it would seem an ideal time to plan the best way to consolidate this work.

One suggestion has been that a new formal partnership should be set up. The purpose of this would be to identify and train Russian teachers of palliative care. This is an interesting prospect and one that deserves serious consideration. It is not possible to perpetuate teaching trips of this nature. Monies are becoming more and more difficult to obtain and with ever rising costs, more and more expensive to fund. Time and travel over such a great distance, geo-physical barriers and huge cultural differences add to the problems. There is now enough knowledge and interest in Palliative Care for individuals regionally to recognise if it is the area of work in which they would like to specialise as teachers.

Another way to move the service forward would be to do a “shadowing” trip with a physician and a Nurse Specialist actually spending mornings working at the bedside with Siberian colleagues and discussing patient care and decision making in the afternoons.

Our Russian colleagues are asking us for more help and support in their work in any way possible and these two methods would give positive outcomes. We should also be continuing in some areas to continue to train and update.

Conditions and support for the dying and those facing life-threatening illnesses has considerably improved over the years and help for those in the field of Palliative Care and must be continued as a real humanitarian cause.

6. Regional Reports:

Arusha ,Tanzania.

Excerpts copied from the APCA Newsletter and republished here with permission.

The meeting brought together the growing number of palliative care practitioners across Africa to discuss the challenges and share experiences of delivering palliative care in resource poor countries. The event’s aim was to consolidate APCA as the organisation charged with promoting palliative care across the continent by coordinating efforts to provide training, support and standards of care for professionals and others involved in palliative care delivery. The meeting started with the first ever AGM for APCA and a selection of its board of directors.

The AGM was followed by a two day conference to share experiences of palliative care provision in sub-Saharan Africa. On the last day there was a consultative meeting with representatives of President Bush’s Emergency Plan for AIDS Relief (PEPFAR). More than $2.2 billion of the $15 billion pledged by the US government against HIV/AIDS in Africa has been earmarked for palliative care. This is the first global commitment of this magnitude and, APCA members hope, provides a major opportunity for the scaling up of palliative care provision across the continent.
Why Palliative Care?

Despite the huge numbers of people needing treatment and care as a result of the HIV/AIDS pandemic, the provision of palliative care remains extremely limited in sub-Saharan Africa. Few governments have mobilized the policies and resources to ensure that doctors, nurses and other professionals are equipped to provide appropriate and affordable care to the millions of people who need it. The availability of drugs for controlling pain and treating opportunistic infections remains a lottery. In some countries, restrictive laws which prevent or limit the use of oral morphine, for example, mean that patients and their families are suffering unacceptable levels of pain and distress unnecessarily.

Representatives from hospices and other programmes which provide home-based palliative care in different communities across 22 African countries came together for the event. The gathering also included donors to these programmes, including The Diana, Princess of Wales Memorial Fund, The Open Society Institute (SOROS) and representatives of President Bush’s Emergency Plan for AIDS Relief (PEPFAR), Help the Hospices, The Catholic Relief Society, The National Hospice and Palliative Care Association (NHPCO), The Federation of Hospices in Sub-Saharan Africa (FHSSA) and a representative from the Global Fund’s Technical Review Panel.

The highlights

The first edition of the APCA journal of palliative care was launched. Julia Downing, the Journal’s co-editor noted, “In the palliative care training declaration signed in Cape Town—three things stood out for me and there were the need for:
1) A regional palliative care association
2) A palliative care journal for the region
3) A palliative care text book for the region”.

In Uganda, nurses and clinical officers have been permitted to prescribe morphine after undertaking nine months of palliative care training, which is a major step in ensuring the accessibility of palliative care drugs
In Tanzania, the Muheza palliative care project has been integrated into existing heath services through the district hospital, ensuring sustainability of palliative care provision.
The Palliative Care Association for Tanzania was launched during the conference.
In Kenya, a doctor-on-rotation programme ensures that trained doctors receive exposure to palliative care through Nairobi hospice before they are posted to the various health facilities in Kenya.
In South Africa, a mentorship programme involving 28 hospices is being used to
promote Integrated Community-based Home Care, with established organizations
providing guidance and support to those still developing.
In Zimbabwe, palliative care training is being offered to communities who are
providing the care. Although there is moderate government support for palliative care,
champions mainly Island Hospice and The Hospice Association of Zimbabwe have
also undertaken extensive training among health professionals.

APCA’s Role

Participants embraced APCA’s new board and agreed that APCA will be catalyst for
palliative care expansion across sub-Saharan Africa. They endorsed APCA’s various
objectives which are to:

Promote the availability of palliative care for all in need. ??Encourage governments in sub-Saharan Africa to support affordable and appropriate palliative care which is incorporated into the whole spectrum of health care services.

Promote the availability of palliative care drugs for all in need. ??Encourage the establishment of national palliative care associations in all African countries.

Promote palliative care training programmes suitable for sub-Saharan African countries.
Develop standard guidelines for training and care at different levels of health professional and care providers.

Regional Report: Cuba
Dr Ivan Justo & Mrs Jennifer Kwakwa

In Cuba it is estimated that there are over 250 000 terminally ill patients. Most of them receive care at the primary health level from their family physicians, and also the vast majority will die at home and will receive assistance from diverse specialists in hospital or at home through the National Palliative Care Program.
This program was first created in 2000. It is not yet implemented all over the country and there is an urgent need for increasing care-givers’ knowledge about palliative care and how to provide services in view of the lack of resources, such as drug formulations, syringe drivers, etc.
Considering these circumstances, a Palliative Care course was organized for the first time in Cuba, in coordination with BESO, Help the Hospice, and Tomás Romay’s Policlinic. This course created an opportunity for Cuba and Britain to work together on this issue. After only one promotion, we received many requests from health professionals interested in the course. The keen interest of this initial response was later repeated again and again during subsequent teaching and meetings. It is very important to note that we received immediate support from the Health Ministry to arrange for a BESO palliative care teacher Mrs Jennifer Kwakwa from the U.K. to work here for a month. I had some knowledge of the English language, but I had never worked as an interpreter. So, since as a doctor I am familiar with medical terms, and due to my previous participation in international conferences in Cuba, I assumed the role of interpreter. We both ensured that translations were closest to its original content.
We had “good” conditions to teach in my policlinic: very effective air conditioning, four computers, and one laptop. We therefore opted to project slides in Spanish on the four PCs for the attendees, and Jennifer used the laptop with the English version at the same time as I translated her discussion. It was hard work translating all the materials into Spanish but was very necessary given that not all attendees were able to understand English. The first days were especially difficult as Jennifer and I sought to ensure we fully understand each other given the complexities of medical terminology and different cultural and philosophical approaches to palliative care of our very different countries. We also took time to discuss some minor changes in the program modifying it to precisely target the core issues in palliative care. Course participants belonged to a variety of specialty areas: doctors, nurses, psychologist, psychiatrists, social workers, surgeons, oncologists etc.

The program explored almost all aspects of Palliative Care, starting with the Cecily Saunders definition, W.H.O.’s definition; Jenny Kwakwa’s which included the aim for a good death:

"To enhance the living time left, to each and all those dying, to aim for a ‘good death’ and to help the carers (both family/friends and health professionals) cope during the dying stages and for the future"

Kwakwa J

Then we crucially defined the timescale of palliative and curative juxtaposition, terminal, and the last few days of life, issues. Topics covered included: symptom control, specific life limiting illnesses, breaking bad news, spiritual aspects, ethics, and euthanasia. During the lectures there often emerged confrontations between cultures, but this was beneficial for the participants because many of the mistakes or myths presently visible in our practice had already appeared in England, and this experience proved helpful in promoting good palliative care in our country. For example on the initial quiz, holistic aspects in palliative care were evaluated, and this reflected how different the approach is to dying patients in Cuba, and some therapeutic myths regarding the use of morphine, were explored. The discussion about the quiz was by itself an entire lecture, and it was so profitable that it was included at the beginning of all lectures. We identified breaking bad news as one of our main goals in promoting palliative care in Cuba. Cuban practice is to not tell the patient about the diagnosis, neither about the time limit of the disease, nor about cancer, “how to break bad news” was always an intense session because it pushed attendees to think about how common it is not to tell patients the truth, even when they requested it. Mostly the Cuban medical staff obeys the family decision of trying to protect the terminally ill person from suffering, and to protect themselves as well, frightened as they may be by mythical fears for example that the patient may commit suicide. In fact, we were showing evidence to the contrary - few patients committed suicide, and not knowing the truth is a major cause of suffering and leaves the patient without the opportunity of making decisions about the last period of his or her life. In the same way in the last minutes of all teaching was a short PowerPoint lecture titled, “If I were dying I would like…” in which critical aspects of care from the dying patient’s viewpoint were silently read, pointing to the need for a patient’s care to be carefully balanced between medical decisions, psycho-social decisions, family decisions, religions considerations, etc., and the humanistic perspective of those caring for dying patients.
During 27 days, from Monday to Friday, a total of 74 lecture hours were done in different health settings, including a two-week course in the Tomás Romay Policlinic, two day teaching in hospitals, visits to other policlinics, visits to a family doctor’s office, home visits to better understand palliative care patients’ situations in Cuba, a meeting at an international conference about palliative care organized by the IAHPC with North Americans participants, and a presentation by the head of the Cuban National Program in Palliative Care. This culminated in a request that we close this conference with our own short presentation and Jenny gave a brief overview of her experiences in Cuba and we finished by providing the silent audience reading (in first Spanish then English) of the patient’s wishes PowerPoint presentation. On the last day of the visit Jenny and I privately met with the head of the Cuban National Program in Palliative Care Dr. Jorge Grau and discussed many issues with regard to palliative care service development in both our countries. For example patient empowerment, family support, generic drug manufacture, evidence-based practice and the successful multi-disciplinary teaching.

Regional Report : UK
Derek Doyle OBE, MD (Edinburgh)
The right to live and the right to die in the United Kingdom

Two related news items may interest, and even challenge, readers. Judges in the High Court of the UK have just (July 2004) ruled that doctors will only have the right to withdraw treatment from patients if their lives have become intolerable. The ruling came in a case brought by a terminally ill man with a degenerative condition, who argued that it should be for him, and not his doctors, to decide whether to withdraw artificial feeding from him after he is unable to move or speak. Until now the decision whether or not to continue with hydration, feeding etc. was largely based on doctors’ assessments of ‘quality of life.’ Now the General Medical Council will have to replace its ‘ quality of life’ guidelines with a tougher ‘ intolerability’ test. The London ’ Times’ commented that “ the ruling reflects a shift of power from the medical profession and into the hands of patients. It also, however, forms part of a less welcome shift in power, out of the hands of practitioners and into the arms of the courts.” ( Saturday July 31)

Assisted suicide is firmly back on the UK agenda. Baroness Warnock, the brilliant academic and author of the report some years ago which came down against it has declared that she is now persuaded of its worth. One of the UK’s three leading political parties - The Liberal Democrats - has made it a party political issue. A recent opinion poll has shown that 80% of the British public are in favour of assisted suicide.

All of us in palliative care will surely welcome discussion of patient rights and patient autonomy, and applaud anything which reminds us and our clinical colleagues of the necessity to discuss everything with our patients and to be aware of their wishes, difficult as that can be when they change so frequently with every twist and turn in their condition. Presumably we shall welcome this further reminder, if any was needed, that palliative care always has a place, always focuses on quality of life, and always puts the patient at the centre of our thinking.

Will we be left wondering how ‘ intolerability’ will be defined by individual patients, how it might be measured, and how patients unable to communicate with us will inform us of their wishes? Will it be long before we discover, what some of us have long suspected, that assisted suicide is the thin end of the wedge, the last step before legalisation of euthanasia?

Today’s news items will make good discussion points for our patients and topics for our tutorials but, worldwide, they deserve more serious attention than this and who better to address such issues than those of us who work in palliative care.

7. Paediatric Palliative Care

Excerpts from a Newsletter from Australia
Reprinted in part with permission

Stefan J. Friedrichsdorf, MD, Fellow, Paediatric Pain & Palliative Care
The Children's Hospital at Westmead
Sydney / Australia

Office: +61-2-9845 1089
[email protected]
[email protected]

8. Newsletter Paediatric Palliative Care July 2004

Conferences & Workshops
Home Care for Seriously Ill Children: A Manual for Parents.
Online Journal "The Suffering Child"
Education in Paediatric Palliative Care

Conferences & Workshops

25-28 August 28 2004, Copenhagen, Denmark
"Understanding diversities - development of strategies for psychosocial oncology"

13-19 September 2004, Highfield, Southampton, UK
Developing and Managing Human Resources in Palliative Care. Sponsored by the University of Southampton
[email protected]

15–18 September 2004, Oslo, Norway
SIOP 2004: International Society of Paediatric Oncology (SIOP).

16-17 September 2004, Coogee Beach, Sydney, Australia
Across the Spectrum in Palliative Care
Palliative Care Association of NSW
[email protected]

16-18 September 2004, Auckland, New Zealand
Making Contacts : The Joint ANZSPM and 16th Hospice New Zealand Palliative Care Conference

19-23 September, 2004, Montreal, Canada
15th International Congress on Care of the Terminally Ill

26-29 September 2004, Edinburgh, UK
Children's Hospice International 16th World Congress
“Completing the Circle of Care”
In partnership with
Association for Children with Life-threatening or Terminal Conditions (ACT)
Children’s Hospice Association Scotland (CHAS)

29 September – 2 October 2004 – Bucharest, Romania
International Congress on Palliative Care: Experiences & Perspectives

14-17 October, 2004, White Point Beach Resort, Nova Scotia, Canada
International Forum on Pediatric Pain

12-14 November, 2004, Dearborn, Michigan, USA
NHPCO's First National Conference on Pediatric Palliative and Hospice Care
National Hospice and Palliative Care Organization

2-3 December 2004, Cardiff, UK
2nd International Cardiff Conference 2004
Paediatric Palliative Care
Evidence – Who needs it?

17-19 February 2005, Recklinghausen, Germany
3rd Conference on Children’s Pain Management and Paediatric Palliative Care
Dattelner Kinderschmerztage – Kongress für Kinderschmerztherapie und pädiatrische Palliativmedizin
(Conference language: English and German)

4 March 2005, Sydney, Australia
Annual Paediatric Palliative Care Symposium
Pain & Palliative Care Department, The Children’s Hospital at Westmead
[email protected]

6-10 April 2005, Aachen, Germany
9th Congress of the European Association for Palliative Care and 5th Congress of the German Association for Palliative Medicine

17-21 August 2005, Vancouver, Canada
World Gathering on Bereavement

Home Care for Seriously Ill Children: A Manual for Parents
There is a section on relief of pain and other symptoms that is useful for parents caring for a child in any setting.
This manual is available at

Online Journal "The Suffering Child"
available on

Some of you may have heard of End of Life Nursing Education Consortium (ELNEC) under the direction of Dr.'s Betty Ferrell and Marcia Grant. This August they will sponsor the second 'train the trainer' program for Pediatric Palliative Care in Pasadena California. I have been privileged to be part of the advisory group of Pediatric Pal Care nursing professionals who have contributed to the content of this course and can testify to the excellent content and materials that are provided to participants. More information is available at their web address

We at the University of the West of England offer a short taught post basic module run at diploma and degree level entitled 'Children's Palliative Care' It can be taken as a stand alone module or as part of a variety of ongoing degree and diploma courses. We are considering offering this 'on line' in the near future. The next course comences in March 2004, and there are still vacancies.
Further details from the course leader - Maggie Whittle, Senior Lecturer Children's Nursing.
Tel 0117 3288526.
E Mail [email protected]

Online paediatric palliative care courses

The National Center for Death Education, Mount Ida College, in collaboration
with the National Hospice and Palliative Care Organization, offers an online pediatric palliative care series. No special software or advanced computer skills are needed. Students can read lecture notes and participate in discussion at their convenience, day or night and regardless of time zone. Topics include an introduction to pediatric palliative care, pain and symptom management, and psychosocial care and bereavement. For more information visit the website at

9. Webmaster's Corner

Welcome to the Webmaster's Corner!
Here you can learn about the new articles & features we've added to the IAHPC website each month.

New Browser Buddy - You may have noticed a new feature we have on selected pages named the IAHPC Browser Buddy. With this you can save the current page, Search the page, look a word up in the dictionary, print the page and save it in your favorites/Bookmarks.
To close the Browser Buddy just click the X at the top right hand side.
Is there a page you wish Browser Buddy to appear on?
If yes, email us at [email protected]

The IAHPC Fact Sheets are now available in Portuguese and to download in MS.Word Format in Portuguese.

Our Book & Video Shop has has a few changes in the navigation to help you find your way around better.
You can now view by author or category. Last month we added over 30+ new titles & over 25+ reviews.

The International Directory has had 14 new listings this month, a great resource for all.

Have a hospice and/or palliative care related question? Or just want to discuss hospice & palliative care issues?
Join in at our Forum
. No registration required. It's Free

Coming Events! Do you have a Hospice & Palliative Care event you wish to promote?
Please visit our Future Events section to view events and add your event to our website.
4 new listings added this month including a Hospice/Palliative Care course or two!

Did you know you can Subscribe & Save Up To 80% on popular magazine subscriptions while helping the IAHPC!
Over 80,000 titles to choose from.

What's Coming!
We have more plans for exciting new additions to in the coming months.
Drop by often & don't miss out!

Until next month!
Anne Laidlaw

IAHPC Webmaster
Comments/Questions about our website?
Email us at: [email protected]

10. Editor's Notes
William Farr, PhD, MD


We are delighted to announce that, from 2004, Progress in Palliative Care will be including a regular column from the IAHPC.

Progress in Palliative Care has recently appointed a new Editor-in-Chief (Professor David Currow at the Flinders University of South Australia) and international editorial board.

Journal mission

Progress in Palliative Care is a multidisciplinary journal with an international perspective. It is published six times a year by Maney Publishing ( on behalf of Leeds Medical Information. It provides a central point of reference for all members of the multi-disciplinary palliative care community: medical consultants, nurses, hospital support teams, home care teams, hospice directors and administrators, pain centre staff, social workers, chaplains, counsellors, information staff, paramedical staff and self-help groups. The emphasis of the journal is on the rapid exchange of information amongst those working in palliative care.

Progress in Palliative Care is a journal that embraces all aspects of the management of the problems of end-stage disease. It provides a single forum for current trends and controversies, and a major listing of the international research literature, including that which is novel and pertinent though not widely available. Material for the whole multi-disciplinary palliative care community is brought together in one journal. It is published on the premise that the field is expanding so fast and that published information is so widely scattered that a single, easily digestible source, with a strong research orientation, is essential to enable colleagues to keep abreast of new developments.

Contents include:

Invited critical reviews of the relevant field by experts in all aspects of palliative care

Comprehensive bibliography of recent research based articles published in the international journal literature. Compiled by an experienced team of indexers at Leeds Medical Information the bibliography is drawn from over 1000 journals and references are published within 1-8 weeks of original publication.

International perspectives including profiles of palliative care initiatives and issues from across the globe, and a regular feature from the International Observatory on End of Life Care

During 2004 a new section looking at the literary, ethical and holistic aspects of palliative care from both patient and professional perspectives is being developed.

Online publication

Since 2003 the review-based content has been available free of charge to subscribers via the Ingenta Journals Service at
The first online issue of 2004 is available as a free sample issue.

More information

For further details about the Journal, please visit

Special subscription offer to members of the IAHPC

Progress in Palliative Care is available to members of the IAHPC at a specially reduced rate for 2004. A subscription includes access to the online content. The 2004 rates are as follows (six issues):

Europe: £75.00 USA: $120.00 Rest of World: £75.00

To arrange your subscription, please contact: Publications Sales Department, Maney Publishing, Hudson Road, Leeds LS9 7DL, UK
Email: [email protected]; Fax: +44 (0113 2486983) and quote your IAHPC membership details.

for Social Workers

The National Association of Social Workers (NASW) is offering a new continuing education course, "Understanding End of Life Care: The Social Worker's Role," through the association's NASW WebED online training Web site,

The course, which launched in June, is free and provides 2.0 continuing education unit hours for social workers who complete the content and take the exam.

The course was developed as part of a Open Society Institute's Project on Death in America grant to advance social work practice in end of life care.

The course targets social workers working with individuals and their loved ones who are coping with issues surrounding death and dying. Social workers addressing these concerns work in a range of practice settings, including healthy and mental health agencies, hospitals, hospices, nursing homes, day care and senior centers, correctional systems, substance abuse programs and others. The course is designed to increase social wokers' knowledge about the complexities of end of life care in the United States and to help them gain information, skills and resources that will enhance their practice in end of life practice.


8th Annual Interdisciplinary Approach to Palliative Medicine in Cancer Care
Sponsored by the Department of Palliative Care and Rehabilitation Medicine – UT MD Anderson Cancer Center
October 29-31, 2004
Intercontinental Hotel
2222 West Loop South
Houston, Texas USA
Information and Registration Click Here for more info

Developing and Managing Human Resources in Palliative Care
September 13-19, 2004
Sponsored by the University of Southampton
Information and registration:
Bridget Wilde
Division of Social Work Studies
University of Southampton
Highfield, Southampton SO17 1BJ UK
Email: [email protected]
Tel 023 8059 5780
Fax 023 8059 4800

The Development and Philosophies of Palliative Care
September 20 -24, 2004
Sponsored by the University of Southampton
Information and registration:
Bridget Wilde
Division of Social Work Studies
University of Southampton
Highfield, Southampton SO17 1BJ UK
Email: [email protected]
Tel 023 8059 5780
Fax 023 8059 4800

Developing and Managing Human Resources in Palliative Care
September 13-19, 2004
Sponsored by the University of Southampton
Information and registration:
Bridget Wilde
Division of Social Work Studies
University of Southampton
Highfield, Southampton SO17 1BJ UK
Email: [email protected]
Tel 023 8059 5780
Fax 023 8059 4800

The Development and Philosophies of Palliative Care
September 20 -24, 2004
Sponsored by the University of Southampton
Information and registration:
Bridget Wilde
Division of Social Work Studies
University of Southampton
Highfield, Southampton SO17 1BJ UK
Email: [email protected]
Tel 023 8059 5780
Fax 023 8059 4800

African Psycho Oncology Society
11th International Conference
15 to 17 October 2004
Sponsored by The Pan African Psycho Oncology Society (PAPOS )
Gallagher Estate, Midrand, Gauteng, South Africa
Registration and Information:
Mr. M.S. du Toit
PAPOS Conference Organiser
E-mail: [email protected]
PAPOS Website:

The American Psychosocial Oncology Society (APOS)
APOS is now accepting abstracts for its 2nd Annual Conference, 27 - 29 January 2005, at the Wyndham Phoenix, in beautiful Phoenix, Arizona. The meeting is dedicated to Translating Psychosocial Oncology Research into Interdisciplinary Practice and will bring together the top leaders in the field.
Please visit for abstract submission and more information on the meeting.
The deadline to submit an abstract HAS BEEN EXTENDED TO 20 AUGUST 2004. Submit now!

Hospice and Palliative Care: Current Issues
September 9 and 10, 2004
Mount Nittany Medical Center
State College, Pennsylvania
Additional information and registration:
Find out more by visiting

IAHPC Clearing House Project

Donate books and journals to be sent to colleagues in developing countries.
Contact Ms. De Lima


Please consider joining the IAHPC's effort to improve palliative care in developing countries. We recently developed a new sliding fee schedule.
Join by Clicking on this secure Membership Application –
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Or Contact
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E-mail Here

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