On 8th February, APLI and TIPS-India held their third ECHO Hamrahi session. The topic was Opioid availability in India with Dr Rajagopal, Pallium India as key speaker, followed by three speakers from across India, Drs Ali Azher, Thanal, Lakshadweep, Rita Rani from Mahavir Cancer Sansthan, Patna, Bihar and Iqbal Bahar, Cachar Cancer Centre, Silchar, Assam.

There were 22 participants, many from Pallium India team of regional coordinators across India.

After a review of the 2014 Amended NDPS law and related 2015 rules by Dr Rajagopal, there was discussion about why there were still so many districts across India which were still following the pre-2014 NDPS rules, despite it now being against the law to do so. Clinicians shared their struggles to obtain oral morphine for patients to continue outside the institutional walls and the push-back they encountered from regulatory authorities and, sadly, from colleagues who were poorly informed about safe opioid prescribing and management of severe cancer pain.

All three regional presenters were working in Registered Medical Institutions (RMIs) which were providing a continuous supply of oral and injectable opioids for their patients. Cachar Cancer Centre has had not interruption in supply for over three years. Thanal Lakshadweep has been established as an RMI since 2013 and is working to obtain direct supply of opioids rather than having to order via Kerala with all the resulting delays, often over three months. Advice was to order much longer supply to avoid stockouts and shortages, while also working toward establishing a more reliable supply chain.

For Bihar, we were all disturbed to hear that there are only two out of the 38 districts with RMIs and so the capacity to ensure that a supply of oral opioids is available to their patients. This translates to an enormous burden of unrelieved suffering. The population of Bihar is estimated at 127 million by 2020, the third largest state by population in India. The major care providers for palliative care are centered in Patna at Indira Gandhi Institute of Medical Sciences (IGIMS), Mahavir Cancer Sansthan, AIIMS Patna, and the Homi Bhabha Cancer Hospital and Research centre (HBCHRC), Muzaffarpur.

Dr Amal Kumar, Bihar State Drug Controller, attending Opioid Availability Workshop, IGIMS, 2018
Many institutions are still operating according to the pre 2014 Amended NDPS, effectively operating against the law in doing so. This was disappointing. I was personally present at a state-wide workshop held at IGIMS in 2018, co-conducted by the Pallium India, with Dr Rajagopal as keynote speaker. This was attended by the State of Bihar Drug Controller and clinicians from many hospitals in Patna and beyond. The change in the national law was clearly laid out and its implementation discussed in detail. However, despite the passage of 3 years, the situation remains largely unchanged with only four RMIs across the entire state.

However, Dr Rita Rani’s presentation on the progress at Mahavir Cancer Sansthan inspired us all. As well as establishing a palliative care team, ward, outpatient clinic and emergency palliative care area, MCS is working toward opening a large hospice centre, with 100 beds, to cater to the needs of the many patients who present with advanced, incurable cancer to that institution. This would be a very significant addition to the care of patients with cancer in Bihar. They have also run many IAPC sensitization courses for volunteers, and End of life nursing education consortium (ELNEC) course for nurses.

Challenges are many. For example, most doctors avoid prescribing oral morphine for fear of side effects and she estimates that 95% of cancer patients in Bihar have poorly managed pain. Dr Rita shared that many times her patients’ opioid management is ceased by other practitioners who put them back onto tramadol resulting in recurrence of severe pain. However, despite this, oral morphine 10mg tablet use at MCS has more than doubled since 2017, now up to 98254 tablets. So there is great cause for optimism that the care of people with severe cancer pain in Bihar will significantly improve thanks to the work of Dr Rani and her team.

Delirium in Palliative Care

Session 8
TIPS- APLI ECHO session
Faculty:

Gauri Godbole, Clinical Pharmacist (Aged and Palliative Care), Management of Delirium in Palliative Care

Dr Nisha Nadarajan, Palliative Care Advance Trainee, Presentation: Case presentation

Attendees: 23

The session started with a report on the recent evaluation of the program and topic requests from the survey respondents.

Gauri gave an excellent talk about the management of delirium in palliative care. She stressed the non-pharmacological approaches of re-orientation (including using hearing and visual aids), quiet and familiar surroundings and people, correcting dehydration or electrolyte disturbances, addressing anxiety and attempting to normalise the sleep-wake cycle. If medication is used, keeping to a minimum dose and frequency and assessing for adverse effects regularly, is advised.

Nisha’s case of an elderly, non-English speaking lady with osteopenic pelvic fractures, hypoxia from pneumonia, constipation and dehydration, and poorly controlled pain illustrated the complexity of managing delirium and the multiple co-contributing causes which are often present. We discussed the place of interventional procedures to manage her pain, the practical challenges of epidural insertion in a delirious patient and the way practice is influenced by what is possible and available in different settings, both across countries but also within countries and health services.

This was a wonderful night at the South Australasian Indian Medical Association gala dinner, who are fantastic supporters of APLI. Through ticket sales and auctions on the night, over $7000 was raised to support Project Hamrahi. APLI sincerely thanks the SAIMA organising committee for once again donating the proceeds to Hamrahi and to improving palliative care for patients across India.

Also a huge thanks to Christine Drummond, Maite Uribe, Seshu Boda, Chris Waples, and family and friends, for all you did to make this night a great success.

Dhanyavaad.

APLI interview conducted by Joan Ryan with Dr Ravi Kannan of the Cachar Cancer Hospital and Research Centre, which was screened at the gala dinner, along with a slideshow of images from Project Hamrahi.

Opioids for Cancer Pain

Dr Anil Tandon: Opioids for chronic cancer pain
Dr Mukul Mishra: Opioids and Palliative Care in Mahavir Cancer Sansthan, Patna

This 7th ECHO Hamrahi session saw us revisit issues of opioid prescribing for severe chronic cancer pain. Dr Tandon shared clinical tips from his experience as a Hamrahi mentor in several sites across India.

• Avoiding implementing the WHO pain ladder as if it is a stepladder upon which you start at the lowest rung and work up, is an important principle. The ladder was developed to provide clinicians with a simple strategy for prescribing analgesics according to intensity of pain. If pain is severe, then strong opioids plus non-opioids +/- non steroidal anti-inflammatory medications, are indicated as ‘first line’ analgesics. When strong opioids such as morphine are available, then there is little indication for weaker opioids in managing cancer related pain.
• The principle of double effect is over-stated in the textbooks and earlier literature. This ethical principle argues that if an action is morally good and the good effect is the intended effect, if the action also carriers a secondary effect which may involve shortening of life, that is acceptable. However, there is no evidence that patients are dying sooner because of careful effective pain management, proportionate to their pain severity and in keeping with their renal function and comorbidities.
• Respiratory depression occurs when opioid dose far exceeds the pain threshold or when other conditions (eg. renal failure) intervene.
• There is no ideal opioid for hepatic failure

Dr Mishra shared the story of palliative care development at Mahavir Cancer Sansthan in Patna, Bihar since 2018. The number of patients seen in the Palliative Care OPD has increased from 293 in 2018, to 1,054 in 2021. Opioids have been available at MCS since 2005 but prescribing has now started to increase, rising from 40,838 10mg tabs in 2017, to 98,254 tablets in 2021. However, prescribing of 30mg tablets has not increased greatly.

Statewide, 95% of cancer patients have poorly managed pain, due to lack of available opioids, lack of knowledge of health care professionals, opiophobia and fear of addiction. Bihar does not have a State Palliative Care policy but awareness raising is continuing with multidisciplinary workshops and lectures, community sensitization and recruitment of volunteers. There are plans to establish a training centre for palliative care in Patna, develop home based community services and a Diploma of Palliative Medicine.

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.

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.

Methadone in pain management

Didactic by Dr Sunil Kumar Mupliyath
Case presentation by Dr Jessica Mather-Hillon

Factors which make prescribing methadone stressful/difficult:

• Unfamiliarity with the drug
• Used for unstable patients with poorly controlled pain, in what may already be a stressful situation
• Toxicities and interactions
• Many potential drug interactions, which may increase or decrease bioavailability of methadone
• Long time to steady state which also varies according to age and hepatic function
• Complexities of converting from a different opioid to methadone, with conversion ratios changing as previous MEDD rise

However, developing expertise in prescribing methadone for pain management is important because:

• It can be used at a low dose as an adjuvant analgesic with actions beyond opioid receptors
• Therefore has a role in treating neuropathic pain, opioid poorly responsive pain, when opioid tolerance is diagnosed
• It is recommended for patients with severe renal impairment such as hepatic metabolism
• Once steady state reached, can dose twice a day, so effectively as a long acting opioid which is important when slow release morphine formulations are unavailable or too expensive.
• It is affordable
• If an institution has RMI, they can order methadone as well as morphine. NB RMI is not specific to any particular opioid. It allows institution to order any opioid.

The topic of the 5th ECHO Hamrahi session, taking place on the 12th of April, 2002, was QI in palliative care. After an introduction from Dr Odette Spruijt, various topics were presented by Dr Vidya Viswanath, Dr Anjum Joad and Dr Sunil Kumar.

Dr Odette Spruijt – Didactic

Introduction to the PC-PAICE/ EQUIP program, (Palliative Care – Promoting Assessment and Improvement of the Cancer Experience / Enable Quality, Improve Patient care – India ) established in 2017 by Stanford Uni.

This program had Stanford organisational and QI leaders and collaborators in India, as well as coaches from peer institutions in the US and Australia. It was the first cohort of seven leading palliative care programs in India. It subsequently developed with Tata Trusts and National Cancer Grid India, initiating a QI and educational hub led by Dr Nandini Vallath and Dr Sarbani Ghosh. The second cohort had seven sites during 2018 and 2019.

In 2019 it transitioned to Enable Quality, Improve Patient Care, India (EQUIP-India), led from Mumbai and expanded to palliative and oncology services. It continues the same methodology and incorporates culture-nuanced structure, processes, contents, evaluation and national mentoring capacity alongside international mentors.

Odette also reviewed of some of the QI tools taught to cohorts – A3 approach, Root cause analyses utilising Fishbone, GEMBA walks, Pareto charts, 2×2 charts, 5 ‘Whys’, and Run Charts to ‘tell the QI story’

Dr Vidya Viswanath – Homi Babha Palliative Care , Vizag, AP – Organising Home Care Services

• This was a QI project which aimed at improving home care system, recognising erratic home care visits with no system in place. They developed a SMART goal – to increase from 2-3 visits per week to 6 per week.
• Baseline Run Chart showed varied bt 0-4 visits.
• GEMBA walk most valuable – went to each person involved in the process of organising and conducting home visits, asked and observed their processes.

Achieved their SMART goal through two key interventions: development of software to categorise patients in need of home care vs OPD; received a grant to develop home care for city-based patients.

Dr Anjum Joad – BMCHRC, Jaipur, Rajasthan. COPE – Comprehensive Out Patient Evaluation

Their project was to improve documentation of comprehensive assessment of new outpatients on first visit to OPD, defined as completing seven assessment forms with a SMART goal to increase completion from 20 % to 75 % of patients by June 2019.

Project included root cause analyses using Fishbone, Pareto and 2 x 2 table to identify interventions which may have the greatest effect on driving change in the desired direction. The outcome was to develop one form which incorporated all the essential elements of assessment – called the 4S.

Dr Sunil Kumar – TIPS, Trivandrum, Kerala – City Homecare team, Relax! Protocols are ready for you

The third project, presented by Dr Kumar, aimed to improve staff satisfaction with the quality of home care services, from a satisfaction score of 5.82 to 7.6. The goal was maintaining appropriateness of registration process at 80% and improving triage process accuracy from 33% to 66%

The team developed seven interventions including algorithms and tools for triaging, dedicated phone follow-up processes, a Field Support Team, training and role-plays for service providers, brochures about the homecare service, clarifying purpose and scope, and systems to disseminate information. Each intervention was allocated to a dedicated staff member to implement and maintain. While this system has not continued according to the project, it has influenced ongoing service development and been adapted according to resources and learnings.

These were real world projects so all team results fluctuated with staff shortages and other resource issues. All agreed that participation in these QI programs resulted in great learning and examination of practice. Even when projects were not sustained, the learnings and impact on overall service quality improvement, reflective practice, new thinking and team engagement continued to influence and motivate participants.

Cachar Cancer Centre continues to be one of the most active sites attending the ECHO Hamrahi program. This time, it looked like the entire nursing team was present, alongside Sarita Chhetri, showing the great support for palliative care development at Cachar!

Following an excellent introductory lecture by Ms Rachel Coghlan, physiotherapist, we moved to hear about two cases which illustrated the importance of assessing frailty and risk of falls in this patient population.

Dr Priyanshu, physiotherapist from Homi Babha, supported by team psychologist and Dr Vidya, discussed the management of an 81-year-old woman with metastatic SCC oesophagus and breast cancer, presenting with multiple symptoms of dysphagia, breathlessness, fatigue and restricted mobility. Her palliative performance scale was 60%. She was increasingly dependent on her son and daughter-in-law for care, with some tensions arising in these relationships as a result. The team discussed her symptom management and the psycho-social care provided by team psychologist and others, to the patient and her caregivers. They presented a comprehensive care plan which summarised the interventions on the psychical, psychological, practical, anticipatory and decision-making domains.

There was active discussion about the types and value of various frailty assessment tools, and their integration into routine clinical care.

The second case presentation was led by Sarah Begley, palliative care clinical nurse consultant in Melbourne, with reflections on management of frailty from Joan Ryan, CNC Sydney, and Rachel Coghlan. Each discussed this from the perspective of a community care setting (Sarah), hospital consultancy (Joan) and from the physiotherapist perspective (Rachel). An interesting point was the judgement required to achieve an acceptable balance between safety and mobility risk reduction, and the patient’s goals and quality of life, which often involves some risk-taking.

The 4th ECHO Hamrahi session took place on 8th March 2022, the theme being “Frailty and falls in the palliative care setting”. The session was led by nursing and allied health members of the palliative care teams in Australia and India. There were 30 participants including several newcomers to Hamrahi from sites in the north and north east of India. We enjoyed hearing from Dr Nisha Nadarajan, palliative care advanced trainee, about her current audit of falls in Eastern Palliative Care service in Melbourne’s western suburbs.

Cachar Cancer Centre continues to be one of the most active sites attending the ECHO Hamrahi program. This time, it looked like the entire nursing team was present, alongside Sarita Chhetri, showing the great support for palliative care development at Cachar!

Following an excellent introductory lecture by Ms Rachel Coghlan, physiotherapist, we moved to hear about two cases which illustrated the importance of assessing frailty and risk of falls in this patient population.

Dr Priyanshu, physiotherapist from Homi Babha, supported by team psychologist and Dr Vidya, discussed the management of an 81-year-old woman with metastatic SCC oesophagus and breast cancer, presenting with multiple symptoms of dysphagia, breathlessness, fatigue and restricted mobility. Her palliative performance scale was 60%. She was increasingly dependent on her son and daughter-in-law for care, with some tensions arising in these relationships as a result. The team discussed her symptom management and the psycho-social care provided by team psychologist and others, to the patient and her caregivers. They presented a comprehensive care plan which summarised the interventions on the psychical, psychological, practical, anticipatory and decision-making domains.

There was active discussion about the types and value of various frailty assessment tools, and their integration into routine clinical care.

The second case presentation was led by Sarah Begley, palliative care clinical nurse consultant in Melbourne, with reflections on management of frailty from Joan Ryan, CNC Sydney, and Rachel Coghlan. Each discussed this from the perspective of a community care setting (Sarah), hospital consultancy (Joan) and from the physiotherapist perspective (Rachel). An interesting point was the judgement required to achieve an acceptable balance between safety and mobility risk reduction, and the patient’s goals and quality of life, which often involves some risk-taking.

There were 22 participants, many from Pallium India team of regional coordinators across India.

After a review of the 2014 Amended NDPS law and related 2015 rules by Dr Rajagopal, there was discussion about why there were still so many districts across India which were still following the pre-2014 NDPS rules, despite it now being against the law to do so. Clinicians shared their struggles to obtain oral morphine for patients to continue outside the institutional walls and the push-back they encountered from regulatory authorities and, sadly, from colleagues who were poorly informed about safe opioid prescribing and management of severe cancer pain.

All three regional presenters were working in Registered Medical Institutions (RMIs) which were providing a continuous supply of oral and injectable opioids for their patients. Cachar Cancer Centre has had not interruption in supply for over three years. Thanal Lakshadweep has been established as an RMI since 2013 and is working to obtain direct supply of opioids rather than having to order via Kerala with all the resulting delays, often over three months. Advice was to order much longer supply to avoid stockouts and shortages, while also working toward establishing a more reliable supply chain.

For Bihar, we were all disturbed to hear that there are only two out of the 38 districts with RMIs and so the capacity to ensure that a supply of oral opioids is available to their patients. This translates to an enormous burden of unrelieved suffering. The population of Bihar is estimated at 127 million by 2020, the third largest state by population in India. The major care providers for palliative care are centered in Patna at Indira Gandhi Institute of Medical Sciences (IGIMS), Mahavir Cancer Sansthan, AIIMS Patna,  and the Homi Bhabha Cancer Hospital and Research centre (HBCHRC), Muzaffarpur.

Many institutions are still operating according to the pre 2014 Amended NDPS, effectively operating against the law in doing so. This was disappointing. I was personally present at a state-wide workshop held at IGIMS in 2018, co-conducted by the Pallium India, with Dr Rajagopal as keynote speaker. This was attended by the State of Bihar Drug Controller and clinicians from many hospitals in Patna and beyond. The change in the national law was clearly laid out and its implementation discussed in detail. However, despite the passage of 3 years, the situation remains largely unchanged with only four RMIs across the entire state.

However, Dr Rita Rani’s presentation on the progress at Mahavir Cancer Sansthan inspired us all. As well as establishing a palliative care team, ward, outpatient clinic and emergency palliative care area, MCS is working toward opening a large hospice centre, with 100 beds, to cater to the needs of the many patients who present with advanced, incurable cancer to that institution. This would be a very significant addition to the care of patients with cancer in Bihar. They have also run many IAPC sensitization courses for volunteers, and End of life nursing education consortium (ELNEC) course for nurses.

Challenges are many. For example, most doctors avoid prescribing oral morphine for fear of side effects and she estimates that 95% of cancer patients in Bihar have poorly managed pain. Dr Rita shared that many times her patients’ opioid management is ceased by other practitioners who put them back onto tramadol resulting in recurrence of severe pain. However, despite this, oral morphine 10mg tablet use at MCS has more than doubled since 2017, now up to 98254 tablets. So there is great cause for optimism that the care of people with severe cancer pain in Bihar will significantly improve thanks to the work of Dr Rani and her team.