At what point should palliative care be integrated into MDR-TB care?

Francis Varaine, MSF

WHO, Geneva 18th November 2010

Palliative care in MDR TB

• Palliative care : various definitions, various concepts

• Palliative care in MDR TB : proposition for discussion

Palliative care in MDR TB

No mention of palliative care in DR TB guidelines :   « Supportive care for patients in whom all the possibilities of MDR-TB management have failed »

«Palliative care should be offered to all MDR TB patients who no longer qualify for active treatment to ensure that those who are no longer capable of being treated are permitted to live out their life with

minimal suffering and loss of dignity. » Apocalypse or redemption: responding to extensively drug-resistant tuberculosis Ross Upshur, Jerome Singh & Nathan Ford Bulletin of the World Health Organization 2009;87:481-483. doi: 10.2471/BLT.08.051698

«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»

http://www.who.int/cancer/palliative/definition/en/

WHO: Palliative care (cancer)

Palliative care for children is the active total care of the child's body, mind and spirit, and also involves giving support to the family.

– It begins when illness is diagnosed, and continues

regardless of whether or not a child receives treatment directed at the disease. […]

– It can be provided in tertiary care facilities, in community health centres and even in children's homes.

http://www.who.int/cancer/palliative/definition/en/

WHO: Palliative care for children (cancer)

Differs across sources

• «The specialised care of people who are terminally ill.»Australian Institute of Health and Welfare. 2008

• « The active total care of patients whose disease is not responsive to curative treatment »

• «The active holistic care of patients with advanced progressive illness.»

NICE www.ncpc.org.uk/palliative_care.html

• «The active holistic care delivered to a person suffering of a progressive or terminal serious disease.»

Société Française d’accompagnement et de soins palliatifs

Palliative Care complements and enhances antiretroviral treatment (ART), going beyond medical disease management to address symptoms and minimize suffering.

It begins with the HIV-positive diagnosis and extends though the end of life, using a family-centered approach.

The U.S. President's Emergency Plan for AIDS Relief 2009. http://www.pepfar.gov/press/84749.htm

Palliative care in HIV-AIDS

Shifting paradigm?

• Beneficial outcomes of a simultaneous care model that provides both palliative care and disease-specific therapies beginning at the time of diagnosis.

• The new approach recognizes that lifethreatening illness, whether it can be cured or controlled, carries with it significant burdens of suffering for patients and their families and that this suffering can be effectively addressed by modern palliative care teams. […] Reducing patients’ misery may help them live longer. […] Palliative care (should be) an essential and routine component of evidence-based, high-quality care for the management of serious illness.

Palliative Care — A Shifting Paradigm, Amy S. Kelley, M.D., M.S.H.S., and Diane E. Meier, M.D. Early Palliative Care for Patients with Metastatic Non–Small-Cell Lung Cancer. Jennifer S. Temel,et al. N Engl J Med 363;8 NEJM.org august 19, 2010

Proposition for discussionMDR TB: Cure rate 45%, Death: 16%, Failure 7%, Default 22%*Treatment causes frequent and severe side effects

Palliative care for MDR TB

• Should begin at the time of the diagnosis

• Is not limited to– Patients who do not respond to active treatment – Patients who no longer qualify for active treatment

• Includes but is not limited to «end of life care»

Unpublished meta-analysis. 9280 patients. Benedetti, Bauer, Menzies et alRevision of WHO DTB guidelines 2010