By Dr. GVM Chamath Fernando
Family physician; WHO Primary Healthcare Young Leader; Lecturer, Faculty of Medical Sciences & Palliative Care Lead/Coordinator, National Centre for Primary Care and Allergy Research, University of Sri Jayewardenepura, Sri Lanka
The element of palliative care was recently incorporated among the pre-existing promotive, preventive, curative, and rehabilitative domains of primary health care (PHC) in the 2018 Astana Declaration, adopted by all UN member states including Sri Lanka. The Sri Lankan PHC system received global praise for its recent containment and management of COVID-19 through efficient inter-sectoral collaboration.
Nonetheless, palliative care still has room for growth. While Sri Lanka boasts the best quantitative health indices in South Asia, in 2015 Rannan-Eliya and colleagues revealed facts that dispute the quality of care1. The establishment of palliative care units and hospices by different nongovernment organizations, albeit sporadic, is commendable. Nevertheless, the geographically scattered establishment of these services with inconsistent resources may mean that accessibility is patchy. Most importantly, the lack of clinicians primarily qualified in this unique discipline could lead to variations in standards of care.
In 2017, Professor S. Prathapan and I conducted a survey that identified inadequate palliative care knowledge among Sri Lankan pre-residency doctors in medical schools2. Of the four domains evaluated (general principles, service organization, clinical management, and ethical considerations), the survey showed that the domain of ethics was the least understood.
Revelations from the survey led to the incorporation of palliative care fundamentals into the undergraduate Family Medicine curriculum at University of Sri Jayewardenepura. In the absence of teaching slots designated for palliative care, an optional online learning module was created covering basic concepts, ethical perspectives, communication skills, home-based care, and pain management. Murtagh and colleagues revealed the fragmentation of palliative care teaching owing to poor interdepartmental collaboration3, showing the need for an integrated undergraduate palliative care curriculum with liaison between all clinical departments.
As with many other countries, most Sri Lankan medical graduates deliver primary care at some point in their careers. The vast majority do not receive formal palliative care training before they enter practice as community-based doctors. General practitioners should follow a standardized postgraduate training program that enriches them with a sound knowledge of generalist palliative care.
The role of the specialist palliative care physician in sustainable health care systems to resolve complex palliative care issues is undisputed. However, in order to fulfil the routine care needs of these patients — which range across physical, psychosocial, and spiritual domains — primary care clinicians must also undergo considerable postgraduate training on the generalist form of the discipline. It is general practitioners, providing care to the entire nation regardless of class and location, who could ensure that all who need it will receive palliative care.
Specialists tend to hold disparate views and sensitivities on the goals of patient care, ethical issues, patient autonomy, death, and dying. The priority a critical care physician places on quantity-of-life over quality may starkly differ from that of a palliative physician. Therefore, it is imperative to integrate the expertise of palliative physicians from countries with well-established palliative care systems in a contextually appropriate manner in the training of generalists and locally qualified specialists. Clinical ethicists and faculty from the humanities and social sciences can shape clinicians’ practice and attitudes in line with patients’ and society’s expectations.
The currently redundant pearls of undergraduate and postgraduate medical education in Sri Lanka — discussing ethical dimensions of cases and development of soft skills, including communication and interprofessional courtesy — must resurface in their training.
All doctors can now prescribe opioids for up to one month. Until two years ago, prescriptions were limited to one week. Morphine is the only opioid available in the state sector free of charge. It comes in the oral (immediate and sustained release) and parenteral formulations. Although some patients are prescribed fentanyl patches, they need to pay out of pocket. However, while volunteering in the palliative care clinic at the National Cancer Institute of Sri Lanka (Apeksha Hospital), I noticed that the availability of particular formulations of morphine was patchy. On occasion, state sector pharmacies outside hospitals hesitate to issue opioids even for patients with valid prescriptions. I have noticed a bit of judging there, especially involving patients who appear less well-to-do.
Sri Lankan doctors do receive basic education, yet minimal hands-on experience in prescribing opioids may hinder their confidence. Patients and clinicians also suffer from “opiophobia,” another obstacle. It is imperative to de-mythologize opioids and couple classroom education with hands-on training on the safe, effective, and judicious use of narcotic analgesics and other medications for symptom control.
Different ways of integrating palliative care into PHC have shown promising effects in countries with different health care systems and resources. It is still unclear which model can be best adapted to the Sri Lankan context. Nevertheless, interdisciplinary PHC models are most likely to succeed under Universal Health Coverage4. This means advocating for concurrent palliative care training opportunities for allied health care professionals involved in PHC. Regular evaluation of educational programs from clinical, ethical, and patient-centric viewpoints must be followed by appropriate refinement of service delivery.
1. Rannan-Eliya RP, Wijemanne N, Liyanage IK, Jayanthan J, Dalpatadu S, Amarasinghe S, et al. The Quality of Outpatient Primary Care in Public and Private Sectors in Sri Lanka — How well do patient perceptions match reality and what are the implications? Health Policy Plan 2015; 30(suppl 1): i59-74.
2. Fernando GVMC, Prathapan S. What Do Young Doctors Know of Palliative Care; How Do They Expect the Concept to Work?: A 'palliative care' knowledge and opinion survey among young doctors. BMC Res Notes 2019; 12(1): 419.
3. Murtagh FEM, Bausewein C, Verne J, Groeneveld EI, Kaloki YE, Higginson IJ. How Many People Need Palliative Care? A study developing and comparing methods for population-based estimates. Palliat Med 2014; 28(1): 49-58.
4. Fernando G, Hughes S. Team Approaches in Palliative Care: A review of the literature. Int J Palliat Nurs 2019; 25(9): 444-451.