WHO Public Health Strategiesfor developing palliative NCCP
Barcelona, March 2011
Jan Stjernswärd MD PhD FRCP (Edin)
Ethics
begins in the opening that freedom provides-
the thought that things
should be other than they are and
the confidence to make that future concrete
Highest stage of moral reasoning
is not ruled by
self-interest, the opinion of others, fear of punishment
but live according to self imposed universal principles
such as those of justice and
respect for the dignity of
persons
All humans’ beings share a condition
that requires a range of
common responses – this week – deal with the threat of mortality,
un-nessecary pain and suffering and wish for a good quality of life as
well as death
Value pluralism .
Some cultures values
autonomy and individuality
many others value
social cohesion, community and
tradition more highly
(Segment of a 2500 year old Turkish carpet) (The oldest known carpet in the world found in Pazyryk, Altai Mountains of Central Asia)
Do it Your own way
death of parents in law Sri Lanka
vs
USA
overmedicalised, commercialised
vs
Nordic Countries
Georgia
(pain, no drugs, priests)
Uganda
(morphine free, PC Nurses can give morphine)
Mongolia
(incurable 80%, PC NCI,40 liver cancer,
Vaccination, NCCP Referral polices, 39 million)
USA
(Disney land)
Socio-economic and cultural solutions
will be as important-if not more-
than the medical efforts
in achieving palliative care coverage
1986
Catalonia WHO Demonstration Project, started 1989 globally is the first having documented a comprehensive
coverage (> 80%) in its population (> 6 million)
for all in need of palliative care regardless of cause .
“Socio-economic and cultural solutions will be as important- if not more, than the medical efforts in achieving palliative care coverage”
“A medical Institutionalized approach will notreach all in need of palliative care in a society, nor will the usual hospice approach”
“…Catalonia serves as a brilliant model, for theimportance of an integrated GOV and community NGO approach. Each one in isolation, will notachieve much”
Wisconsin WHOCC
(first, oldest)
Oxford WHOCC
(NPCP, Education)
London WHOCC
(latest)
Catalonia WHOCC
(Rolls Royce )
Kerala WHOCC
(community approach)
Kerala NNPC• Succeeded making PC a peoples movement
• Established high ethical standards covering most terminally ill
• Demonstrated an alternative to present over medicalised , over specialized and in long run unaffordable care of the dying
• Shown financial sustainability
• Shown that social support, psychological support, nursing care and partially medical management can be done by the community
Stjernsward: Indian J Pall Care. December 2005
Palliative Medicine – The Global Perspective:
Closing the Know-Do Gap
Jan Stjernswärdand
Xavier Gómez-Batiste
Ministry of Health OfficialsOther Ministries e.g. Social Affairs, Higher Education, Women’s Affairs
International GOV organizations and NGO (e.g. WHO, EU, IAHPC, UICC)Directors Cancer Centers, AIDS, Geriatric
Drug regulatorsChief Pharmacist
Deans Medical SchoolsDeans Directors Nursing Schools
Representative Family doctors /GPsRep. Social Workers
National NGOs, Religious Org. Journalists/advocacyRelevant leading clinicians, doctors/nursesInternational Faculty /Resource person (s)
Walch D, Pall Med (in Press) :Stjernsward J Gomes Batiste X
Participants NPCP Policy Workshop
Factors influencing a patient’s perception of pain
Other symptoms
Adverse effects of treatment
PHYSICAL
Total Pain
ANXIETY
DEPRESSION ANGER
Fear of hospital or nursing home
Fear of pain
Worry about family and finances
Fear of death
Spiritual unrest, uncertainty about future
Loss of social position
Loss of job prestige and income
Loss of role in family
Insomnia and chronic fatigue
Sense of helplessness
Disfigurement
Bureaucratic bungling
Delays in diagnosis
Unavailable physicians
Uncommunicative physicians
Failure of therapy
Friends who do not visit
WHO: Cancer Pain Relief and Palliative Care, TRS 804, WHO ,Geneva 1990
Total Pain
Hospice
T
TPC
T
T
NCCP
PP PC
ED
T
Pillars of National Cancer Control Programs
Surgery
Chemotherapy
Palliative Care
Radiotherapy
T
EducationEducation
ImplementationImplementation
PolicyPolicy
DrugAvailability
DrugAvailability
WHO Strategy: Foundation Measures
NS/WHO 3 first foundation measures:
Cost little, but BIG effect Curbing pain and suffering in a most cost-effective way, that even may save money , as shown by Catalonia
Implementation-
Closing the “ Know-Do-Gap ”:
•Finances
•Manpower
•Instituonalisation
Example
access to essential medicines
71 court cases from 12 countries analyzed.
In 59 cases access to essential medicines was enforced through the courts as part of the right to health.
Hogerzeil et al.
Conclusion
Our Might for the Patients Right
will be that we know the solution
and have the knowledge to deliver it.
Remember the 3 Ts:
Things Takes Time
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