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