improving palliative care at a global level
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Improving Palliative Care at a Global Level. Kathleen M. Foley, MD Patient Advocacy Meeting Budapest June 29-30,2009. 2002 WHO Definition of Palliative Care - PowerPoint PPT PresentationTRANSCRIPT
Improving Palliative Care at a Global Level
Kathleen M. Foley, MDKathleen M. Foley, MDPatient Advocacy MeetingPatient Advocacy Meeting
BudapestBudapestJune 29-30,2009 June 29-30,2009
2002 WHO Definition of 2002 WHO Definition of Palliative CarePalliative Care
"Palliative care is an approach which improves quality of life of patients and their families facing 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"
Palliative Care as a Public Palliative Care as a Public Health IssueHealth Issue
affects all peopleaffects all people need for better information on need for better information on
end-of-life careend-of-life care potential to prevent sufferingpotential to prevent suffering potential to prevent diseasepotential to prevent disease
Palliative Care as a Palliative Care as a Prevention ModelPrevention Model
prevents needless sufferingprevents needless suffering provides peer educationprovides peer education provides patient centered careprovides patient centered care incorporates self-management incorporates self-management
programsprograms
The continuum of palliative The continuum of palliative carecare
Diagnosis Death
Therapies to modify disease(curative, restorative intent)
Actively Dying
BereavementCare
Life Closure
Therapies to relieve suffering, improve quality of life
6m
EducationEducation
ImplementationImplementation
DrugAvailability
DrugAvailability
WHO Public Health WHO Public Health ModelModelWHO Public Health WHO Public Health ModelModel
PolicyPolicyPolicyPolicy
Context
Context
Outcomes
Outcomes
EducationEducation
ImplementationImplementation
DrugAvailabilit
y
DrugAvailabilit
y
WHO Public Health WHO Public Health ModelModelWHO Public Health WHO Public Health ModelModel
PolicyPolicyPolicyPolicy
Context
Context
Outcomes
Outcomes
EducationEducation
ImplementationImplementation
DrugAvailability
DrugAvailability
WHO Public Health WHO Public Health ModelModelWHO Public Health WHO Public Health ModelModel
PolicyPolicyPolicyPolicy
Context
Context
Outcomes
Outcomes
0
10
20
30
40
50
60
70
Denm
ark
Austri
a
Icela
nd
Franc
e
Norway
Sweden
Switzer
land
Luxe
mbo
urg
Unite
d Kin
gdom
Gibr
altar
Irelan
d
Belgiu
m
Nethe
rland
s
Ger
man
y
Spain
Slove
nia
Polan
d
Czech
Rep
ublic
Finlan
dIta
ly
Eston
ia
Hunga
ry
Bulga
ria
Slova
kiaM
alta
Lith
uani
a
Roman
ia
Latv
ia
Andor
ra
Croat
ia
Ukrai
ne
Yugos
lavia
Gre
ece
Belar
us
Alban
ia
Turke
y
Mac
edon
ia
Consumption of Morphine in Europe Consumption of Morphine in Europe mg/capita, 2001mg/capita, 2001
Source: International Narcotics Control Board; United Nations Demographic YearbookSource: International Narcotics Control Board; United Nations Demographic YearbookBy: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2004By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2004
Mg/capitaMg/capita
UkraineUkraine1.3 mg/capita1.3 mg/capita
Global meanGlobal mean5.4 mg/capita5.4 mg/capita
Sources: International Narcotics Control Sources: International Narcotics Control Board; United Nations population dataBoard; United Nations population dataBy: Pain & Policy Studies Group, By: Pain & Policy Studies Group, University of Wisconsin/WHO University of Wisconsin/WHO Collaborating Center, 2008Collaborating Center, 2008
2006 Global 2006 Global Consumption of Consumption of MorphineMorphine
0
20
40
60
80
100
120
140
160
154 Countries
Global mean, 5.9847 mgCOUNTRY Mg/capita
Albania 0.4644
Armenia 0.8187
Georgia 1.8200
Hungary 2.1643
Moldova 1.0331
Romania 0.0837
Serbia 0.1339
Ukraine 1.7845
HungaryHungary
MoldovaMoldova
AlbaniaAlbania RomaniaRomania
SerbiaSerbiaArmeniaArmenia
UkraineUkraine
GeorgiaGeorgia
Sources: International Narcotics Sources: International Narcotics Control Board; United Nations Control Board; United Nations population data By: Pain & Policy population data By: Pain & Policy Studies Group, University of Studies Group, University of Wisconsin/WHO Collaborating Center, Wisconsin/WHO Collaborating Center, 20082008
EURO Consumption of Morphine, EURO Consumption of Morphine, 20062006
0
20
40
60
80
100
120
140
160
180
Aust
ria
Denm
ark
Fran
ce
Portu
gal
Norw
ay
Switz
erlan
d
Icela
nd
Unite
d Kin
gdom Swed
en
Slove
nia
Slova
kia
Germ
any
Belg
ium
Gibr
altar
Irela
nd
Neth
erlan
ds
Luxe
mbou
rg
Bulga
ria
Czec
h Re
publi
c
Israe
l
Polan
d
Esto
nia
Spai
n
Finlan
d
Malta Italy
Lithu
ania
Ando
rra
Hung
ary
Cypr
us
Latvi
a
Geor
gia
Ukra
ine
Croa
tia
Rep.
of M
oldov
a
Arm
enia
Bela
rus
Gree
ce
Alban
ia
Russ
ian F
eder
ation
Azer
baija
n
Serb
ia
Uzbe
kistan
Kyrg
yzsta
n
Roma
nia
Turkm
enist
an
Mace
donia Turke
y
EURO mean, 12.5917 mg Global mean, 5.9847 mg
COUNTRY Mg/capita
Albania 0.4644
Armenia 0.8187
Georgia 1.8200
Hungary 2.1643
Moldova 1.0331
Romania 0.0837
Serbia 0.1339
Ukraine 1.7845
GeorgiaGeorgia
HungaryHungaryUkraineUkraine
MoldovaMoldova
AlbaniaAlbaniaRomaniRomaniaa
SerbiaSerbiaArmeniaArmenia
World Health Assembly Cancer Prevention and Control 58.22
25 May 2005
Urges member states to ensure the medical availability of opioid analgesics
Requests the WHO Director General (1) to explore mechanisms for funding cancer prevention, control and palliative-care, especially in developing countries.
(2) to examine with the International Narcotics Control Board how to facilitate the adequate treatment of pain using opioid analgesics.
INCB Annual Report for 2004
March 2005
““In view of the continued inadequate global In view of the continued inadequate global consumption of opiates for the treatment of consumption of opiates for the treatment of pain, the Board reiterates that it would pain, the Board reiterates that it would welcome a further increase in global demand welcome a further increase in global demand for opiates. The Board encourages for opiates. The Board encourages Governments to take steps to increase the Governments to take steps to increase the medical use of opiates in their countries in medical use of opiates in their countries in order to meet their real needs for the treatment order to meet their real needs for the treatment of pain.”of pain.”
WHO Access to Essential Medicines Program
Created an office for controlled Created an office for controlled substances as essential medicinessubstances as essential medicines
Appointed Willem Scholten as Appointed Willem Scholten as program directorprogram director
To develop a strategic plan with NGO To develop a strategic plan with NGO partnershipspartnerships
WHO Access to Essential Medicines
Program To focus on low and medium To focus on low and medium
resource countriesresource countries To support pain and palliative To support pain and palliative
care as a human rightcare as a human right
Publications on International Publications on International Palliative Care Issues Palliative Care Issues
Journal of Pain and Symptom Journal of Pain and Symptom Management Volume 33 ,Number 5 Management Volume 33 ,Number 5 May, 2007: Advancing Palliative Care: May, 2007: Advancing Palliative Care: The Public Health PerspectiveThe Public Health Perspective
Health Economics and Palliative care; Health Economics and Palliative care; What We Know and What We Need to What We Know and What We Need to Know. In press, 2008 Know. In press, 2008
World Cancer Declaration 2008World Cancer Declaration 2008
Outlines the critical steps needed to build the Outlines the critical steps needed to build the basis for sustainable delivery of effective basis for sustainable delivery of effective cancer prevention, early detection, treatment cancer prevention, early detection, treatment and palliative care worldwideand palliative care worldwide
World Cancer Summit, Geneva,2008World Cancer Summit, Geneva,2008
World Cancer Declaration World Cancer Declaration 20082008
Based on: Based on:
Article 25 of the Universal Declaration of Article 25 of the Universal Declaration of Human Rights declares that “everyone Human Rights declares that “everyone
has has the right to a standard of living, adequate the right to a standard of living, adequate for health and well being for himself and for health and well being for himself and
his his family, including medical care.”family, including medical care.”
7. 7. many more cancer patients in pain will have many more cancer patients in pain will have access to effective pain control measuresaccess to effective pain control measures
2020 Goals2020 Goals
7. the number of cancer patients with access to 7. the number of cancer patients with access to appropriate treatment, rehabilitation and palliative care appropriate treatment, rehabilitation and palliative care in adequately equipped treatment facilitiesin adequately equipped treatment facilities
9. the number of cancer patients in pain worldwide 9. the number of cancer patients in pain worldwide that have access to effective pain controlthat have access to effective pain control
Intermediate TargetsIntermediate Targets
3030
Strategies for the advancement of Palliative
Care as a Human Right
Submission to the committee ICESCRSubmission to the committee ICESCR Submission to the office of the Special Rapporteur Submission to the office of the Special Rapporteur
to the UN Human Rights Commission on the right to to the UN Human Rights Commission on the right to healthhealth
Promotion of an International Convention on PainPromotion of an International Convention on Pain Encourage human rights organizations to become Encourage human rights organizations to become
involved in advocacy for palliative careinvolved in advocacy for palliative care Use current declarations (Cape Town, Korea, Use current declarations (Cape Town, Korea,
Budapest) as advocacy tools with your governmentBudapest) as advocacy tools with your government
www.equalpartners.info
In this 47-page report Human Rights Watch said that countries could In this 47-page report Human Rights Watch said that countries could significantly improve access to pain medications by addressing the causes of significantly improve access to pain medications by addressing the causes of their poor availability. These often include the failure to put in place their poor availability. These often include the failure to put in place functioning supply and distribution systems; absence of government policies functioning supply and distribution systems; absence of government policies to ensure their availability; insufficient instruction for healthcare workers; to ensure their availability; insufficient instruction for healthcare workers; excessively strict drug-control regulations; and fear of legal sanctions among excessively strict drug-control regulations; and fear of legal sanctions among healthcare workers.healthcare workers.
Access to Pain Treatment as a Human Access to Pain Treatment as a Human RightRight
““Please , do not make us Please , do not make us suffer anymore…….”suffer anymore…….”
http://www.hrw.org/en/reports/2009/03/02/please-do-not-make-us-suffer-any-morehttp://www.hrw.org/en/reports/2009/03/02/please-do-not-make-us-suffer-any-more
Promoting Hospice & Palliative Care Worldwide
IAHPC 2006
Developed essential drug list for Developed essential drug list for palliative carepalliative care
Drafted WHO monograph on palliative Drafted WHO monograph on palliative carecare
Sponsors international faculty Sponsors international faculty scholars awardscholars award
Sponsored 2006 Venice Declaration o Sponsored 2006 Venice Declaration o the need for research in palliative the need for research in palliative care.care.
Joint Declaration and Statement Joint Declaration and Statement of Commitment: Palliative Care of Commitment: Palliative Care and Pain Treatment as Human and Pain Treatment as Human Rights Rights
Project coordinated by the IAHPC and Project coordinated by the IAHPC and WPCA sign on at WPCA sign on at www.hospicecare.comwww.hospicecare.com
IAHPC List of Essential IAHPC List of Essential MedicinesMedicines
34 medications are listed34 medications are listed 14 medications currently on the 14 medications currently on the
existing WHO Essential Listexisting WHO Essential List
IAHPC List of Essential IAHPC List of Essential MedicinesMedicines
Global Access to Pain Relief Global Access to Pain Relief InitiativeInitiative
Supported by International Union Supported by International Union Against Cancer (UICC)Against Cancer (UICC)
-global advocacy initiative-global advocacy initiative
-raise awareness for policy change-raise awareness for policy change
-focus on cancer patients-focus on cancer patients
Dr. Simbo Daisy Amanor-Boadu
Nigeria
Prof. Snežana Bošnjak
Serbia
Prof. Rosa Buitrago Republic of Panama
Mrs. Nguyen Thi Phuong Cham
Vietnam
Dr. Henry Dr. Henry DdunguDdungu
UgandaUganda
Dr. Jorge Dr. Jorge EisenchlasEisenchlas
ArgentinaArgentina
Dr. Marta Dr. Marta Ximena LeónXimena León
ColombiaColombia
Mr. Gabriel Mr. Gabriel MadiyeMadiye
Sierra LeoneSierra Leone
2006 International Pain Policy Fellowship
Pain & Policy Studies Group
University of Wisconsin
October, 2006 Madison, Wisconsin
Supported by the
Open Society Institute
To provide research-based information on palliative care in the global context
To disseminate this information through the Observatory website and through other means
To undertake primary research studies to generate such information
To support academic work in resource poor regions
To work in partnership with key organisations and individuals
IOELC Aims
Monitoring—Opioid Monitoring—Opioid ConsumptionConsumption
Grants FundedGrants Funded
The Romania ProjectThe Romania Project
WHO workshop in Budapest (2002)WHO workshop in Budapest (2002)(Bulgaria, Croatia, Hungary, Lithuania, Poland, Romania)(Bulgaria, Croatia, Hungary, Lithuania, Poland, Romania)
Prescribing severely restricted in RomaniaPrescribing severely restricted in Romania
–- - Complicated forms and authorizationsComplicated forms and authorizations
– Dose and time limits; no flexibilityDose and time limits; no flexibility
– For incurable cancer, not for HIV/AIDSFor incurable cancer, not for HIV/AIDS Many patients die before obtaining morphineMany patients die before obtaining morphine 35 year-old anti-narcotics law and regs35 year-old anti-narcotics law and regs Ministry of Health appointed a CommissionMinistry of Health appointed a Commission New statute sent to Parliament July 2005New statute sent to Parliament July 2005 New regulations to be finalized in 2006New regulations to be finalized in 2006
WHO Workshop,Budapest 2002
Change is possible if we work together
Progress in Europe
1.1. FranceFrance: : 7 days7 days 28 days28 days
2. 2. ItalyItaly: : 8 days8 days 1 month; 1 month; Rx simpl.Rx simpl.
3. 3. GermanyGermany: : 1 day1 day no limit no limit
4. 4. PolandPoland: : 100 mg100 mg 4.0 grams4.0 grams
5. 5. Romania:Romania: 3 days3 days 30 days30 days
Mongolia Pain Relief &Mongolia Pain Relief &Palliative Care InitiativePalliative Care InitiativeMongolia Pain Relief &Mongolia Pain Relief &
Palliative Care InitiativePalliative Care Initiative
MongolianMinistry of Health
MongolianPalliative Care
Society
WorldHealth Organization
Education . . . Education . . .
2001-5:2001-5: 400 doctors, 600 nurses 400 doctors, 600 nurses sensitized sensitized
(MPCS – Odontuya, OSI )(MPCS – Odontuya, OSI )
2004:2004: Established regional training center, Established regional training center, regular journal (MPCS – OSI )regular journal (MPCS – OSI )
2004: 2004: Palliative care recognized as medical Palliative care recognized as medical discipline (3 months CAQ )discipline (3 months CAQ )
2005:2005: State University of Ulaanbaater adds State University of Ulaanbaater adds palliative care to medical palliative care to medical
curriculumcurriculum
PolicyPolicy
2002:2002: Leadership conference - workgroupsLeadership conference - workgroups2004:2004: Follow-up conference – policies, Follow-up conference – policies,
Rx rules change – Palliative care Rx rules change – Palliative care included in national health planincluded in national health plan
2005:2005: Standards for palliative careStandards for palliative care2006-9:2006-9: National Health PolicyNational Health Policy Develop Develop
guidelines, train professionals, guidelines, train professionals, Establish MD Teams all aimags, districtsEstablish MD Teams all aimags, districts
2006+: 2006+: Develop National Cancer ControlDevelop National Cancer Control Policy Policy
Prescribing OpioidsPrescribing Opioids
2002: 2002: Only oncologists RxOnly oncologists Rx
10 tabs or amps per Rx per 3 10 tabs or amps per Rx per 3 daysdays
2005:2005: Any doctor can Rx, Any doctor can Rx,
Amount needed for 7 daysAmount needed for 7 days
ImplementationImplementation
2000:2000: NCC – 10 bed PCU (OSI )NCC – 10 bed PCU (OSI )
2002:2002: NCC – PCU NCC – PCU to 16 beds ( MOH ) to 16 beds ( MOH )
2002-present: 2002-present: 4 hospices in UB4 hospices in UB
2006:2006: 20 General Oncologist start20 General Oncologist start community palliative care networkcommunity palliative care network
around aimag and district around aimag and district hospitals hospitals
( each will have 2-5 PC beds( each will have 2-5 PC beds ) )
The Ocean Road Cancer Institute The Ocean Road Cancer Institute Palliative Care Centre, TanzaniaPalliative Care Centre, Tanzania
WHO Community Health Approach to Palliative Care for HIV and Cancer Patients in
Africa
Model Initiative in Providing Palliative Care
Uganda Ministry of Health included palliative care in its National Health Sector Strategic Plan
Uganda developed and funded an essential drug program and changed restrictive laws to allow oral morphine in home-based settings
Policy Initiative Policy Initiative ExamplesExamples
Hungarian ExperienceHungarian Experience– IPCI sponsored Policy Conference resulted IPCI sponsored Policy Conference resulted
in Hungarian Health Insurance Fund in Hungarian Health Insurance Fund sponsoring a pilot program to develop six sponsoring a pilot program to develop six model palliative care programsmodel palliative care programs
– Palliative care has been included in the Palliative care has been included in the National Cancer Control ProgramNational Cancer Control Program
– The MOH has committed to develop The MOH has committed to develop palliative care services in all regions in palliative care services in all regions in the country by 2010the country by 2010
Not-for-profit, non-governmental organizationNot-for-profit, non-governmental organization Founded 1998 by International Union against Cancer Founded 1998 by International Union against Cancer
(UICC) & Institut Pasteur, Brussels(UICC) & Institut Pasteur, Brussels National Cancer Institute (NCI) assists by providing National Cancer Institute (NCI) assists by providing
financial, technical & intellectual support financial, technical & intellectual support Located at Institut Pasteur, BrusselsLocated at Institut Pasteur, Brussels Branches in USA, France, Egypt & NepalBranches in USA, France, Egypt & Nepal Offices in UK, Brazil, India & Tanzania Offices in UK, Brazil, India & Tanzania
ADVANCING PALLIATIVE CARE INTERNATIONALLY
World Health OrganizationGeneva - WHO Cancer Unit Europe – WHO Aging Program
UN AIDS Global Fund for TB, Malaria & AIDS PEPFAR European Union European Parliament Council of Europe
ADVANCING PALLIATIVE CARE INTERNATIONALLY (NGO’s)
International Association of Hospice and Palliative Care
Help the Hospices OSI’s International Palliative Care Initiative National Hospice and Palliative Care
Organization
ADVANCING PALLIATIVE CAREINTERNATIONALLY (NGO’S)
International Psycho-oncology Society (IPOS)
European Federation of IASP Chapters (EFIC)
European Society of Medical Oncology (ESMO)