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.
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.
Patient examples (consent was given to publish these photos)
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.
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 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.
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.
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.
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.
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.
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)
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.