Advancing Palliative Care In The Public Sector_drrichardlim

Advancing Palliative Care in the Public Sector Dr. Richard Lim Boon Leong, Leong, MBBS(Mal) MBBS(Mal) MRCP(UK) Consultant Palliative Medicine Physician, National Advisor on Palliative Medicine, Ministry of Health Malaysia

Palliative Care in the Ministry of Health : When did we start?

WHO Definition “Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.”

HKL in 1950s – 1970s

History of Palliative care in MOH

Oncology and RT Dept. Sarawak GH 1995

History of Palliative Care in MOH

Queen Elizabeth Hospital, Kota Kinabalu 1995

1998 MOH Directive z

1998 – MOH directive for all state hospitals to set up Palliative care Units (PCUs (PCUs)) or Palliative Care Teams (PCTs) PCTs) by the year 2000

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A palliative care kit was developed to guide hospitals as to how to develop palliative care units.

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Workshop on improving availability of pain relief drugs sponsored by WHO and MOH held in 1999.

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12 Clinical attachment training programmes were held in Kota Kinabalu from 1999 till 2002.

Alor Setar

Kota Bharu Tanah Merah

Baling Kuala Krai Pulau Pinang

Kuala Terengganu

Bukit Mertajam Taiping Ipoh Manjung

Kuantan Jerantut Segamat

Klang Batu Pahat Seremban

Melaka

Kota Tinggi Johor Bharu

QEH

Sandakan

Miri

Tawau

Sarawak General Hospital

Network to supply opioid analgesia to interior regions

Network of PC Teams in 16 district hospitals

Distribution of PCUs and PCTs in Malaysia in 2002 State

PCU

PCT

BEDS

Perlis

-

1

4

Kedah

1

5

19

Penang

1

1

12

Perak

1

5

23

Selangor

-

2

2

N Sembilan

1

2

18

Melaka

1

Johor

1

Pahang

1

Terengganu

1

4

14

Kelantan

-

3

4

Sabah

2

17

47

Sarawak

Total

6 8

35 8

1

2

8

11

50

200

ISSUES z

No clearly defined vision or mission statement on palliative care by MOH

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Lack of career structure and job opportunities

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No set standards of care – no authority on palliative care

z

Lack of clinical leadership and stakeholders to champion palliative care in the MOH.

History of Palliative Care in MOH

Dec 2002 – PCU selayang developed as first MOH unit with specialised palliative care.

History of Palliative Care in MOH z

Dec 2004 – Proposal to develop palliative medicine as a medical sub-specialty.

z

2005 – Palliative Medicine was recognised as a medical sub-specialty in MOH

NATIONAL CANCER MANAGEMENT IN MALAYSIA 20 - YEAR MASTER PLAN GOAL 6: PALLIATIVE CARE

TARGETS

2006-2010 (RMK9) z

Specialized palliative care services in 6 regional hospitals with palliative medicine and pain specialists

z

All medical schools to include palliative care education at the undergraduate and postgraduate levels

z

To integrate palliative care in nurse training programs.

z

Develop cancer pain management Clinical Practice Guideline (CPG)

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To network with other palliative care service providers within each region

The Big Challenge

Improving Effectiveness, Efficiency and Equity of Palliative Care Services In Malaysia

How Can We Achieve This?

Step 1:

Defining a Vision

Defining a Vision z

The MOH has made a firm commitment to the development of palliative medicine as a service for the country.

Vision z

To achieve universal pain and symptom relief in all cancer patients.

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To achieve pain and symptom relief in nonnon-cancerous life threatening conditions.

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To create a unified effort by all healthcare providers to ensure holistic and comprehensive palliative care throughout the country providing a support system for patients wherever they may be. be.

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To promote universal understanding on endend-ofof-life issues maintaining the ethical principles of medicine while upholding human dignity. dignity.

Step 2:

Developing Specialised Care

Step 2 – Developing Specialised Care z

Training of specialists in the field of Palliative Medicine.

z

Develop a post-basic palliative care nursing course for specialised nursing needs.

Why specialised care? z

Palliative Care is a fulltime medical field that requires commitment, dedication and professionalism.

z

A career structure is required in order to allow doctors and nurses who were interested to focus on palliative care as a full time job.

z

Clinical leadership and stakeholders must be created in order to develop effectively.

Clinical Excellence z

Palliative medicine is a growing field of medicine worldwide with a growing body of evidence supporting the skills and knowledge of palliative care.

z

As a specialty it allows these skills and knowledge to be recognised and acknowledged by colleagues and peers.

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With such recognition can palliative care receive the support and resources it requires to advanced forward and serve the population in need.

Specialist Palliative Care z

3 year fellowship programme post MRCP/MMED

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Structured training: 6 months : basic oncology / radiotherapy 1 year : inin-patient palliative medicine (Selayang (Selayang)) 3 months : community palliative medicine (local) 1 year :overseas training (Aust (Aust / UK / Singapore) 3 months : elective training (geriatrics, rehab, psy) psy)

Specialised Care z

British Assoc. for Pall Care recommendations: 1 consultant : 160,000 population

z

Based on population statistics and standards of human development in Malaysia as compared to UK, the current suggested norm for palliative care specialists is: 1 consultant : 1,000,000 population

Palliative Medicine Physicians in Public Sector z

Currently 1 trained consultant, 2 physicians in training to complete by end of 2009 / early 2010

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1 physician in HUKM in training to complete in 2009 2 physicians in UMMC in training

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Step 3:

Organisation and standardisation

Step 3: Organisation and standardisation z

Need to improve and standardise level of care in each unit.

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Need to coordinate and improve the development of palliative care in each state.

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Need to coordinate and improve community palliative care services in each state.

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Need for good link and partnership with NGO and to develop policies to allow partnership with NGO for community care

Hospital-based Palliative Care Services

PCU or PCT z

Palliative care unit (PCU) = 4 or more beds.

z

Palliative care team (PCT) = less than 4 beds.

Palliative Care Beds in Malaysia z

British Pall Care 2000 guidelines recommend:

36-54 beds per million population z

Palliative Care Australia 2003 guidelines recommend:

67 beds per million population z

Based on current healthcare resources and human development standards, the current suggested beds required is 20 beds per million population. (532 beds)

z

Currently we have 6.8 beds per million population

Beds but do they function? z

Majority of beds not providing specialist palliative care.

z

For units without specialist care no standard of care or guidelines available yet.

z

Concept of palliative care still not well understood even within established units.

z

Essential drugs for palliative care still not available in established units or not easily obtained.

Characteristics of Successful Units z

Dedicated Clinical leadership

z

Supportive Hospital director and Matron providing resources.

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Independent unit with separate 24 hour staffing and adequate nurse pt ratio (ideally 1:4).

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Dedicated medical officers working under the supervision of the specialist in charge.

New definition of Palliative Care Unit z

Must be supported by hospital administration and given continuous support and effort to provide appropriate resources.

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Must have a dedicated clinical leader (ie specialist or senior medical officer) who has clear understanding of palliative medicine and basic principles of specialised palliative care even though may not be a specialist in palliative medicine.

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Need not have a dedicated ward or beds but MUST have admission rights and designation of patients to be under the care of the palliative care unit as the primary team.

New definition of Palliative Care Unit z

Must have dedicated medical officers who work under the direct supervision of the clinical leader / specialist in charge.

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Must have dedicated nurses whose job description is specific to provide palliative care either hospital based or sometimes community based.

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Must have access to essential drugs for palliative care and certain equipment such as syringe drivers etc.

Ideal Organisation structure HOSPITAL DIRECTOR

Matron

PCU ward sister

PCU Staff nurses (post basic + nonnonpostpost-pasic) pasic)

Department of Medicine / Other Dept interested

Department of Anaesthesia

Palliative Medicine Unit

Pain Specialists

Consultant Palliative Medicine Physician / Other Specialist / clinical Leader

Medical Officers

Community Palliative Care Services

ESSENTIAL Relationship Hospital Based Palliative Care • Consultative Service • In patient Palliative Care Unit

Community Palliative Care •hospice organisation • homecare team.

Community Palliative Care z

Majority provided by NGOs and very little by MOH

z

NGOs are a vital resource that helps provide comprehensive palliative care to patients.

z

MOH must continue to support NGOs

Supporting NGOs through: z

Medical specialist input

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Networking to supply medications to patients

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Improve referral systems

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Education of volunteers and NGO staff

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Funding

Community Care in MOH z

44% of population live in rural areas

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At present NGOs exist only in urban areas.

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Need for homecare services in rural areas not serviced by NGO groups.

Can we utilise our existing public health network?

Where are we going?

Developments in progress z

On going specialist training and upgrading of state hospital units.

z

Increasing awareness in government medical schools – HUKM and UMMC developing palliative care units and training specialists.

z

Palliative care undergraduate curriculum in most major medical schools.

Developments in progress z

Development of Cancer Pain Management Clinical Practice Guideline.

z

Development of Post Basic Palliative Care Nursing course (Curriculum still in planning)

z

Development of Paediatric Palliative Medicine (Hospital Melaka)

z

Incorporating palliative care training in public health sector geriatric programme.

Are We Progressing?

“We are taking too long to develop”

“You mean it will take 3 years to train ONE specialist?!” “We cannot be waiting for the government while people are suffering”

START LOW GO SLOW BUT DO SO