International Association for Hospice and Palliative Care 

Subject: IAHPC Newsroom 2005; Volume 6, No 6, June

William Farr, PhD, MD
Editor

Liliana De Lima, MHA
Coordinator

Alou Design
Layout and Distribution

To send an email to one of the IAHPC Newsletter team members,
visit the following page http://www.hospicecare.com/contact.htm

Dear Members and Colleagues:

The June issue of the IAHPC newsletter is now on our website at URL:
http://www.hospicecare.com/newsletter2005/june05/index.html

PDA version is located here:
http://www.hospicecare.com/newsletter2005/june05/pda.html

We are delighted to be able to provide to you information about the exciting developments in palliative care/hospice taking place around the globe. This issue is particularly large due to the many contributions from so many interesting and devoted people who are trying to make a difference for many people in need of palliation. Please join us in our goal to “Promote Hospice and Palliative Care Worldwide.” If you are not a member, please consider becoming one! To join go to URL: http://www.hospicecare.com/join.htm

Table of Contents:

Message from the Chair and Executive Director – Dr. Foley and Ms. De Lima

Article of the Month – Carla Ripamonti, MD

IAHPC Traveling Fellow’s Report - Vivek Khemka , MD

IAHPC Traveling Scholar’s Report - Martha Ximena Leon, MD

Book Reviews – Roger Woodruff, MD

IAHPC Faculty Development Award Report - Msemo Diwani. MD

Contributions from IAHPC Board Members
‘The Right to Die’ and ‘The Right to Live’ Debate – Dr. Derek Doyle
Dr. Derek Doyle writes about the manifesto of the National Council for Palliative Care and the response to it by the three major political parties in the United Kingdom

Regional Reports: From the Czech Republic and Nepal

What’s New?

Webmaster’s Corner – Anne Laidlaw

Editor’s Notes – William Farr, PhD, MD

Until next month!

Kathleen Foley, MD
William Farr, PhD, MD

Message from the Chair and Executive Director

Kathy Foley, MD
Liliana De Lima, MHA

Dear readers:

We are pleased to announce that IAHPC has established a collaboration agreement with the World Health Organization (WHO) Cancer Control Program to work in three important areas: participating in the cancer advisory group; furthering the development of educational programs in palliative care and reviewing the WHO Essential Drugs List for palliative care medications. We think this is a great opportunity to capitalize on the expertise of IAHPC and find ways in which we can collaborate together with WHO to promote and develop palliative care around the world.

There are several reasons for the lack of access to palliative care, some of which are due to inadequate health care policies in developing countries. Recently, the World Health Assembly (WHA) met in Geneva and approved a new resolution for the WHO Cancer Control Program which includes palliative care and pain relief as important components of the program. This is a crucial decision by the WHA and should serve as a tool to request changes in policies at the national level so that palliative care is incorporated in the mainstream of cancer care. The press release from WHO announcing the decisions adopted by the WHA in Geneva is available in the WHO website at
http://www.who.int/mediacentre/news/releases/2005/pr_wha05/en/index.html

The new Resolution for the Cancer Control Program is available in http://www.hospicecare.com/who/cpc.pdf

We invite you to use this announcement and document to bring attention to the new resolution and push the palliative care agenda in your countries through your Ministries of Health, Cancer Institutes, National Cancer Control Programs and Universities.

As we mentioned in past newsletters, last year we established a Faculty Development Program with Amrita Institute of Medical Sciences in India under the supervision of Dr. MR Rajagopal, one of our Board members. The program pays for the salary of Dr. Gayatri Palat, who is now teaching palliative care full time for graduate students. This month, in partnership with the MD Anderson Cancer Center in Houston , we will be sponsoring Dr. Palat to visit the Department of Palliative Care as an IAHPC Traveling Scholar for one month. We are very glad to be able to sponsor her trip and in partnering with the MDACC to further the development of the program in Amrita.

We are also glad to announce that Dr. Derek Doyle's acceptance speech of the American Academy of Hospice and Palliative Medicine (AAHPM) Lifetime Achievement Award is now available in the AAHPM website at

http://www.aahpm.org/membership/drdoyle.html

Dr. Doyle is one of the founders of IAHPC and a great leader for us. We invite you to listen, hear and reflect on his wonderful words. We are honored and proud to have him as part of our team.

Many thanks to Purdue Fund and especially Ms Pamela Bennett, Executive Director of Advocacy, for its recent donation to IAHPC. We are very grateful for this donation and their support to our educational programs which will enable IAHPC to continue providing support to programs and individuals in developing countries. We hope that this will motivate other foundations and corporations to support IAHPC and the promotion of adequate care to patients with advanced and incurable diseases.

Until next month,

Kathy Foley, MD
Chair, Board of Directors

Liliana De Lima, MHA
Executive Director

Article of the Month

Dr. Carla Ripamonti ( Italy )

The management of xerostomia in patients on haemodialysis: comparison of artificial saliva and chewing gum

Author(s): Bots CP, Brand HS, Veerman ECI et al.
Abstract:  Palliative Medicine 2005; 19: 202-207

Patients on haemodialysis (HD) therapy because of end stage renal disease (ESRD), have several oral complications present, among them are an impaired salivary flow rate and an increased subjective sensation of dry mouth, or xerostomia - both negatively influence their quality of life.

HD treatment has a direct effect on the degree of xerostomia, however, other factors such as medication, depression or HD-induced stress all may play a role in the perception of dry mouth.

The aim of this study in ESRD patients on chronic HD was to compare the effectiveness, taste, global assessment and the patients’ preference for artificial saliva versus sugar-free chewing gum.

In a multi-centre study, 89 ESRD patients, undergoing HD for at least 3 months, with an age greater than 18 years, and who were mentally and physically able to participate and complete the study, gave their consent and entered the study. Sixty-five (73%) of them (42 men and 23 women, mean age 54.6 years) completed the 6-week crossover clinical trial.

After baseline measurements, patients were randomly allocated to either chewing gum (menthol-containing, sugar free, Freedent White Wm. Wrigley Jr. Company, Chicago , USA ) or the artificial saliva (Xialine, Lommerse Pharma BV , Oss , Holland ) or vice versa. Between the two-treatment periods, there was a two-week wash-out period. At the beginning and at the end of each 2 week period, the perceived xerostomia was measured by means of the Xerostomia Inventory (XI) (ref. Thomson WM et al. Community Dent Health 1999; 16: 12 -17). The effectiveness of the treatment, preferences, and side effects were assessed by means of a questionnaire (100 mm VAS).

The patients had to chew 1-2 pieces of gum, six times a day for at least 10 min during the day when their mouth was dry. During the artificial saliva treatment period the patients had to spray saliva substitute 3 consecutive times for at least 6 times a day and also during the night as needed.

Chewing gum was found to be easier to use (p<0.05), produce a more significant effect on thirst relief (p<0.001) and xerostomia (p<0.001) and had a more pleasant (p<0.05), flavourful (p<0.001) and intense taste (p<0.001) than artificial saliva. Thirty-seven per cent of patients on chewing gum preferred sweet mint flavour, whereas 28% preferred a stronger flavour such as peppermint.

The therapy was beneficial in 47 (72%) patients on chewing gum and in 28 (43%) patients on artificial saliva (p<0.001). The therapies were both beneficial in 22 patients, whereas both therapies were not beneficial for 8 patients.

A significantly higher number of patients (70%) on chewing gum compared to those on artificial saliva (39%) (p<0.001) were pleased to continue for a longer period.

The global assessment was in favour of chewing gum (p<0.001). However, for patients greater than 64 years, the global assessment for artificial saliva was significantly higher than that reported by the younger people.

At the end of the study 39 patients (60%) preferred chewing gum and 10 patients (15.4%) the saliva substitute (p<0.001).

Why I chose this article

Xerostomia is a frequent symptom reported by cancer patients particularly those treated with radiotherapy for head & neck cancer. In this setting some clinical trials have been carried out.

Bots et al. present the results of the first cross over study performed in patients on haemodialysis therapy who have xerostomia. According to different authors, the prevalence of xerostomia in HD patients ranges between 33% and 76%.

The authors of this paper show that a simple, delicious and low cost therapy such as a chewing gum is able to reduce xerostomia in this population of patients.

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

Please visit the following link to read past Articles Of The Month:
http://www.hospicecare.com/AOM/aom_main.htm

IAHPC Traveling Fellowship - India

Vivek Khemka , MD ( March 2005 )

Background

I am a board certified Internist and Geriatrician currently completing my one-year fellowship in pain and palliative medicine at Montefiore Medical Center in the Bronx in New York. As part of my fellowship I had the option to travel anywhere in the world for four weeks as an elective to learn or teach palliative medicine. I chose to travel to India where I originate from to see the progress made in palliative care and to conduct workshops for physicians as an introduction and basic training in palliative care.

There was no palliative care training available in Chennai when I went to medical school over a decade ago, as well as later when I worked there. This visit was designed to look at the present state of palliative care and to develop ways of improving and strengthening existing services through collaboration, and also to look at possibly integrating palliative care education into post graduate training.

India is home to almost a fifth of the world’s people. There is an estimate of over a million and a half people diagnosed with cancer every year and several millions living with HIV; most of whom are diagnosed in the late stages. The ageing population is also growing and they present with several other chronic diseases. The medical curriculum lacks geriatric education. In the past decade, there has been rapid economic progress and improvements in health care in both the government and private sectors. Despite this there are still hundreds of millions of people lacking access to basic health care and because of this, cancer, HIV and many other diseases are diagnosed in the very late stages of the illness. Even among those with access to care, only a tiny fraction have access to palliative care and even fewer have access to opioids for pain relief and end of life care. This is despite the fact that India is the largest legal producer of morphine in the world. As in most parts of the world, there is a paucity of palliative care training in medical and nursing schools with the major training centers concentrated in the Southern state of Kerala. Due to the involvement of the Indian Association of Palliative Care, there is a gradual improvement in palliative care education in some urban areas. There is a basic six-week course on palliative care at the Amrita Institute of Medical Sciences (AIMS) and few other places in Kerala. AIMS also has an advanced two year post graduate training program.

My visit to India was planned to provide a workshop on basic training based upon the EPEC (Education in Palliative and End-of-Life Care) curriculum, which has been a very effective program here in the US and has also been used in a few other countries. I chose to use the EPEC curriculum since I am an EPEC trainer and also since it is a very simple and flexible model for teaching palliative care. I had planned, and was able, to provide copies of the EPEC curriculum to all participants because of the grant from the IAHPC.

I had worked at Sundaram Medical Foundation in Chennai before I left the country and was familiar with the practice environment; it seemed to be a good place for me to start. My host Dr. Arjun Rajagopalan, Chief of Medical Staff, has been very supportive of furthering palliative medicine education and extended an invitation to teach there. I did workshops at Rajiv Gandhi Cancer Institute in Delhi, the capital of India, Bhagwan Mahaveer Cancer Institute in Jaipur, the capital of the state of Rajasthan, at Sundaram Medical Foundation in Chennai and also at the Barnard Institute of Radiology and Oncology at the Madras Medical College (now known as Chennai Medical College) in Chennai which is one of the oldest medical schools in the country.

Activities

The day after I reached Chennai I went to the Sundaram Medical Foundation to meet Dr. Arjun Rajagopalan and discuss the details and arrangements for the workshop. Two days later I left for Kochi , in Kerala, to meet Dr. M. R. Rajagopal at Amrita Institute of Medical Sciences and to spend time learning from him about the state of palliative care in India and about his program - he is one of the first people to specialize in palliative medicine in India . He heads the departments of anesthesia and pain palliative medicine and directs the only post graduate diploma training program in pain and palliative medicine in the country. While in Kerala, I also had the opportunity to present several modules from the EPEC curriculum that I had modified for the Indian setting.

Dr. Rajagopal and I also had an opportunity to make a presentations to the medical board of the institution on the issues of non-beneficial treatments and the withholding/withdrawing of artificial ventilation and other life support measures at end-of-life when patients did not want them, or when it was obvious they were futile - there are presently no clear guidelines in India on these issues. We had discussions on the ethical and legal basis on how these issues were approached in the US and other countries. The possibility of multiple medical societies coming up with a joint statement on this issue was also explored.

Non-beneficial treatments and withholding/withdrawing treatments have been an issue the Indian Society of Critical Care Medicine (ISCCM) has looked at in great detail from both a medical and ethical perspective and had recently drafted a set of guidelines which they had offered for comment. In the absence of clear detailed legal guidelines, this is the best set of guidelines available to physicians in India . Another barrier we discussed was the distinction between physician assisted suicide and euthanasia which are not legal in India . We also discussed the role of palliative care in the intensive care units when the patients’ condition worsened despite the best available treatments, and in accordance with their wishes.

I then spent two days at Rajiv Gandhi Cancer Institute in Delhi . I conducted an interactive workshop over two days, which was well received by the faculty and staff. I then went to Jaipur where I visited Bhagwan Mahaveer Cancer Institute. I attended a workshop on interventional and non-interventional pain. I conducted a two day interactive workshop on the complete EPEC curriculum. The most interesting parts of the workshop were the legal issues, which were presented by Dr Kabra, a surgeon and a lawyer, who is also associated with the Avedna hospice in Jaipur. Dr Rakesh Gupta, surgical oncologist and Oxford trained in palliative medicine and founder of Rajasthan Cancer Foundation, made an excellent presentation on communicating bad news to patients and families and the importance of involving patients in the decision making process. In most non-western cultures including India , there has always been the notion that telling patients the diagnosis will harm them and families do not want their loved ones to know they have cancer. We discussed this since in reality most patients already know their diagnosis either form reading their multiple test results, which they have easy access to, or from speaking with other patients during treatment. Most physicians felt it was better to talk to the patient about their diagnosis and involve them in the treatment plan rather than the patient finding out on their own.

I returned to Chennai and networked with some community and hospital based physicians and had the opportunity to learn how they approached palliative care issues in the environment of restricted access to opioids and the lack of experience in using them. I conducted a two-day workshop at Sundaram Medical Foundation using the EPEC curriculum - it was attended by physicians and residents from the hospital as well as from the community. Drs. Rajagopal and Gayatri Palat traveled from Kochi to study the effectiveness of the EPEC curriculum as a teaching tool in the Indian setting. Dr. Reena George, Oncologist and Head of Palliative Medicine at Christian Medical College , Vellore made a presentation on common physical symptoms and their management in patients with advanced disease and at end-of-life. We again discussed the legal and ethical issues and the possibility of preparing a joint position statement on treatments at end-of-life based upon the ISCCM guidelines. The workshop was also covered in a leading daily newspaper.

The next day I visited the Barnard Institute of Radiology and Oncology at Madras Medical College . I had opportunity to make presentations on communicating bad news and on legal issues; both were well received and followed by detailed discussions on various aspects of palliative medicine and the role of oncologists and other physicians in continuing to care for the patients even in advanced disease.

I then visited Jeevodaya Hospice for cancer patients, which is run by missionary nuns who are also trained in nursing. They provide charitable in-patient palliative care to patients with advanced cancer. I was very moved by their dedication and involvement in providing care when others were unable to do so. It gave me the feeling that people still care for others; I hope it is not lost in our society.

I also visited Dean Foundation in Chennai, which is a charitable organization run by Deepa Muthiah providing palliative care to those who are not able to afford it. I learnt about their extensive use oral morphine and their use in palliative care of complementary and alternative medicine which is more acceptable to many of their patients.

Observations:

• There is a lack of awareness about palliative care among people, physicians and healthcare workers.
• There is a lack of access to palliative care.
• Most palliative care centers were concentrated in one state in India . Kerala has more palliative care clinics than the rest of the country put together.
• There is a lack of standardized training programs and only one post-graduate training program in palliative care in the entire country.
• Restrictive regulations and a lack of opioid availability contribute to the already poor availability of palliative care.
• The focus on a single drug Morphine as the solution to all palliative care needs has in many ways prevented further developments and resulted in the lack of other cost effective potent opioids, especially methadone, from being used. Some gains have been made in opioid availability, but it is still a tiny fraction of the need.
• There is a lack of clear guidelines for palliative and end-of-life care.
• There is a willingness among a few physicians and certain medical societies and organizations to get involved in improving the situation despite the slow process by the government.
• Most palliative care programs are charitable and focus on the poor. People who can afford to pay for services have little access to them. Hospitals and physicians do not see palliative care as a revenue-generating specialty and therefore are not interested in this area.
• Existing Palliative care programs are struggling for resources and funds to survive.

Accomplishments in collaboration with the institutions in India :

• Distinction between euthanasia, physician assisted suicide and withholding/withdrawal of treatments was made clear during the workshops.
• Legal and ethical issues in palliative and end-of-life care were discussed in detail and participants gained an insight into the various aspects of palliative care.
• A collaborative process was initiated along with the EPEC project for adaptation of the EPEC curriculum as a teaching tool in India and for future workshops. The feasibility is being studied and should be underway within this year.
• A process for inter-society collaboration for the study and issuance of a joint statement regarding ethical and medical issues in end-of-life care was initiated.
• Awareness was created about the mechanism established by the IAHPC and AIMS whereby physicians may obtain formal training in palliative care at AIMS under an IAHPC scholarship program.
• I provided several books on palliative care to each of the institutions I visited during my trip to India .

Future Follow-up Plans:

Efforts are underway to identify a core group of physicians and other experts who would be willing to pursue a long-term plan through regular visits to centers in India . The aim of this group would be to start programs that are able to achieve self-sustainability within a reasonable time.

I hope to be able to visit India again within the year to follow up on this plan. In the meantime, technology and the Internet, have enabled us to keep in touch very cost-effectively.

A few weak opioids are available; however in the class of strong opioids, only the cheapest (morphine) and the most expensive (fentanyl) are currently available.

I hope to work collaboratively with the palliative care physicians and policymakers in India to make opioids, other than morphine, more available.

This is a shortened version of Dr. Khemka’s report; the complete report may be read on our website at URL:
http://www.hospicecare.com/travelfellow/tf2005/india.htm

IAHPC Traveling Scholar’s Report

Martha Ximena Leon, MD

We are currently developing a Department of Palliative Care at the Universidad de La Sabana in Bogota, Colombia. The new knowledge that I acquired in the Congress of the European Association for Palliative Care (EAPC) in Aachen, Germany, is helping me organize the educational, research and clinical resources that we have at the University. In the congress workshops we exchanged ideas in on how to implement educational strategies for undergraduate courses and general practitioners which is going to be very useful. I also learned new tools that are helping me design research protocols that we will be able to apply with our patients and hopefully the results will have an impact in the quality of life of patients in Colombia and Latin America. The possibility to meet people from all over the world who are working in palliative care and to build networks of support was very important. This will help us exchange ideas, provide the opportunity to learn from people who have more experience, give us support for different projects and the possibility to know programs with different models of care.

I learned a lot of things and many ideas came to my mind during and after the Aachen Congress. Because of this I am very grateful with the IAHPC for giving me this opportunity.

Martha Ximena Leon MD

Roger Woodruff, MD ( Australia )

A LITTLE BIT OF HEAVEN FOR THE FEW?
An oral history of the modern hospice movement in the United Kingdom

David Clark, Neil Small, Michael Wright, Michelle Winslow, Nic Hughes
Observatory Publications, 2005
239 pp ISBN 0 95441920-0
RRP £15.
Available at www.observatory-publications.net or www.amazon.co.uk

This wonderful book is an oral history of the modern hospice movement in the United Kingdom, collected and collated by Professor David Clark and his team. Here are the memories, motivations, the perseverance and the achievements of 80 individuals who helped make the modern hospice movement what it is.

The book is arranged by themes: how and why they became involved with hospice care; the development and expansion of the hospice movement; the development and meaning of team work; the emergence of professional palliative care organizations; the spiritual dimensions of hospice care; the management of physical suffering; the evolution of bereavement care; and, unfinished business.

And the title? Dr. Graham Thorpe of Southampton posed the question “Should we be offering a service to South Hampshire or “a little bit of heaven for the few”?”, underlining the challenges that still remain if all in need are to receive the care they require and deserve.

Fascinating reading.

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PSYCHOLOGICAL METHODS OF PAIN CONTROL
Basic Science and Clinical Perspectives

Donald D. Price and M. Catherine Bushnell (Eds)
IASP Press, 2004
308pp ISBN 0-931092-52-3
RRP $US63.00.

The involvement of psychological factors in the perception of pain has been recognized since antiquity. Aristotle alluded to the concept that pain was a somatopsychic phenomenon when he described it as a ‘passion of the soul’. This book reviews our rapidly increasing understanding of the psychoneurophysiological mechanisms involved in pain modulation and their potential use in clinical therapy.

The first section addresses how general factors modulate pain, including personality and demographic, environmental and psychological factors. The second section deals with specific psychological factors that modulate pain such as attention and emotions, and environmental and behavioural factors. The next section is about placebo analgesia, which makes most interesting reading. As our knowledge of the psychoneurophysiological mechanisms increases, I was left wondering whether placebo analgesics might become part of standard therapy in certain defined situations and be accepted as ethically correct. The last section details what we know about the psychoneurophysiological mechanisms and clinical applications of hypnotic analgesia.

This is an up to date review of both the basic science of the psychoneurophysiological mechanisms involved in the modulation of pain and their present and possible future applications in the clinic, and should be of interest to both researchers and clinicians.

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PHYSICIAN-ASSISTED DYING
The case for palliative care and patient choice

Timothy E. Quill and Margaret P. Battin (Eds)
Johns Hopkins University Press, 2004
342 pp ISBN 0-8018-8070-X
RRP US$26.95, £19.50

This book was compiled in response to the volume edited by Kathleen Foley and Herbert Hendin (The Case Against Assisted Suicide; For the Right to End-of-Life Care, Johns Hopkins University Press, 2002; see review) and to stress what the authors see as the positive aspects of Physician-Assisted Dying.

The tone is set in the introduction. Those in favor of Physician-Assisted Dying champion the causes of patient autonomy, mercy (the relief of pain and suffering), and patient non-abandonment (all very positive), whilst those who oppose it are worried about the wrongness of killing, diminished integrity of physicians, and the risk of abuse (all very negative).

The book is divided into four parts. The first examines the critical values of autonomy and mercy. The second explores the clinical, philosophical, and religious issues that underlie end-of-life practices. Part three examines practice in Oregon and the Netherlands . The last section deals with some of the legal and political turmoil that has surrounded the debate on Physician-Assisted Dying in the United States.

The opening chapter by Marcia Angell in an impassioned statement, based around the tragic circumstances of her father’s suicide, that Physician-Assisted Dying should be legalized and that “many people would choose [it]”. But in Chapter 11, where Linda Ganzini reviews the Oregon data, it is seen that only between one-third and one-half of one percent of patients dying of cancer in Oregon have availed themselves of the State’s legalized Physician-Assisted Dying.

The chapter on patient autonomy deals with just that, and does not adequately address what effect legalizing Physician-Assisted Dying might have on the autonomy and rights of other people in society.

There are several chapters that discuss the Dutch practices, focusing particularly on the one thousand patients a year who are euthanized without specific request. [The fact that, according to the figures published by the Dutch, the incidence of non-voluntary euthanasia is a multiple of that number is not discussed]. But back to the one thousand. We are told that these patients had either expressed a wish for euthanasia at some time in the past (current wishes were not important) or they were incompetent. That’s not what the published data says. We are also told “In a number of cases [in which patients were euthanized without explicit request] the decision had been discussed with the patient.” That’s a new twist.

Mention is made in several chapters that, as a result of the open and honest system they have, the incidence of non-voluntary euthanasia is lower in The Netherlands than in other less advanced countries, including Australia . These studies (e.g. Kuhse et al) are based on deliberately ambiguous questions that have been publicly discredited. I received a questionnaire last year, based on the Dutch format, for the International Collaborative Study on End-of-Life Decisions in Medical Practice. It asked the question regarding a patient in pain “Would you intensify the alleviation of symptoms by using drugs, taking into account the possibility or certainty that this could hasten the end of the patient’s life?” So a good doctor, practicing good medicine, carefully titrating drugs to improve patient comfort, could or would be recorded as taking active steps to hasten death. So much for all those reports.

This is a worthwhile book and, given that any discussion has more than one side, I would recommend it to anybody with an interest in the debate about Euthanasia and Physician-Assisted Dying. But it did nothing to change my views, particularly about the Dutch practices. There are repeated references throughout the book that, if you just think about it properly, there is really no difference between hastening death and letting die. Death is a natural end to a life and will come to us all. Killing is something else. Or that’s what I think.

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20:20 VISION – THE SHAPE OF THE FUTURE FOR PALLIATIVE CARE

The National Council for Palliative Care, 2005
16pp
RRP £10
Available from www.ncpc.org.uk

This booklet is the report of progress to date of 20:20 Vision, The National Council for Palliative Care’s group charged with the task of identifying what the palliative care needs of society will be in 20 years time and developing long-term policy to meet those needs. The material is presented as eight themes: Demographic change—An ageing society/Grey power and consumerism/Workforce changes/Cultural and ethnic diversity/Epidemiological change/A society engaged with its health?/Living alone and in communities/Invigorating civil society.

Whilst written for Palliative Care in the United Kingdom, most of the issues discussed are generic and would apply to the future development of palliative care in any developed society. The material is well presented and is thought-provoking. I had wondered whether the politically-correct march to consumerism in health care was really an advance or not, and noted with interest the recent Lancet editorial (April 30) that said “The strategic mistake made by politicians is to put the patient before everything else in the quest to achieve effective health care.” At £10, this booklet is not cheap but I think it will be of use to anyone who is involved with policy development for the palliative care services of the future.

Roger Woodruff

Director of Palliative Care, Austin Health, Melbourne , Australia
(May 2005)

IAHPC Faculty Development Award: A Report by a recipient

PALLIATIVE CARE IN TANZANIA – THE BEGINING OF THE BEGINNING

by Dr. Msemo Diwani

Palliative care is in its infancy in Tanzania . A situation analysis and needs assessment study on palliative care which was funded by WHO in 2002 revealed that the patient’s main needs were relief of pain and accessible and affordable drugs.

The commonest problem experienced by both the patients and caregivers were economic/financial constraints. In Tanzania , less than 10% of those who need palliative care have access to it.

Ocean Road Cancer Institute (ORCI) has traditionally practiced palliative care since its inception and is the only institute in the country that has oral morphine. Palliative care now exists in ORCI as an independent section with Dr. Msemo Diwani as its head. Dr. Msemo’s post, which is both service and teaching, is funded by the International Association of Hospice and Palliative Care (IAHPC) through a two year faculty development award, after which, the faculty will be responsible for the sustenance of the program.

After his appointment in December 2004 as a Palliative care Consultant and head of the section, the first thing he did was to conduct a brief situation analysis. This revealed a lack of a dedicated full time staff which hampers significantly both service delivery and expansion of palliative care. He restructured the team and defined clear goals and objectives. He made a 2-year plan of action, which will guide him, as well as, become his performance indicators. Significant groundwork has been done on this project. A proposal has been submitted to formally introduce palliative care in the medical and nursing curriculums for undergraduate students. While waiting for this process to be completed, palliative care teaching is carried out under Oncology. Plans are also underway to start a short course in palliative care which will be multidisciplinary and aimed at training health care professionals with the view of establishing palliative care teams in all regional and referral hospitals throughout the country and later to reach all the districts. At the same time, ORCI palliative care services have been expanded to include home based care (HBC), volunteer training and palliative care research.

Ocean Road Cancer Institute, due to its strategic position in the medical school, intends to build the capacity of stakeholders in Palliative care in order to ensure that the many Tanzanians who need palliative care get access to it.

We have no exact figure of the number of patients receiving palliative care annually as we are still analyzing the situation.

With regards to drug availability for palliative care patients, step one drug and some adjuvants are available in all health facilities, and over the counter. Step two and step three drugs are available in most districts, regional and referral hospitals. Oral morphine is only available at ORCI, hence not widely used. Most health professionals do not know how to approach pain effectively. The use of step three drugs will be addressed in the IAHPC faculty development project. The knowledge gap existing among health professionals, as far as pain management is concerned, has contributed significantly to the suffering of our patients, particularly those with chronic pain due to HIV/AIDS and the cancers. Through this IAHPC initiative we believe that pain control eventually will be a reality amongst our HIV/AIDS and cancer sufferers.

Apparently Dar es Salaam city, with over 3.5million inhabitants, utilizes health facilities from its three district hospitals. It has given a green light to organize palliative care training among it’s staff. This was confirmed during my meeting with the City Medical Officer. The home based care program is due to start and will also target this population.

Plans are also underway to nationalize palliative care. Meetings with relevant officials in the ministry in this regard will take place soon. The ministry of health acknowledges that Tanzania is among the most hard hit by the HIV/AIDS pandemic in sub-Saharan Africa and with its poor resources, palliative care will be a most effective and realistic way of addressing the suffering of these people.

To read about previous IAHPC Faculty Development awards go to URL:
http://www.hospicecare.com/faculty/

Contributions from IAHPC Board Members

‘The Right to Die’ and ‘The Right to Live’ Debate

Dr. Derek Doyle ( Scotland )

The debate about the so-called “ Right to Die “ continues in the United Kingdom as in several other countries. Much of it has centred on what is the perceived risk of doctors continuing to maintain life which, in the opinion of the patient, no longer has any quality or is characterised by pain and suffering of one kind or another.

The attitude of the medical profession has, by and large, been that the decision to treat or to maintain life should be left to them, the doctors. Predictably this has led to claims that this gives doctors too much power over life and death.

In 2002 the General Medical Council (GMC), the body regulating medical practice, issued guidance that doctors might stop feeding and rehydrating a patient by artificial means if they judge that the “ patient’s condition is so severe, or the prognosis so poor, that providing artificial nutrition and rehydration may cause suffering or be too burdensome in relation to the possible benefits.”

Now a gentleman with progressive cerebellar ataxia has brought an action which challenges a doctor’s right to discontinue such feeding and hydration, claiming that it imperils his “ right to live.” Knowing that eventually he will lose the ability to swallow he claims that doctors might decide that his life is no longer worthwhile and discontinue artificial feeding and hydration with the result that he would suffer “ pain and extreme distress” in the two or three weeks it would take for him to die from malnutrition.

Lawyers acting for the GMC claim that all this is putting doctors “ in an impossibly difficult situation.” A patient would be able to force a doctor to provide a form of treatment that the doctor might consider of no clinical benefit if not harmful.

Now the government has stepped in citing the expense of keeping someone alive. Lawyers acting for the Department of Health are now, in effect, supporting the GMC, claiming that if patients have a right to demand life-maintaining treatment it will create “ a culture in which patients request treatments no matter how untested, inappropriate or expensive, regardless of the views of doctors.” The court has been told that a bed in an intensive care unit costs £ 1,500 a day, and one in a high dependency unit £ 800 a day.(US$ 2,400 and US$ 1280 respectively).

However, the financial implications are not the only ones in the United Kingdom today. The much-vaunted National Health Service is chronically short of resources. The country has only 4 critical care beds / 100,000 population compared with 25 in Germany and 24 in the US .

This on-going debate has major implications for us in hospice and palliative care. In many countries there is diminished respect for, unquestioning trust in, doctors and increasing suspicions that they wield too much power and influence particularly with respect to life shortening and life prolonging. Rather than be subjected to the ethical, legal, and financial pressures discussed in this article some hospital doctors will opt for their terminally ill patients to be transferred to hospices and palliative care units. How long will it be before we hear of more patients there being the subject of legal battles? What of the financial implications for palliative care units of maintaining life, whether it is with drugs, feeding or hydration? Again looking at the UK , only 25-30% of running costs are now met from government subsidies, leaving vast sums to be found elsewhere.

For a long time we have had palliative care patients tell us that they most definitely do not want euthanasia, but if it is costing the country so much to care for them, as politicians never stop telling us, they wonder if it is their moral duty to die sooner rather than later if it saves precious resources. A newspaper headline today states “ Health minister puts a price on the right to life.”

This current debate about recognising the inevitability of death and the rights of patients to share in decision making (or make decisions against the informed advice of their doctors) must also be seen against a rapidly changing medical care background. Under a new contract British general practitioners / family doctors were allowed to choose whether they would provide “out-of-hours medical care”(either with their partners or using a local co-operative) or opt out of all evening and night care. Close on 100% opted out, ending a long tradition of British medicine which had ensured that when a doctor was needed at night the one who came to the house (for example to a terminally ill patient) would be one known to the patient. Under a relatively new European Union directive junior hospital doctors work much shorter hours, making it more likely that when one is called to a bedside it will be one unknown to the patient. A harsh judgment perhaps, but many people are now hinting that doctors are less caring, less deserving of unquestioning trust. They see challenging doctors motives and recommendations, as in the “right to live, right to die debate” as both necessary and timely.

The debate continues and is likely to do so for a long time in the United Kingdom .

Derek Doyle writes about the manifesto of the National Council for Palliative Care and the response to it by the three major political parties in the United Kingdom

Some readers will know that Britain is due to have an election in May to elect a new government, the present one - a Labour one led by Tony Blair – having been in power for eight years. The other two major parties are the Conservatives (the main opposition party) and the Liberal Democrats.

In January 2005 the National Council for Palliative Care, an umbrella organisation bringing together all providers of palliative care in the UK, in association with the All Party Parliamentary Palliative Care Group produced a manifesto based on 3 principles and incorporating 4 pledges.

• That everyone has a right of access to palliative care services appropriate to their need
• The everyone should be able to exercise choice about their place of death at the end of life
• That everyone is entitled to a good death.

This manifesto, having been warmly welcomed by voluntary sector providers, was then sent to each of the main political parties listed above for their responses.

Perhaps predictably they were all enthusiastic about palliative care and, in different ways, pledged their political and financial support. Again as might be expected, the present government highlighted what it had done for palliative care in recent years and would continue to do if re-elected, whilst the others pledged to better that. Their pledges of financial support and encouragement have to be seen against the number of providers in the UK – 220 adult in-patient units (3156 beds), 33 children’s hospices (255 beds). 358 community (home) palliative care services, 263 Day Units and 361 hospital palliative care teams. The Conservative Party in particular mentioned NICE, a name that may puzzle readers of this newsletter. It stands for National Institute for Clinical Excellence, the body setting and monitoring clinical standards in the UK.

What relevance has all this to other countries, many much less fortunate than the UK?

Firstly it reminds us that nearly 40 years after Cicely Saunders opened St Christopher’s in London palliative care providers in the UK still have to ‘sell’ themselves. It is also a reminder of the usefulness of a body such as the All Party Parliamentary Group, which ensures that politicians of different parties, policies and priorities are kept informed about palliative care. Worldwide experience has shown that informed politicians and administrators can make all the difference to the acceptance and development of palliative care in a country. Several countries now have groups similar to this one serving the politicians of England, Wales and Northern Ireland. We need not be cynics to know that pre-election promises do not always mature into post-election fulfillments, but the National Council for Palliative Care has acted very responsibly and shrewdly by getting the political parties to put in print what they plan/ ”promise” to do. We may be sure that they will not hesitate to remind the politicians of those promises and pledges.

Readers might like to read more at URL:
www.ncpc.org.uk/newsroom/pcmanifestoresponse.html

IAHPC Regional Reports

From the Czech Republic

Presentation of the outputs of the “Palliative Care in the Czech republic ” project (2003-2004) in the Parliament of the Czech Republic - February the 15th 2005.

Project Palliative Care in the Czech Republic (CR) seeks to radically improve the care provided to the incurable, dying and their families in the Czech Republic. It aims to improve the knowledge of both professional and lay public about modern palliative care and to promote principles of quality care for the dying throughout the whole health and social care system.

Cesta domu (The Homecoming), a hospice unincorporated association, was a bearer of the Project. The Association focuses on two complementary areas of activities:

• It has founded and operates a home hospice in Prague , where specific support is provided to families who decided to care for their dying relatives at home;
• It endeavours, after social and legislative structural changes, to enable the Czech Republic to extend quality care to the dying.

The Project was funded from the Public Health programme introduced by the Open Society Fund, Prague.

In May 2004 a report about the state of Palliative care in CR was presented in Parliament:

Dying and Palliative Care in CR (situation, reflections, prospects)

Research report and critical issues for the development of palliative care in the Czech Republic

The report includes an analysis of epidemiological data on dying, a public opinion research, an opinion poll performed in selected groups of inhabitants, a “focus group” research among health care professionals, education programmes mapping, a questionnaire survey of current providers of palliative bed care in the Czech republic, a description of a mobile hospice pilot project and, based on data collected, it defines areas decisive for further improvement of palliative care in the Czech Republic.

The first major research in the Czech Republic focused on the care for terminally ill and dying, in years 2003-2004, and was one of the issues of this report. The following results were obtained and presented:

• The public is unhappy with current state of care for dying. Even the best evaluated area of care (treatment of pain) was judged as “good” by only 7% of respondents, and “as rather good” by 29%
• Alarming is the discrepancy between preferences of the public and real status of care provided for terminally ill and dying in our country: approximately 75% of all deaths occur in health care or social care facilities (hospitals, nursing homes, retirement homes), yet 80% of those, who responded to this question, would not want to die in these institutions.
• The group of students evaluated current care for dying even more critically than the public. It is therefore not surprising, that 91% of them evaluate the improvement in care for dying as important.
• The most critical in their evaluation of the care for dying are those, who have most experience with it, which are health care providers and social workers. And especially those, who provide care for dying most frequently (oncologists, workers of nursing homes, retirement homes and hospices).
• Large numbers of dying suffer from inadequately controlled pain and other physical symptoms, though modern medicine can effectively treat most such problems.
• The area of care for terminally ill and dying viewed most critically by both lay and professional public is the lack of attention paid to psychological suffering of patients and the lack of attention given to their family and friends.
• 90% of interviewed young physicians feel that they are not trained to communicate with the terminally ill and their families.
• Specialized, modern palliative care in hospices is available to only 1% of all terminally ill and dying.
• Continuity and coordination of care for dying is frequently poor. In the last weeks of their life, patients are frequently being transferred between various health care facilities.
• Participation by patient and family in important decision -making about treatment is rather an exception. Communication between physicians and patients regarding diagnosis and prognosis varies and generally is inadequate.
• The family of a terminally ill patient who decides to care for their patient at home undergoes a risk of an extremely demanding process without the security of any financial support, and, at times, against opposition from their physician.
• No institution in Czech Republic currently monitors quality of care for dying. Criteria for this care have not been developed.

The research proved that there is a pressing need to:

• Improve quality of care for dying
• Radically increase access to modern palliative care
• Develop home-based palliative care
• Profoundly improve the care for dying in health care and social institutions, most of all in nursing homes and retirement homes

A review of areas where the need for change seems most pressing was presented:

• Education of health care providers and other caring professionals.
• Influencing professionals, primary through their medical societies,
• Support of local innovative projects.
• Follow-up and evaluation of care for terminally ill and dying.
• Development of home-based palliative care
• Utilization of proven methods from abroad
• Ongoing popularization of the theme of care for dying

As concrete contributions toward the realisation of changes occuring in the systém to provide care to dying in CR, Cesta domu has organized a second presentation in Parliament in February 2005. Also, 5 publications were presented to, and discussed with, the health care providers, politicians and to the public. They were edited by Cesta domu as an answer to the main problems and barriers of the Palliative care environment in the Czech Republic.

Presented were these publications as outputs of the project:

• On Organisation of Palliative Care - An essential document of European significance emphasizing palliative care as an enormously important part of the system of health care services.

• Palliative Care Policy in the Czech Republic - A draft of palliative care policy in the Czech Republic is based on the hitherto experience with delivering palliative care both abroad and in the Czech Republic.

• Education in Palliative Care - A draft of training programmes designed for university and graduate education of physicians.

• Home Palliative Care Standards - A draft of basic standards applicable to special palliative home care.

• Respect for Human Dignity - A guide for professional training, education and training of students in medical, health care and health and social care schools and universities.

All these publications are now of great interest to health care providers, both professional and non-professional. The draft of the Concept of Palliative Care in the Czech Republic is now used as a working document by the Ministry of Health Committee for Palliative care. Based on this project, in April, 2005, Cesta domu has prepared a new website www.umirani.cz (umirani = dying) for wide use by the public.

We hope the presentation in Parliament in February will bring about the most important changes in End of Life Care in CR. Much has been done by volunteers, nurses, civic initiatives and hospice-care providers, but now we expect an important step forward by government and other institutions.

Martina Spinkova, Cesta domu, Prague
1. 5. 2005

IAHPC Regional Reports

From Nepal

A Palliative Care Initiative in Nepal

The Princess Alice Certificate in Essential Palliative Care (International) was completed in Kathmandu on February 27 2005 .

This eight week home study course involving a five module handbook, with associated video programmes, and a case based portfolio has been run in the United Kingdom at Esher and at Belfast since 2001. During this time, over 500 candidates have enrolled in the programme.

Together with Partnership in International Medical Education (PRIME), the course was established in Nepal in an attempt to meet a growing need for palliative care education.

Jenika Graze, a specialist palliative care nurse from Australia currently working in Nepal , who was responsible for co-ordinating the course, explained that,

“We hoped that by providing a recognised qualification that was focused on practical palliative care, we could start to address some of the palliative educational needs that are arising across the country.”

In total, some 27 candidates completed the course in Kathmandu . These included 17 doctors and 10 nurses from 10 different hospitals across the country.

The eagerness of these candidates to learn was emphasised when many chose to fly into Kathmandu to bypass the Maoist siege of the city and the disruption caused by the recent power takeover by King Gyendra.

Specialist nurse Lynne Kovan and palliative care consultant Dr Max Watson travelled from the UK to conduct a final three days of revision lectures and the course assessment at Patan hospital in the Kathmandu valley. During the three day revision programme there was also an opportunity for valuable net-working and sharing of ideas from different palliative care professionals working in a wide range of Nepali settings.

Despite the teaching being carried out mostly in English, which, for many of the candidates was a third or even fourth language, the quality of work completed by the Nepali doctors and nurses compared very favourably with that of students back in the UK.

The course also allowed for practical teaching in the use of syringe drivers, which until now have not been readily used in Nepal . Through the generous donations of various bodies, some 30 syringe drivers were left under the care of Hospice Nepal who has taken on the responsibility for training other centres in syringe driver use, distribution and monitoring.

Dr Rajesh Gongol, a consultant general surgeon and one of the co-founders of Hospice Nepal , spoke very enthusiastically about the course.

“The certificate programme has more than matched our expectations and through the use of lots of Nepali pictures and illustrations has been made very relevant to our practical palliative care needs. We hope that the course will be run on a regular basis to help meet the huge palliative care needs of the country”

Learning to “Drive” in Nepal

By Jenika Graze

With bated breath and unsteady hands the needle is inserted. Patients and relatives crane to see. We listen for the whirring sound. Nepal ’s first syringe driver starts doing its work. 24 hours later Ramesh’s pain is under control. Five days later he is back in his hillside village home, surrounded by his family.

What a responsibility! Thirty syringe drivers neatly stacked on the bookshelf in my study, waiting for the right time to be introduced into various institutions around Nepal . These, the first ever syringe drivers in Nepal, were brought to Kathmandu in February 2005 by Dr Max Watson and Practice Facilitator Nurse Lynne Kovan (associated with The Princess Alice Hospice and PRIME - Partnership in International Medical Education) who were here to complete the eight week distance learning certificate programme in palliative care that had begun at the start of the year. 27 health professionals, from all over Nepal , were trained and assessed during this workshop.

The buzz of excitement and the flow of creative ideas, which were shared over the course, and in particular the last four days of intensive teaching, resulted in increased palliative care awareness, knowledge and many concrete plans for the development of improved palliative care services in Nepal.

After a decade of being told, by aid organisations and health care professionals, that palliative care is ‘the icing on the health care cake’ and therefore not appropriate in Nepal, it has been exciting to see minds changing and a growing awareness of the importance and need for appropriate palliative care provision.

This new awareness has been demonstrated by a surge of interest in palliative care education, the introduction of palliative care education into existing teaching programmes and the development of hospices and dedicated palliative care beds.

Hospice Nepal is a 9 bed home which was established in 2000, first as four beds in a hospital ward, then eighteen months later as a dedicated hospice building. It was here, under the careful supervision of Dr Rajesh Gongal , that in April 2005, we used a syringe driver as part of our palliative care service for the first time in Nepal . After two education sessions with four of the hospice nursing staff, and then a half hour practical assessment for each of them, we were ready to go.

One month later, seven patients have benefited from the availability of syringe drivers as a means to help in medication administration. As the nurses see their application and the effects on patients and families their confidence in the application of the technology has grown.

Historically introducing such “hi-tech” expensive devices in a resource limited country like Nepal has many potential drawbacks and pitfalls, and ensuring that benefits would out-way the potential harm has been a major concern from the outset.

• The use of inferior quality batteries, due to their significantly reduced cost, has resulted in several of the syringe drivers ceasing to work at some point in the 24 hr medication period. It is vital that the type of batteries recommended by the syringe driver manufacturers are used.

• The use of oral medicines unrelated to those available for syringe driver administration, has made syringe driver dose calculations very difficult.

• The unavailability in Nepal of long infusion sets and transparent sterile dressings, has required creative alternative solutions and many hours searching pharmacy shops in the bazaar. Currently we are using the sterile plastic cover of a butterfly needle as our clean transparent dressing over the needle insertion site.

These issues require innovative approaches and supportive guidance to consolidate, and make practical within the actual Nepal context, the theory that has been taught.

Despite the challenges, the benefits in quality of life for the Nepali individuals who can access this technology have been clear.

Four hourly intravenous Morphine injections are the main mode of giving analgesia to patients in Nepali Institutions who are experiencing severe pain because oral morphine is not yet available in Nepal . The supervised introduction of syringe drivers provides for the opportunity that such patients no longer need to spend their last weeks and days in hospital and in addition they will have improved symptom control.

The inspiration to persevere with this approach comes not from an awe of “high tech western medical instruments”, (the corridors of Nepali hospitals are filled with enough dust covered detritus to make even the most technophile skeptical), but from the unfurrowed brow of Ramesh, who was at last able to return home to his village and family, free from the pain and nausea that took him to Kathmandu four months previously.

What’s New?

Dear colleagues,

We are pleased to announce the posting of a new Country Report for Nigeria, which can be found at the following address:
http://www.eolc-observatory.net/global_analysis/nigeria.htm

Over the coming days, a further 18 reports from countries within Africa will be posted. We encourage you to keep returning to our site for further updates at:
http://www.eolc-observatory.net/global_analysis/africa.htm

With best wishes,
The Observatory team.
Anthony Greenwood

Information Support Officer
International Observatory on End of Life Care
Institute for Health Research
Bowland Tower East Lancaster University
Lancaster LA1 4YG United Kingdom
Tel: 01524 594976 Fax: 01524 525250
Email: [email protected]

International Observatory on End of Life Care Research Summer School - July 2005
For further information:
http://www.eolc-observatory.net/school/index.htm

Visit our not-for-profit publishing arm, Observatory Publications.
http://www.observatory-publications.net/

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13^th International Conference of the Indian Association of Palliative Care

Dear friends,

We are extremely happy to inform you that our website www.chennaiapc.com is ready and you can get all the information regarding the 13^th International Conference of the Indian Association of Palliative Care (IAPC) being organised by the Chennai Association of Palliative Care at Chennai on 10,11 and 12 February 2006. You can download the registration form from the website.

We will be happy to answer any queries. We look forward to your participation and sharing your ideas for the overall successful outcome of the conference.

Warm Regards,
Mallika Tiruvadanan
Organising Secretary

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HIV/AIDS and Human Resources

A short summary of an editorial in the Bulletin of the World Health Organization on HIV/AIDS and human resources, 2005, April 83 (40) can be read at:
http://www.who.int/bulletin/volumes/83/4/en/index.html

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East Delhi

This is to inform you that Sr. Leonarda, a nurse on our home care team and coordinator of our CanSupport centre in East Delhi, recently went to London to receive the prestigious ‘Best Palliative Care Nurse of the Year Award, 2005’ which has been jointly instituted by Macmillan Cancer Relief and the International Palliative Journal of Nursing.

Sr. Leonarda has been with CanSupport, a not-for-profit organisation that runs free home care and day care services for people with terminal cancer and their families, since 1998. This award is of great significance for not only does it bring international recogntion to our home care programme, but it also draws attention to the pivotal role that nurses play in the delivery of palliative care. To quote Sr. Leonarda, after she received the award at a glittering ceremony held on the 18th of March at the Savoy Hotel, London , “I was overjoyed to be in the company of caring people from different parts of the globe united by a common purpose. Receiving this award has given recognition to the role of nurses in palliative care. This Award will continue to inspire me and my colleagues to work harder for the comfort of our patients. None of us can do this work alone. We work as a team. I was touched by the joy experienced by all my team members when I received this award. It was as if each one of us had been recognised. Above all, there is a sense of pride that CanSupport has got the international recognition it deserves”.

Harmala Gupta
President CanSupport (caring for people with cancer)
Address: Kanak Durga Basti Vikas Kendra Sector 12, R.K. Puram,
New Delhi-110022
Tel: 26102851, 26102869
Fax: 26102859
Email: [email protected]
Website: www.cansupport.org

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Journal of Palliative Medicine Update

We are pleased to announce that the first three volumes of Journal of Palliative Medicine (1998-2000) are available online for the first time! Now in its 8th volume, these original twelve issues are replicas of the print edition. We are offering a special package price of $49* for a personal online subscription or $99 for institutional/library access. To order this valuable back issue package, please visit
http://cl.exct.net/?ffcd16-fe6d16707465077c741d-fdf81576746c017e73167072
or recommend this offer to your library by forwarding this message to your librarian.

Enhance your resources and searching options by adding these early issues to your current subscription. If you don't already receive JPM, now is the time to subscribe to the full online collection of the leading publication in the field.

Journal of Palliative Medicine, the official publication of AAHPM, is the leading peer-reviewed journal on hospice and palliative care featuring the latest information and protocols that enable you to provide optimal care to your patients. To view a complimentary online issue, and to subscribe, visit www.liebertpub.com/jpm.

*AAHPM members will be able to access these issues at
http://cl.exct.net/?ffcd16-fe7416707465077c7715-fdf81576746c017e73167072
at no extra charge.

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16TH POSTGRADUATE COURSE IN PALLIATIVE MEDICINE

14 th-16 th July 2005

Organised by: Singapore Hospice Council and Singapore Medical Association

What can course participants expect?

A foundation in the principles and practice of palliative medicine applicable to all major specialties.  This course will increase professional confidence and competence in the management of patients with terminal illnesses.  There will be didactic lectures, tutorials, workshops and panel discussions which  will impart skills such as symptom  control,  communication  with patients and their families, dealing with psychological problems and  the  use  of  hospice  services  in Singapore. Course participants  will also  have  unique opportunities to personally assess patients and  to  discuss the most appropriate management strategies with palliative care physicians and other specialists in the field.

Who should attend?

Any doctor (medical officer, specialist or family physician) who is interested to learn about Palliative Care. Palliative Care is defined by WHO 2002 as “An approach which improves quality of life of patients and their families facing life-threatening illness, through the prevention and relief of suffering by means of early detection and impeccable assessment and treatment of pain problems, physical, psychological and spiritual.”

Venue, Facilities and Fee

Auditorium, Level 3, Hospice Care Association, 12 Jalan Tan Tock Seng (308437).
Lunch, morning and afternoon teas will be provided.
Fee: $250.00 (inclusive of lunch and teas)

Enquiries and accommodation for foreign participants

Singapore Hospice Council Secretariat. Tel: 6256-2677 Fax: 6258-9007
Email: [email protected]
Closing Date: 5 July 2005

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9th Annual Interdisciplinary Approach to Symptom Control, Palliative and Hospice Care

FEATURING: Palliative Care Board Review

Sponsored By: The University of Texas M. D. Anderson Cancer Center , Department of Palliative Care and Rehabilitation Medicine

Houston , Texas October 14 - 16, 2005

Event Description:

Attendees of this conference will learn state-of-the-art pain and symptom management. Effective communication with patients and families at the end of life and issues of hope and grief in patients and families dealing with advanced diseases will be discussed. Also to be discussed are moral and ethical dilemmas facing clinicians who provide end-of-life care. BOARD REVIEW for candidates eligible for The American Board of Hospice and Palliative Medicine will also be offered. This review will feature world re-known educators in the field of hospice and palliative medicine.

Contact Information:

Jennifer Anderson, Department of CME/Conference Services
Email: [email protected]

Event Website:* Palliative Conference Homepage http://www.mdanderson.org/prof_education/cmecs/display.cfm?id=155683d9-71ab-4ecc-9545352b6cd73955&method=displayfull&pn=6b1866eb-d2d7-4cee-9769db428bb091a4

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2005 Seminar in Health Care Ethics

Sponsored by The University of Washington School of Medicine

August 1-5, 2005
University of Washington Campus Seattle, USA

Information and Registration:
Continuing Medical Education
1325 4th Ave, Suite 2000
Seattle WA 98101-2506
Ph (206) 543-9496
Website: www.uwcme.org

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The bill states, “To amend the Public Health Service Act to increase the number of permanent faculty in palliative care medicine at accredited allopathic and osteopathic medical schools and to promote the development of faculty careers as academic palliative specialists who emphasize teaching…..”

US residents may want to read the act. If they find it useful, they might want to support this act by writing to their government representatives. Colleagues in other countries may also find this document of help as they attempt to expand palliative care education in their region.

Go to URL: http://thomas.loc.gov/home/c109query.html
Then insert S. 1000 into the Bill Number Box and click Search

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Current Concepts in Palliative Care: Update and Review Course

Sponsored by the American Academy of Hospice and Palliative Medicine

San Antonio , Texas , USA
Hyatt Regency San Antonio August 25-27, 2005

Course information and registration:
AAHPM
PO Box 839
Glenview IL 60025
USA
Website: www.aahpm.org

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Hospice Medical Director Course

Sponsored by the American Academy of Hospice and Palliative Medicine

San Antonio , Texas , USA
Hyatt Regency San Antonio August 25-27, 2005

Course information and registration:
AAHPM
PO Box 839
Glenview IL 60025
USA
Website: www.aahpm.org

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The American Psychosocial Oncology Society (APOS)

Now accepting abstracts for its 3rd Annual Conference, 16 ­ 19 February 2006 , at the Amelia Island Plantation, in Amelia Island, Florida. The meeting is dedicated to /Synthesizing Research, Advocacy and Program Development to Optimize the Quality of Care.

Please visit www.apos-society.org for abstract submission and more information on the meeting.
The deadline to submit an abstract is 11:59 pm EDT , 5 August 2005.

APOS has confirmed the following Invited Speakers for the 3rd Annual Conference:

   * Barbara Andersen PhD, The Ohio State University, opens the conference with a presentation on psychosocial interventions at the Opening Plenary;

   * Kathleen Foley MD, Memorial Sloan-Kettering Cancer Center, will be present to receive the 4th Holland Distinguished Leadership Award for her important contributions to the field;

   * David Spiegel MD, Stanford University School of Medicine, will address “Stress and Cancer: Innovations in Biopsychosocial Interventions, Endocrine and Immune Function.”

APOS is proud to announce the following Preconference training sessions, scheduled for Thursday, 16 February 2006:

· Persistence Pays Off: Funding Opportunities for Psychosocial Oncology Research

Coordinator: Diana Jeffery PhD, National Cancer Institute

· Supporting Parents with Cancer and their Children

Coordinator: Anna Muriel MD, MPH, Massachusetts General Hospital

· Hypnosis as an Intervention

Coordinator: Joel Marcus PsyD, Scott & White Memorial Hospital & Clinics

· Psychiatric Aspects of Palliative Care and Symptom Management

Coordinator: William Breitbart MD, Memorial Sloan-Kettering Cancer Center

· Patient Advocacy Training

Coordinator: Kim Thiboldeaux, The Wellness Community

· Creative Solutions with Technology

Coordinator: Mitch Golant PhD, The Wellness Community

· Statistics and Study Design for Psychosocial Oncology

Coordinator: Christopher Recklitis PhD, MPH, Dana-Farber Cancer Institute

Program Subject to Change

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Geriatric Oncology: Cancer in the Elderly

6th Meeting of the International Society of Geriatric Oncology
September 29th - October 1st, 2005
Crowne Plaza Hotel and Conference Center Geneva , Switzerland

Abstract Deadline: July 1st, 2005

Information and registration:

Email: [email protected]
Phone +39 039 23 26 183
Fax +39 039 33 09 918
www.cancreworld.org/siog

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2005 National Hospice Palliative Care Conference

Kaleidoscope:  dialogue and diversity in hospice palliative care
September 25 - 28, 2005
Shaw Conference Centre Edmonton , Alberta

The Preliminary Program and Registration Form for the 2005 National Hospice Palliative Care Conference is now available on the CHPCA Web Sites for download!
http://www.chpca.net/events/conference.htm

Webmaster's Corner

Anne Laidlaw

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Coming Events! Please visit our Future Events section to view events and add your event to our website. 9 new listings added this month!
http://www.hospicecare.com/future.htm

Did you know?

* The plastic things on the end of shoelaces are called aglets.
* The device at the intersection of two railroad tracks to permit the wheels and flanges on one track to cross or branch for the other is called a frog.
* The pin that holds a hinge together is called a pintle.

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IAHPC Webmaster

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Editor’s Notes

William Farr, PhD, MD (USA)

The Clearing House Program – notes from recipients

Dear Liliana:

I would like to convey my sincere thanks to you and IAHPC for sending me the books,journals and other reading material from the IAHPC clearing house programme. These are indeed useful to us.

Regards

Dr Suman Bhasker
Assistant  Professor [Radiotherapy]
Dr BRA IRCH,AIIMS
New Delhi-110029, INDIA

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Dear Liliana

Thank you very much for the books, magazines, journals etc. They have added value to our small resource area, we are actually trying to develop a resource centre. I am sure slowly we will get there.

Eunice

An RN, that currently works with the Hospice Association of Zimbabwe (HOSPAZ) in Harare , Zimbabwe.

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Prescription Monitoring Programs

Update on state prescription monitoring programs (PMP) . According to a recent review by the Pain & Policy Studies Group (PPSG), 21 states have PMPs or legislation that allows implementation of a PMP. There has been a steady increase in the number of states with PMPs that rely on electronic transmission of prescription data and that monitor most or all classes of controlled substances. In addition, several more states are considering PMP legislation. The PPSG encourages publication of studies that evaluate the outcomes of PMPs on diversion and abuse and their impact on medical practice.

A trend graph and listing of states can be found at:
http://www.medsch.wisc.edu/painpolicy/domestic/diversion.htm

William Farr, PhD, MD
Newsletter Editor

Letters to the editor may be submitted at the following page
http://www.hospicecare.com/contact.htm

****Thanks to all contributors to this issue.****

William Farr, PhD, MD
Newsletter Editor
www.hospicecare.com

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