Dr. Chitra Weerakkody, Founder Trustee, Sahan Suwa Charitable Trust, Sri Lanka, represented us at a World Health Organization (WHO) regional consultation in Colombo on 7 to 9 June 2016, on strengthening health systems’ responses to address non-communicable diseases in the South East Asia region. She contributed to discussion on ‘Overcoming the bottle necks of non communicable disease services in primary health care’.
In a powerful and well-received speech, published below, Dr. Weerakkody told the story of a patient whose severe pain was treated successfully and described the difficulty in accessing morphine, barriers to palliative care and called for improvements.
Mrs. S., 45 years old, rang me a few weeks ago, prior to discharge from the hospital where she was treated for a pathological fracture. She requested admission to the hospice as she was in severe pain due to bone metastasis in her arms, shoulders, ribs, spine and legs from breast cancer.
Bone pain is difficult to treat. Morphine helps a great deal but is not sufficient. She was started with morphine tablets four-hourly and we increased the dose gradually, along with an NSAID (nonsteroidal anti-inflammatory drugs) and an anxiolytic. Once the pain was controlled, she was given morphine controlled release tablets, 60mg bd.
More than 90 percent of Mrs. S’s pain was controlled within the next two weeks. She was then able to sit up, eat and talk to her relatives. She had had a very difficult life in the past and we helped her psychological pain by getting a counselor to visit her. She felt so much better afterwards.
Aware that she was dying, she told me that she did not need further radiotherapy or chemotherapy. Her only wish was to go home and spend her precious time left with her two children and, “Maybe,” she said “Make a curry for them with my own hands!”
Is that too much to ask? Isn’t this what palliative care is about?
She was discharged home with morphine for pain control and the option of getting readmitted if unable to manage at home.
According to recent statistics, in Sri Lanka, more than 75 percent of all deaths are due to non-communicable diseases, which shows the extent of palliative care needs in our country. I would like to share with you the problems I have seen during the last seven years as a doctor practicing palliative medicine. The current state of palliative care in our country is fractured. Despite some initiatives and good training programs for doctors and nurses during the last three years it is not systematic, and professional and public knowledge of palliative care is limited.
It is heartening to know that palliative care is included in the National Cancer Control Policy, and that the government of Sri Lanka has endorsed the national strategic framework on palliative care. But improvements on the ground are yet to be seen. Access to pain medicine especially for the poor has been an issue. Sometimes patients have to buy certain medicines when these are unavailable in the hospital. Morphine, which is necessary to control severe pain, is available only in the larger districts and teaching hospitals. General practitioners do not have access to morphine. Tramadol is not available in smaller pharmacies.
These are the improvements needed for providing effective palliative care:
Note: The original speech by Dr. Weerakkody has been edited for reasons of space.