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Palliative Care on the Move in Northern Province, Sri Lanka

News from Dr Ranjan Mallawaaarachchi, Founder and Coordinating secretary, Regional Association of Palliative Care, Northern Province. Consultant OMF surgeon, District General Hospital, Vavuniya and Teaching Hospital, Jaffna, Sri Lanka.

Dr Rangan Mallawaraachchi

Back ground information

The concept of palliative care is very new for Sri Lanka, with significant developments starting in 2013. This is true for the northern province. This province is one of 9 provinces in SL, and has 5 districts, including Vavuniya. The teaching hospital for the northern province is in Jaffna district, with a district general hospital in each of the other districts. Vavuniya District General Hospital is the second largest hospital in the province, has 20 consultants including pathologist, radiologist, anaesthetist, and Oral Maxilla Facial surgeon who serves the whole of the northern province. Daily, 800 people attend the hospital outpatient department and in my OMF clinic, 1000 patients attend per month.

My interest in palliative care arose as most of my oral/pharyngeal and other head and neck cancer patients present with Stage 3 or 4 disease. Meeting Dr Suharsha Kanathigoda was a turning point in my life and led me to explore the world of palliative care. Currently, there is not one palliative care specialist in SL, many doctors and nurses have misconceptions about opioids, opioid availability was minimal and policies resulted in restriction of availability of opioids for medical use.

The following initiatives have occurred in the northern province to date:
• Establishing the MDT discussion focussed on palliative care
• Establishment of palliative care clinic (H&N oncology)
• Forming the palliative care data collecting centre and referring centre
• Developing H&N oncological hospice, Cheddiculum Base Hospital, Vavuniya, Sri Lanka
• Learning and study in the field of palliative care
• Teaching doctors, medical students, nurses, nursing officers and allied health workers, through workshops
• Started to do small studies such as audits and research
• Founding the regional association of palliative care for the northern province
• Collaborative work with other institutions, professional bodies, agencies who are in the field of palliative care locally and internationally
• Started to sensitize peoples’ hearts, through an awareness program for non-medical people (corporate sector)
• Started home based palliative care services in northern province
• Establishment and strengthening of the hospital based palliative care services
• Promoting palliative care by directing and filming a documentary on palliative care
• Launching the web profile for education, awareness, and teaching in palliative care

Establishing the MDT and role at the General Hospital, in Vavuniya

At this meeting, both  non-oncological and oncological cases are discussed. The team consists of OMF surgeon, oncologist, radiologist, pathologist, pediatrician, psychiatrist, anesthetist, ENT surgeon, physician, general surgeon. Other members of the palliative care team may participate. Each case is discussed in detail in front of the patient and family. Social  issues are explored by the palliative care nurses and bring some solutions.  The  patient is categorized as for home-based, hospital-based or end-of-life care. Home-based palliative care cases are being referred to palliative care collecting centre , OMF unit, General Hospital, Vavuniya.

 

2015 MDT discussions

 

Patient examples (consent was given to publish these photos)

patient-1 patient-2 patient-3 patient-4 patient-5

 

Establishing the Hospital-Based palliative care service at General Hospital, Vavuniya

Initiatives include implementing a pain assessment and management chart  with a ward policy that this is started on every patient admitted.

 

Vavuniya

 

 

Education and training

This has been an important focus since our palliative care work commenced. We have conducted our first palliative care workshop attended by over 600 participants including medicine,  dentistry, allied health, councillors, students, volunteers and community workers. There were many local, national and international participants.

Vavuniya-3

Vavuniya-2

 Vavuniya nursing school, 22/12/2014

 

Cancer hospice in base hospital Cheddiculum ,Vavuniya

This will be the first head and neck cancer palliative house in Sri Lanka. The provincial government is directly involved in establishing this center. The plan is to have a palliative unit and hospice in Cheddikulum Base Hospital, Vavuniya with the support of north province health ministry, RDHS Vavuniya, PDHS, Shanthi Foundation Sri Lanka Cancer Care Association ,Sri Lanka Association of Palliative Care, and other charities. This will be free of charge to patients. It will provide long term care if needed. It will also be an education resource in palliative care practice for the region.

Research

Early research and audit reveals a lack of awareness about the use of opioids, a need for education about the management of patients with oral and pharyngeal cancers and a study of the mode of dying of patients with H&N cancers.

Community services

The Vavuniya region has the first ever palliative care nurses, some of whom are working in a voluntary capacity. Home visits by doctors and nurses in the team reveal the high level of poverty and suffering in this community.

Community

 

 

Mr .M is a 60 year old Muslim man with oral cancer. I operated on him about one year ago, followed by radiotherapy and chemotherapy treatment. Now he cannot open the mouth at all and able to swallow only liquids, with associated weight loss.

Mr M  Mr M-2

Mr M-3

 

 

Poverty and Pain

This elderly woman lived with her daughter in very poor conditions.  The roof of their hut leaked, the toilet was 50m away, there were two plastic chairs, water from the well was unhygienic and had high salt content. Her daughter’s fiancé was asking for a high dowry. She worried about her daughter’s future and not being there to  help her.

Poverty and Pain

 

Forming professional body and the association

I started the regional association of palliative care for the northern province. It was  launched on 13th March 2015.  Dr Kanathigoda,  Director of Shanti Foundation, and WHO are international  patrons. The National Cancer Control Program and Cancer Care Association, Sri Lanka, are national patrons.

Our association has an MOU with the Shanthi foundation of Australia, the Mental Health Society,  Vavuniya and rehabilitation  centre in Base Hospital, Cheddiculum.  It has close working relationships with the Palliative Care Association of Sri Lanka, as well as its national patrons.

Sensitization of the public

We made a documentary on palliative care which was released on the 18th March, 2015 in Vavuniya. 600 free DVD copies were given to the public. It can be viewed on you tube, search for “palliative care documentary , Sri Lanka” or on the official website of the Regional Association of Palliative Care, Northern Province ( www.rapcnp.com)

video

 

Future Plans

We hope to develop our knowledge through visits from and links to international experts, and conduct collaborative studies with international associations, professional bodies and institutions and palliative care specialists. Our dream is that Vavuniya hospice and palliative unit will become an international and local treating center for palliative care. We aim to expand home-based palliative care services to other parts of the country. We will continue to raise public awareness about palliative care and work with charities and  NGO’s to assist the welfare of our patients and  families.

 

Project Focus

As some of you may be aware, in early 2016 the Asia Pacific Hospice Palliative Care Network (APHN) held four ‘APHN Dialogs’, in which clinicians across the Asia Pacific region could link in through Skype to attend a webinar. The following webinars took place:

- A discussion of palliative care service development in the Asia Pacific region, presented by Odette Spruyt
- Pain control in palliative care by Yoshiyuki Kizawa from Kobe, Japan
- Management of the cancer wound by Edward Poon from Singapore
- Bereavement care by Jun-Hua Lee from Taiwan

These sessions were well received and provided a valuable opportunity for clinicians in different countries to learn from an expert in that field and also to share their own professional experiences. Unfortunately, not all countries in the region have reliable internet coverage or sufficient bandwidth so some attendees were unable to join the meetings. In response to this, in recent months APLI has been looking at a new educational initiative in partnership with APHN.

Project Focus aims to set up online discussion groups between palliative care clinicians in specific countries in the Asia Pacific region and APLI mentors. Some nascent palliative care centres struggle with isolation, limited practitioner experience and variable institutional support. In effect, Project Focus would work towards similar objectives to Project Hamrahi: to improve the capacity for best practice patient care in the local setting and to reduce the isolation of palliative care providers in emergent services.

APLI is therefore calling for expressions of interest for mentors to volunteer their services to help support our regional partners. Project Focus would particularly suit clinicians who might otherwise find it difficult to travel overseas for mentoring work, as the contact will be online using a small group discussion format on the ‘Slack’ communication platform. APHN has already identified local clinicians in two separate services in remote and regional Indonesia who would like to be partnered with APLI mentors. In addition to this, there has also been some interest from doctors in Vietnam, Brunei and Nepal whose learning needs were unable to be supported by the APHN Dialogs.

Although the exact process will be flexible, it is proposed that education would begin with case presentations from the local APHN clinicians. These would then serve as a springboard for the APLI mentors to explain current evidence based practice recommendations. The subsequent discussion would then take into account local factors such as medication availability, local resources, staffing and other factors such that a viable and culturally appropriate management plan can be formulated.

I hope that you will share our excitement for this initiative. Project Hamrahi has demonstrated the value of teams of mentors made up of both doctors and nurses working together with local Indian clinicians over a sustained period of time. Project Focus has the potential to broaden the scope of such partnerships to other countries and so I invite you to contact me via chairman@apli.net.au with a short biography and reflection on why you would wish to work as a mentor.

- Anil Tandon

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Your donations to APLI help in the following ways:

assist with training of doctors and nurses in palliative care practice in developing nations

support nurses to travel and teach as part of Project Hamrahi

help with purchase of critical site resources such as essential equipment and supplies,  medicines and educational materials