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Written by Davinia Seah, Christine Drummond, and Dr Odette Spruijt for ANZSPM

Case study

We met Rani on a ward round at the Indian regional cancer centre during our Hamrahi week-long visit. Rani was a 54-year-old woman with widespread inoperable bowel cancer. She had been admitted several days prior with severe abdominal pain and was still very distressed, in terrible pain and vomiting uncontrollably, unable to tolerate anything orally. Her husband, who was with her in the hospital, was feeling helpless and was crying during the ward round. With the hospital team, we were able to conduct a quick but comprehensive assessment that confirmed a bowel obstruction. The team had not previously examined Rani and we encouraged them to do an ongoing assessment and try to identify precipitating or contributing factors that might be reversible. We explained to Rani, her family, and her doctors, that she needed to be temporarily nil by mouth, and what medications might be used to treat her bowel obstruction. We were able to teach the hospital staff how to manage a malignant bowel obstruction using subcutaneous fluids rather than intravenous, which was difficult to maintain in that setting. Under our guidance, the team also started an infusion of subcutaneous medications. By the end of the consultation, Rani’s husband expressed profound gratitude for the concern and care his wife was now receiving from the team. The next day, Rani had improved significantly. She was able to speak clearly to the team and her vomiting had stopped. She was tolerating small amounts of water and her abdominal pain was relieved.

UNFORTUNATELY, this scenario of unnecessary suffering due to a lack of knowledge and skills in palliative care happens often in many parts of India and in low-and-middle-income countries (LMIC) across the world. Many health professionals have not been exposed to palliative care training and fail to recognise their potential ability to alleviate the suffering of patients such as Rani. While these situations also occur in high-income countries, they are much more common in the LMIC setting globally.

Only 14% of the global population has access to fully integrated palliative care. Each year, an estimated 40 million people worldwide need palliative care, of whom 78% reside in LMIC. In India, where palliative care began about 30 years ago, an estimated 5.4 million people need palliative care, but less than 1% can access it.

APLI was established as a non-government organisation in 1996 and is registered as a charity in Australia. APLI aims to raise awareness of palliative care through teaching, advocacy, mentoring and supporting palliative care health care professionals in LMIC in the Asia Pacific region.

APLI mentors are Australian and New Zealand healthcare providers from all disciplines who volunteer their time, energy, and expertise to work alongside colleagues in palliative care services across the Asia-Pacific. In India, services are identified by Pallium India, a World Health Organization Collaborating Centre for Policy and Training on Access to Pain Relief based in Trivandrum, Kerala. Pallium India aims to catalyse the development of effective pain relief and quality palliative care services and their integration in health care across India through the delivery of services, education, building capacity, policy, research, advocacy, and information. Many Indian nationals have completed their palliative care foundation courses and are supported in their development by Pallium India’s regional coordinators.

Rita Rani and team from Mahavir Cancer Sansthan, Patna, Bihar presented at ECHO Hamrahi session on
‘Opioid Availability’ in February 2022

APLI and Pallium India established Project Hamrahi (Fellow Traveller) in 2010 to foster links between palliative care doctor/nurse teams from Australia and new teams in India. It aims to support the development of fledgling palliative care services in India. Volunteers are given the opportunity to work in a different culture and better understand the challenges faced by colleagues in those countries. It strengthens regional relationships and enriches practice in both linked countries.

Prior to the COVID-19 pandemic, APLI mentors would make annual in-country visits to participating sites, accompanied by Pallium India regional coordinators whenever possible. Given international border restrictions, and in response to our evaluation of Project Hamrahi in 2020, our most recent efforts have turned to the use of the ECHO® (Extension for Community Healthcare Outcomes) model to continue the Hamrahi connection and create an Australia-India community of palliative care practice. Hamrahi participants requested more frequent interactions and identified education topics of importance to their day-to-day practice. ECHO Hamrahi began in December 2021 and conducts monthly 90-minute ECHO sessions; the format is an opening presentation on a requested topic, delivered by either an Australian or Indian practitioner, followed by a case or service presentation from an Indian service and one from an Australian mentor/team. The most recent sessions focused on Opioid Availability in India, Falls and Frailty, and Quality Improvement in Palliative Care.

As fellow palliative care physicians, we urge you to consider making a difference in the world of palliative care today. Even though we see gaps in service provision in Australia and New Zealand, we enjoy much better access than most of our near neighbours in the Pacific andbeyond.

Please consider supporting the work of APLI and ECHO Hamrahi through donations, becoming an APLI member, or even by volunteering to be a virtual presenter or participant in one of the ECHO Hamrahi sessions. All levels of experience are welcome as the group is run by a multidisciplinary team of volunteers. Your donation and membership fees received are used to support projects such as ECHO and are tax deductible.

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