We have been wanting to include app reviews in the IAHPC Newsletter for some time, and are delighted to announce that Dr. Romayne Gallagher has stepped forward to take on the task. In future, this space will contain app reviews. Today, we present the story of iPal Global, the phone app that Dr. Gallagher developed to give clinicians basic palliative care assessment and treatment information geared to resource-constrained countries. (A brief bio introducing Dr. Gallagher can be found at the end of this story.)
By Alison Ramsey, Newsletter Editor
Having a world of information eternally at our fingertips is so common among high-income countries that it’s mundane. In low-income countries and remote locations, however, Internet connections and cellular service can be unreliable, even non-existent.
But urgent palliative care — how to relieve pain, cope with bleeding, treat seizures, dose for dyspnea — can’t wait, which is what spurred Dr. Romayne Gallagher to create iPal Global.
The original iPal app, launched in 2014, is a Web-based, quick-reference guide comprising essential palliative care information for Canadian clinicians. iPal Global differs in key ways: it is restricted to IAHPC’s List of Essential Medicines “because it’s a little broader than that of the WHO,” and can be downloaded to phone, tablet, and/or computer.
“When we began looking at our iPal statistics, I was astonished to see that a surprising number of users were from all over the world,” says Dr. Gallagher, who took on the project when she retired from clinical work in 2018. “I thought, ‘How frustrating for people from India, Africa, and other places to be looking at all the medicines we have to choose from, knowing that they’re not available.’ I wanted to make an app for resource-constrained countries focusing on the medications they have, and also dealing with some of the issues they experience.”
Launched a year ago, the free iPal Global app has been downloaded hundreds of times. It covers 22 symptoms and their management (“We tried to put someone in there for almost everything.”), patient assessment, communication, and a pain scale.
Dr. Gallagher combined a lifetime of palliative care learning and practice, input from well-traveled peers, and her students’ design recommendation to include useful “Talk Tips” throughout (e.g., If the patient has many symptoms, ask which symptom is bothering them the most, and manage that symptom as the top priority.)
“We added some symptoms, such as muscle spasm because of spinal cold injuries, and different treatments, such as dealing with bleeding in a way that didn’t involve radiation. The information is pretty standard, but the way you treat it is slightly different,” she says. “And I added self-care. I realized that a lot of people are doing this work out of the goodness of their hearts, in their spare time, doing all sorts of things you wouldn’t normally have to do in a system that is far more frustrating than ours.”
While the app is based on medicines, Dr. Gallagher included some local remedies, such as specific fruits or oils to relieve constipation.
As with iPal, she anticipates updating the app every year or two. “You have to update the information to acknowledge fancy new drugs, if just to point out that the old drug works much better.”
She also acknowledges that the situation on the ground is more complex than access. “In one resource-constrained country, Demerol is used for cancer pain — a tiny dose of 50 mg three times a day — but its effectiveness runs out in three hours. I asked, ‘What do you do when the pain gets worse? Do people die in pain here?’ They die in terrible pain. Yet the pharmacy was throwing out morphine because no one was requesting it.
“I realized that getting good symptom control was understanding the limitations of the system and getting people to work together to make the best use of what they already have before trying to increase capacity.” Opioids, and their correct use, dominate the section on pain.
Dr. Gallagher hopes for feedback: what works, what doesn’t, what to include in updates. Even without feedback, however, iPal Global will continue.
“Often times we influence people far beyond what we realize,” she says. “We just have to do it, and hope it helps someone to relieve suffering, but also increase their confidence: they can do this.”
If you know of a palliative care app suited for review, please contact us.
Dr. Romayne Gallagher was founding director of the Division of Palliative Care at the University of British Columbia, Canada, where she helped establish undergraduate, post-graduate, and interprofessional teaching in palliative care and, until 2018, was a Clinical Professor in the Division of Palliative Care. Dr. Gallagher established a public forum on death and dying, replicated by others in North America and Europe. She has also been a palliative care consultant for more than 17 years.