International Association for Hospice and Palliative Care
Subject: IAHPC Newsroom
Dear Members and Colleagues:
For those of you celebrating a holiday this month, may it be a safe and happy.
Eduardo Bruera, MD
On December 31st, I will complete my term as Chair of the Board of Directors of IAHPC so this is my farewell message to all of you. I am very grateful for the support I received from the IAHPC members, our Board of Directors and the palliative care community in general during my tenure as Chair. When I was elected to this position four years ago, I felt that IAHPC had to become an effective and efficient organization to promote palliative care in the World. With the help of the Board we developed a strategic plan to map the road ahead. I am proud to say that I believe we have accomplished this to a great degree.
The following is a summary of our accomplishments:
Through the Clearing House Program we have been able to send more than 3,000 lbs of donated books and journals to more than 100 programs, libraries and hospitals in 45 developing countries;
Since its beginning, the IAHPC Traveling Fellowship Program has paid for the cost of travel of 29 individuals who spent time teaching palliative care in Argentina, Cambodia, Cameroon, China, Colombia, Congo, Cuba, Ghana, India, Kenya, Kyrgyzstan, Malaysia, Moldova, Mongolia, Pakistan, Papua New Guinea, Russia, St. Lucia, Swaziland, Thailand, The Philippines, Uganda and Vietnam. Our past Chairman, Dr. Roger Woodruff, started this wonderful program and continues to chair the Traveling Fellowship committee. This program is based on the concept that the best approach to teach palliative care is to use a hands-on approach that is tailored to the needs of the local patients and is within the culture, facilities and limitations of each setting. We are very proud of the accomplishments and teachings of these extraordinary individuals.
The Traveling Scholarship Program paid for the travel of palliative care leaders from Argentina, Chile, India, Malaysia, Romania and Zimbabwe to attend palliative care meetings in The Netherlands, USA, Uruguay and Canada.
The Annual Recognition Awards program was created in three categories: Institutional, Individual (named the Professor Vittorio Ventafridda Award) and University. Winners of the Institutional Award include the Programa Casa de Cuidados Paliativos in Chile; the Programa de Cuidados Paliativos in the Instituto Nacional de la Nutricion in Mexico; and the Programa de Cuidados Paliativos in el Servicio Extremeño de Salud in Spain. Winners of the Professor Vittorio Ventafridda Award include Dr Anne Merriman from Uganda; Dr Neil MacDonald from Canada; and Dr Gustavo De Simone from Argentina. The winner of the University Award was the Ludwig-Maximilians-University in Germany for its excellent palliative care teaching program.
The Faculty Development Program was started on 2004. We are now supporting three Palliative Care Faculty positions in Tanzania, Argentina and India and we are sure it will have an impact in the development of palliative care education in developing countries.
The IAHPC website at www.hospicecare.com has become an invaluable tool for information dissemination and promotion of palliative care and is consistently ranked in the first place by search engines. The site now has almost 2,000 pages of information which are constantly being updated. All the pages are free and accessed by more than 1,000 readers every day from all corners of the globe. I wish to thank our Webmaster, Anne Laidlaw, for her support and contributions to our organization.
We developed the IAHPC Press and published the following: Cuidados Paliativos: Guias para el Manejo Clínico, edited by Liliana De Lima and I (in Spanish, as a joint publication with the Pan American Health Organization); The IAHPC Manual of Palliative Care by Drs. Derek Doyle and Roger Woodruff; The IAHPC Fact Sheets by Derek Doyle and the publication Palliative Care in the Developing World: Principles and Practice, edited by William Farr, Roberto Wenk and Liliana De Lima and I. These Fact Sheets and the Manual of Palliative Care are both available for free in our website. I wish to thank Roger, Derek, Liliana, Roberto and Bill for their commitment and hard work in making this possible.
I am also grateful for the hard work put into this Newsletter (NL) by its editor, Dr. Bill Farr. The NL now reaches more than 4,000 people around the world and has become a useful tool to disseminate information and highlight new developments and accomplishments from our palliative care colleagues around the globe. Many thanks also goes out to all those who contributed pieces and stories, especially to our Board members who each month put a lot of work into making this NL a useful tool for all: Doctors Paulina Taboada (Ethics article); Carla Ripamonti (Article of the Month), and Roger Woodruff (Book Reviews).
The organization’s finances have improved and we have all worked very hard in order to achieve this. Many thanks to all the supporters, donors, members, pharmaceutical companies and organizations who donated funds to support our programs during these past four years. Without their support we wouldn’t have been able to achieve our goals. Please remember that IAHPC still depends on your help to continue its work.
My main gratitude goes to the outstanding and generous support received from our Executive Director, Liliana De Lima. Liliana was the force behind all these projects and I consider my main achievement having been able to recruit her to IAHPC.
As the year ends, several of our Board members will be completing their terms: Dr. Young Hong from Hong Kong; Dr Debbie Norval from South Africa; Dr. Elina Clemens from Germany; Dr. Alan Nixon from Canada and Dr. Odette Spruyt from Australia. Please join me in thanking them for their past contributions to IAHPC and their efforts in helping the organization achieve its mission in the promotion of palliative care around the globe. It has been an honor for me to have been able to work with this Board of Directors composed of extraordinary palliative care individuals and professionals.
On January 1st, we will be extremely pleased to receive Dr. Kathleen Foley as the new IAHPC Chair. I look forward to continue serving IAHPC under her outstanding leadership and wish her the best of luck in the upcoming years. IAHPC is really fortunate to have a global leader like her take us into exciting new directions and projects.
I want to take this opportunity to wish all of you a great holiday and the best for the New Year.
Liliana De Lima
As you know, Eduardo is completing his term as Chair of IAHPC by the end of 2004 and his farewell message is included above in this Newsletter. It has been a wonderful experience to work under his leadership and I am very grateful for all his support and encouragement. With Eduardo’s vision, we were able to grow, become a global organization and a resource for individuals and programs around the world. I will always be grateful for his encouragement and mentorship during these last years.
Eduardo has also announced that several of our Board members will be retiring at the end of the year after completing their terms. Many thanks to Debbie Norval in South Africa; Elina Clemens in Germany; Young Hong in Korea; Alan Nixon in Canada; and Odette Spruyt in Australia, for their contribution and help with our programs. I look forward to keeping in touch with them in the future.
Please remember that we are accepting applications for the IAHPC Awards until December 31st, 2004 for Individuals (the Vittorio Ventafridda Award); Institutions and Universities. If you are interested in nominating an individual, institution or university, there are still some days left. Additional information on how to apply is available in our website at http://www.hospicecare.com/Awards/awardsindex.htm or go to www.hospicecare.com click on Resources and then on IAHPC Recognition Awards. The IAHPC Awards program is a great tool to give recognition to those who are doing things right around the world.
I would like to thank those of you who have sent donations to the IAHPC Clearing House program. Your journals and books have proved to be very valuable in 54 countries across all continents and our last shipment of 1,000 lbs is now reaching individuals and programs in developing countries. Some of their testimonials are included in this Newsletter. Our next shipment will be in February 2005, so if you plan to send materials, ship them before January 15, 2005.
Many thanks to those who have renewed their membership using our online system - it has proved to be of great help for us here in Houston. If you still have questions on how to use this new feature, please send Ana Restrepo an e-mail here
I am glad to announce that we have a new category for institutional membership. Programs and institutions in developed countries that join IAHPC will automatically be sponsoring the institutional membership for a program in a developing country. Membership for institutions in rich countries is now set at US $150 per year; while for developing countries remains at US $40 per year. If your institution is interested in helping the development of hospices and palliative care programs around the world, we invite you to join us in this effort.
We are announcing a special promotion to all: If you renew or join IAHPC as a member on or before January 30th, 2005, you can buy the IAHPC Publication “Palliative Care in the Developing World: Principles and Practice” for an additional $10.00 plus $4.00 for shipping and handling. To join or renew, go to www.hospicecare.com, click on Quick Links and then on IAHPC Membership.
Applications for membership can be found in http://www.hospicecare.com/join.htm
Renew your membership online at http://www.hospicecare.com/amember/login.php
Our International Directory of hospices and palliative care programs around the world has recently been renovated and every entry has been updated. Many thanks to our webmaster Anne Laidlaw and her team at Alou Web Design for the effort and hard work in completing this task. If your organization is not listed in our directory, please fill out the online form and send it to us.
The link to the IAHPC International Directory can be found in http://www.hospicecare.com/directory/index.htm
The Health on the Net (HON) Foundation has launched a survey on medical Internet usage. We invite you to complete this survey and help HON gather information on this important topic. To access the survey, click on http://www.hon.ch/Survey/quest_internet.html
Best wishes to all of you, your friends and family members for these coming holidays and hope that next year will be a happy one.
Until next month,
Carla Ripamonti, MD
Pulse Oximetry in Supportive and Palliative Care
Author(s): Vora V.A. and Ahmedzai SH
Abstract: Supportive Care Cancer 2004; 12: 758-61
Respiratory problems are an important issue in the palliative care setting, not only from a diagnostic and therapeutic point of view but also from emotional-related aspects involving patients and families as well as caregivers. In clinical practice, particularly in patients with dyspnoea, it is often necessary to estimate arterial oxyhaemoglobin saturation (SaO2).
In this paper, Vora and Ahmedzai describe in detail the indications, limitations, accuracy and factors that may affect readings of pulse oximetry in different palliative care settings. Pulse oximetry is a non-invasive method for estimating arterial oxyhaemoglobin saturation (normal range of SaO2 is 90-100%), by utilising selected wavelengths of light. The best location for the pulse oximeter probe is the finger, the toe, the ear lobe and the bridge of the nose (only used in infants).
Pulse oximetry has various applications:
Pulse oximetry may however not give accurate information in the following circumstances:
hypothermia, hypovolemia, peripheral vascular disease, severe anaemia (Hb level < 5 g/dL), marked tremors, abnormal haemoglobins (carboxyhaemoglobin and methaemoglobin), and when intravascular dyes such as methylene blue and fluorescein are present.
Moreover, pulse oximetry does not give specific information about the patient’s Hb level, the adequacy of ventilation and sensitive changes in oxygenation.
Why I chose this article
This article allows us to get to know better the benefits of a small instrument such a the pulse oximeter that is easy and useful to use in a palliative care setting. At present, the only established indication for supplemental oxygen in a cancer patient with dyspnea is when oxygen saturation is less than 90%.
Therapy with oxygen is efficient in patients with hypoxemia, whereas in patients without hypoxemia, efficacy of oxygen therapy for dyspnea is no different from air. Pulse oximetry is particularly indicated to evaluate the necessity, or not, to begin oxygen therapy particularly in care settings such as the patient’s own home where oxygen is not within reach.
Roger Woodruff, MD (Australia)
Shirley died today. A senior nurse, much respected, but only 61. A long-serving member of the team on our Oncology/Palliative Care ward. Killed instantly on her way to work by someone trying to overtake a truck. We, who deal with life-threatening illness and death every day, collectively struggled with our grief. Perhaps a timely reminder of how great the needs of grieving relatives can be.
This little book is written to help bring comfort and peace to some of those who grieve. It was written by a nurse who lost both her mother and father
to illness in the space of thirteen days. It comprises a mixture of poems, prose and Biblical quotations. Devoutly Christian, this book may not be for everyone, but it will certainly be helpful to some.
David Kessler. Quill, 2000.
David Kessler describes this book as “one made up of a little psychology, a little medicine, and a little spirituality, mixed with a whole lot of love”, written to familiarize the reader with the physical and emotional aspects of dying. It is written both for those who are dying and for those who love them and care for them. Chapters cover allowing people to live until they die, the expression of emotions, participating in decision making, the management of physical pain, emotional pain and spirituality, how to help children when a parent is dying, and the physiology of the dying process. There are hundreds of illustrative anecdotes throughout the text, which bring it to life and to which the reader can relate. Kessler’s style is clear and easily understood. If patients or carers ask you, tell them to buy this inexpensive but invaluable book, which is so full of information, comfort and love.
Kathleen M. Foley and Hellen Gelband (Eds).
This is the report of the National Cancer Policy Board of the Institute of Medicine and National Research Council on how the provision of palliative care for patients with cancer might be improved. It examines in detail the barriers that prevent many people from receiving effective palliative care where and when they need it. It makes a series of recommendations, both at professional and governmental levels, to improve the system. Whilst describing the situation in the United States, the problems and the principles of the recommendations are universal.
Part II of the report consists of commissioned background papers that examine economic issues, quality indicators, the availability of information, special populations, clinical practice guidelines and professional education, all written by leaders in the field.
This is an excellent summary of the interface between Oncology and Palliative Care and how the situation should and can be improved. At a professional level, it leaves one to ponder the quality of care that is being delivered, and it should be required reading for anybody involved in policy making in this field.
Mark N. Gaze and Isobel M. Wilson.
This book aims to provide a practical guide to nerve blocks and neuromodulation (techniques such as spinal drug delivery or spinal cord stimulation) so that palliative care professionals can make informed decisions about which patients are appropriate to refer for specialized treatment.
Overall, there is a clear, concise description of the various procedures including indications, contraindications and adverse effects. However, I was a little surprised to see that coeliac plexus blocks have to be performed under deep sedation or general anaesthesia, making it an unattractive option for frail or debilitated patients in palliative care; where I work, the blocks are done by the interventional radiologists under CT-control, without general anaesthetic or sedation, with an appropriately good response rate and, so far, without mishap. I also thought that intracerebroventricular injection of opioids deserved more discussion. It is mentioned only once in passing as an alternative for intractable pain in the head. Whilst the published series were not prospectively controlled, there is now a body of evidence that this technique may be useful for intractable pain, including that outside the head and neck. And whilst I am carping, the repeated use of “co-aggulopathy” is annoying and sounds painful.
This book meets its objective of providing the information needed for palliative care professionals to know what to expect of the various interventional techniques. But it would have been even better if there were some discussion of the different options that are available for treating common pain syndromes in a given patient. For example, unilateral arm pain due to malignancy is listed as a specific indication for a brachial plexus block. But what are the alternatives? Epidurals? Spinal opioids? My criticisms aside, this is a very useful text and definitely deserves a place on the palliative care unit bookshelf.
KISUMU HOSPICE AND PALLIATIVE CARE CENTRE
The Kisuma Hospice and Palliative Care Centre was opened in 1998 as a non-profit, non-denominational and non-political entity. Our work started in a small room given to the Hospice by the Nyanza Provincial Hospital, in Kisumu City, Kenya. We have now moved to a larger facility in the city center that was given to us by a kind family.
We care for patients with cancer and HIV/AIDS. Our patients are cared for at the centre as outpatients, and we also provide palliative services to children with Burkitt’s Lymphoma in the Nyanza Provincial Hospital, Kisumu, where they are admitted for both curative and palliative care management. We offer symptom control, and when necessary, we also provide disease control using chemotherapy and radiation. We also provide home care to terminally ill patients because hospital care is very expensive and most patients can not afford it. We provide emotional, psycho-social and spiritual support to our patients.
Two physicians offer voluntary services, myself, a Radiotherapist/Oncologist and Dr. Ruby Sokwala, a Palliative Care Doctor. We also have two senior nursing sisters who are currently studying for a Diploma in Palliative Care with Oxford Brookes University in conjunction with the Nairobi Hospice, sponsored by Hospice Care Kenya, U.K. We also have one secretary and one support staff member who are paid small allowances made possible from our medication sales.
We are very grateful for the support we receive from various non-governmental groups as well as from the government. The Kenya Government contributes salaries for staff since 1998. The Hospice Care Kenya, U.K. has provided us with a vehicle, has funded the purchase of morphine powder, and provided funding for our two nursing sisters education and travel to Nairobi. The chairperson, Liz Salmon, has also made a personal donation to purchase morphine for children with Burkitt's Lymphoma.
The CDC Global AIDS Program supplies funding for drugs, a computer, training on computers for our secretary, stationary, funding for training and team work dedicated to HIV/AIDS patients.
Nairobi Hospice Holland supplies drugs as required and funding for training.
Dr. Diana D'Orazio – Miracle Missions USA provides ongoing support to our patients and their families, funds for Dr. Sokwala to attend a conference in Virginia, USA where she will speak on "HIV/AIDS and HIV Related Cancers in Nyanza, Kenya," and they help orphans and widow groups in Kisumu Hospice and Palliative Care Centre.
Finally, we have twinned with a Hospice in Pennsylvania, USA and receive donations and moral support from local friends of the hospice.
Between January 2002 and August 2004, the number of patients has steadily increased especially since we started giving palliative services to both Cancer patients and HIV/AIDS patients.
Of the above patients 10% were HIV positive. The patients are referred from various hospitals and Patient Support Centres run by CDC in the province.
We provide three courses on Palliative Management each year. Thus far we have trained 98 individuals from community based organisations. This has created an increased awareness of palliative care and a change of attitude about death and dying in the region.
Because of the large area of operation and great interest in the program, the Ministry of Health through the PMO in Nyanza and Medical Superintendent of the Siaya District has offered accommodations and a trained registered nursing officer. Our team from the Hospice will visit every two weeks. We plan to train a clinical officer, or interested doctor, to help the sister care for patients who can not travel to Kisuma, 70 Km away. This move to open a branch in Siaya is in response to the Kenyan Government's plan to have palliative care in every government hospital in conjunction with the patient support centre.
CANCER CONTROL ACTIVITIES
Each October we organize cancer prevention and early detection activities that provide Pap-smears in conjunction with Family Planning Association (K) at our Centre and breast cancer awareness and mammography with Nyanza Provincial Hospital.
Since we started this campaign, we have provided 390 Pap-Smears and the same number of mammograms. We have detected 6 suspicious Pap-Smears, which were sent for biopsy and treatment to the various Gynecologists in Kisumu and to Nairobi.
Sylvia Sauter Carl Johan Fürst
Dissemination of Council of Europe Recommendations.
In Hungary, Poland and Sweden press conferences were held on October 11. Media representatives were invited and many responded to the calls. The activities have led to radio, TV and newspaper interviews and reports. In Poland the Minister of Health was present at the press conference as well as a representative from the Council of Europe who also attended. In Sweden the Health Minister has also been personally informed about the Recommendations. This was a good opportunity to get in touch and discuss palliative care on a national level. We know that there have been palliative care conferences in Croatia and in Serbia in October and the Recommendations have been in focus also there. We know of plans to write reports in national medical journals. There are still great opportunities to use the Recommendations in all the countries of Europe, we have just started, particularly in those where a blot of personal effort have made translations available.
There are some pictures from the media activities in Sweden and Hungary. Have a look on the web site www.eapceast.org
I know there have been activities and that there are plans for activities in other countries and please let us hear from you what has been achieved
and what your plans are. Our plan is to present our joint efforts with the dissemination of the Council of Europe Recommendations in Aachen, Germany April 2005, where the next EAPC conference will take
The American Alliance of Cancer Pain Initiatives (AACPI) has produced the 2nd edition of this pamphlet for public education. The contents of this
pamphlet list common myths and misconceptions about cancer pain and its relief, and give the correct facts.
The second National Associations‘ Meeting will be held on March 15-16 2005 in Seoul, Korea. This follows the successful first meeting of representatives from hospice and palliative care umbrella bodies or National Associations held at The Hague in March 2003, where issues of concern to these organisations were discussed and workgroups were set up to take the work forward. The 2nd Global Summit will be a pre-conference meeting before the 6th Asia Pacific Hospice Conference on 16 – 19 March 2005 – see http://www.aphc2005.org. Please put this date in your diary and book your place! We are expecting costs to be for hotels only – estimated to be £50 for the night (although you may want to stay longer for the Asia Pacific Conference.) Please contact Louise Gray to book your place firstname.lastname@example.org There will be some travel and cost support bursaries for delegates from resource poor countries
If you would like to be part of working groups or keep up to date with their work contact: Nick Pahl, Tel: + (44) (0) 20 7520 8236 email@example.com
Palliative Care for children in the Republic of Belarus is the name of the comment by John Costello and Anna Gorchakova. It was published in International Journal of Palliative Nursing, 2004, Vol 10, No 4.
Anna Gorchakova also received the the Earl A. Grollman Award for Bereavement 2003, for her work in establishing bereavement programs through the Belarussian
Children's Republican Oncology and Hematology Centre and Belarussian Children's Hospice. Some of the programs run by these organizations include monthly meetings with parents who have lost a child,
a “Summer Camp” psychotherapeutic program, and the “Stand of Memory,” located in the chapel of the hospice. Anna Gorchakova has been the Director of the Belarussian Children's
Hospice, the country's first, since 1994.
Ethical eye – Euthanasia, Volume 1 – Ethical and human aspects
We are very interested to get information about activities past, present and coming to spread them for you all to get inspiration and good ideas. So many good
thing are happening - we are looking forward to be able to share them.
Sylvia Sauter Carl Johan Fürst
Welcome to the Webmaster's Corner!
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The International Directory has had a makeover! The directory has a new look along with having
all the entries verified. We have added hundreds of new entries too! If you find an entry that no longer is valid please contact us here.
IAHPC Clearing House program has sent Hospice & Palliative Care materials to help in over 54 countries because of your generous donations. Below are just a few of the letters we have received from the recipients.
I have received the parcel containing donated books, journals and publication on Pall Care today.
Dr. Robert Chen
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Until next month!
William Farr, PhD, MD
Colleagues say thanks to Professor Bruera
It has been a privilege for me to have worked with Dr. Bruera during the past four years. Under his leadership IAHPC has been able to provide new and exciting opportunities and programs for improving palliative care in the developing world. I thank you for your vision, enthusiasm and passion for our mission and for helping us to implement it. I look forward to your continued involvement in this fine organization.
I would also like to add my thanks to all retiring Board members for their dedication and service to the IAHPC; and I wish them well.
For those of us who have been involved with the IAHPC since its inception, we have been blessed by the generosity of so many leaders in our field as they gave of their precious time as Chairpersons during the formative years; they were, in chronological order, Drs. Jo Magno, Derek Doyle, Roger Woodruff, and Eduardo Bruera. I eagerly look forward to working with the incoming Chairperson, Dr. Kathy Foley, and to her I add my warmest welcome!
Happy Holidays to all.
Bill Farr, USA
Well done Eduardo! Without a doubt, your legacy in hard work and innovation will be inspiring for the new leader and all of us.
Thanks for your terrific leadership, vision and energy in chairing IAHPC and for all you have done to support palliative care across the globe. It has been a real pleasure to be part of the board under your direction
World AIDS Day Commemorated
World AIDS Day is commemorated around the globe on 1 December. It celebrates progress made in the battle against the epidemic
— and brings into focus remaining challenges. World AIDS Day events around the globe are listed under National activities. On the occasion of World AIDS Day, UNAIDS released the "AIDS Epidemic
Update 2004" on 23 November, 2004.
Messages of thanks received from recipients of books and journals sent by the IAHPC Clearing House Program.
We at South Coast Hospice are most grateful for the donation of Journals and Publications as part of your Clearing House Program as we are in the
process of building a Resource Centre.
Pain management, e-learning and the Internet
The Internet is providing unprecedented opportunities for pain and palliative care professionals to access information and enhance communication with colleagues and patients. To what extent is the Internet influencing clinical practice, education and research? This question is explored in the current issue of Cancer Pain Release, the publication of the WHO Pain and Palliative Care Communications Program.
The issue features an interview with Dr. Alejandro Jadad, Director of the Center for Global eHealth Innovation at the University of Toronto and an expert on the use of information technologies to transform healthcare.
The issue discusses:
How email, listservs, and web-based decision tools can enhance the practice of pain medicine;
Barriers to e-learning and trends in online continuing education;
Tools and links useful to pain and palliative care clinicians.
To read this issue online, visit:
To subscribe and receive your own print copy of Cancer Pain Release, visit:
Palliative Care in Mexico
The international Observatory on End of Life Care has added new information on palliative care in Mexico.
Date of Event: 27 - 29 January 2005
Online registration is now available for the American Psychosocial Oncology Society (APOS) 2nd Annual Conference via www.apos-society.org. Register now to attend the preeminent conference for professionals on the psychosocial oncology team. Register by 22 December 2004 to receive reduced registration rates. Continuing Education credit is available for physicians, psychologists, nurses, social workers, mental health counselors and pastoral care counselors.
3rd German Conference on Children's Pain Management and Paediatric Palliative Care
Date of Event: 17-19 February, 2005
Conference language: English/German
Ms Wilma Henkel
Date of Event: May 5 - 8, 2005
Registration and Accommodation
If you require any further information regarding the Forum please contact us at firstname.lastname@example.org
Taking Place at: Sydney Convention & Exhibition Centre, Darling Harbour , Sydney
Put these dates in your diary now!
February 28 - March 3 2005
Special Promotion: If you RENEW OR JOIN IAHPC as a member, you can buy the IAHPC Publication "Palliative
Care in the Developing World: Principles and Practice" for only an additional $10.00!
Please consider joining the IAHPC's effort to improve palliative care in developing countries. We recently developed a new sliding fee schedule.
****Thanks to all contributors to this issue.****
Ways to Help IAHPC Financially
Make a donation
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William Farr, MD IAHPC Newsletter Editor Bob Child Distribution Manager