International Palliative Care

Question 1

Factors influencing delivery of palliative care in low and middle income countries

Answer 1

1. Poverty and economic impact of illness
   - Lack of publicly funded healthcare and significant expense of healthcare can push families below the poverty line, especially if associated with loss of lifelihood
   - Resources are limited to provide medicine, support education, and support families economically
2. Role of families
   - In traditional societies, families are involved in providing physical care and companionship
   - Simple drug and nursing protocols can and should be developed, with family members able to be trained in these tasks
   - However, families may override patient autonomy or limit care
3. Disease spectrum and dichotomies in existing services
   - Financial support may be conditional upon providing care to certain conditions (e.g. HIV, but not COPD)
   - Limited resources can limit ability to manage certain symptoms (e.g. lack of radiation available for the treatment of pain or fungating wounds)

Question 2

Palliative Care and public health (rationale, components)

Answer 2

• A public health approach can be leveraged to improve access and ensuring programs are economically viable and sustainable in mid/low income countries

Components:

1. Appropriate policies
2. Adequate drug availability
3. Education for healthcare providers and the public
4. Implementation of palliative care services at all levels in society

Question 3

Ways to improve advocacy for palliative care

Answer 3

• Articles and real life stories in newspapers, on TV and the Internet
• Inviting key decision makers and celebrities/influencers to Palliative Care Day celebrations
• Public awareness programs
• Involving public figures who have encountered PC as ‘mascots’
• Involving corporate organizations, clubs, and professional associations to support PC as a worthy cause
• Teaching PC and related matters in scohol and college education
• Training palliative care workers

Question 4

Grass roots implementation of a palliative care program

Answer 4

1. Needs assessment
   - Who needs PC
   - What are the problems
   - What help are they getting, what is available and what is not
   - What can be added to improve care?
2. Strategy
   - What is already available and what is not?
   - What is the most appropriate setting to begin work in?
   - Which locally appropriate models can we visit/learn from?
   - Is there an existing organization that can take on any part of this?
3. Education
   - Trained doctor and nurse?
   - Volunteers to act as the link between patients and HCPs?
   - How will we empower families to care for patients?
   - Are colleagues sufficiently educated to make appropriate referrals to us?
   - Does the public under stand the benefit of PC?
4. Drug availability
   - Are we able to procure strong opioids (particularly inexpensive morphine preparations?)
   - How much drug do we need to stock?
   - How much free treatment can be provided?
   - Is there enough money for an uninterrupted supply of drugs?
5. Implementation
   - Have we made a practical action plan with short, medium, and long term goals?
   - Deadlines for drug availability and educational activities?
   - Reviews scheduled?
   - Outcome measures?

Question 5

Components of a public health approach to palliative care

Answer 5

1. Government policy ensuring integration with other health services
   - Note Canada has a national strategy with a public evaluation strategy
   - Five working groups to coordinate it, including best practices and quality care, education, public information/awareness, research, and surveillance
2. Education policy spanning healthcare workers (including volunteers) and the public
3. Medication policy ensuring the availability of essential medications

Question 6

Ethnicity - definition

Answer 6

• Reflects the social grouping of people on the basis of historical or territorial identity or by shared cultural patterns and traditions maintained between generations
• May include language (e.g. Hispanic peoples) or shared ancestory (e.g. African Nova Scotians) rather than simply geography

Question 7

Race - definition

Answer 7

• Relies upon perceived biological differences between people and populations
• Largely based upon superficial physical characteristics (e.g. facial features, hair colour, skin colour)

Question 8

Culture - definition

Answer 8

• Patterns, explicit and implicit, of and for behaviour acquired and transmitted by symbols, language, and rituals
• A ‘recipe’ for living in the world
• Not static, rather in a constant process of adaptation

Question 9

Possible explanations to account for under-utilization of palliative care among black and minority ethnic groups

Answer 9

1. Attitudes to palliative care
   - Reduced receptivity to PC on the basis of associations with palliative care
   - E.g. people only go to the hospital to die
2. Ethno-centralism
   - Demand for service can be influenced by the ‘ethnocentric’ outlook of palliative care services that discourages black/minority ethnic groups from engaging
3. Awareness
   - Lack of awareness of services available (magnified by poverity)
4. Social deprivation
   - Low SES associated with increased likelihood of hospital death
5. Dissastisfaction with healthcare
   - Lower utilization of all healthcare services on the basis of disatisfaction
6. Mistrust
   - Lack of trust of the physicians discussing end of life care
   - Particularly relevant for advance care planning
7. Gatekeepers
   - HCPs may be less likely to make a referral for a minority ethnic group

Question 10

Cultural aspects of pain

Answer 10

1. Not all social or cultural groups respond to pain in the same way
2. How individuals perceive and respond to pain (in self and others) can be influenced by cultural background
3. How and whether patients communicate their pain to their HCP and others can be influenced by cultural factors
   - E.g. underlying stoicism, believe that pain is an inevitable part of illnes and to be accepted