Sri Lanka has a population of 22 million and approximately 112,500 deaths a year. The total number needing palliative care in the country can be estimated to be 60 percent of all deaths, or 68,000 people a year, the majority of them dying with Non Communicable Diseases. With the rapid ageing of the population occurring, the highest number of patients needing palliative care will in the future come from the elderly terminally ill. There are no designated palliative care units in Public or Private Hospitals. The country has more than 300 doctors with basic training in Palliative Care, thanks to a major initiative by College of General Practitioners of Sri Lanka. A train the trainer program by Lien Foundation, Singapore, is also on. Palliative Care Association of Sri Lanka, the national umbrella organisation for palliative care in the country has been formed recently. Formal palliative care services are not available in the country except for the few hospices which offer incomplete services to patients with advanced cancer. Most of the patients with diseases other than cancer in need of palliative care are not getting it. Physical symptoms in cancer patients are usually addressed by the treating oncologist as long as the patient is
under his/ her direct care. Anaesthetists are sometimes called to treat difficult pain if the patient is admitted in a cancer hospital.
OPIOID AVAILABILITY AND USE:
Sri Lanka has the largest per capita consumption of Morphine Equivalent in the SEARO region. Medical Supplies Division of Ministry of Health is the national authority for stocking and dispensing morphine in the country. The drug is imported from outside.
All doctors with a licence to practice Modern Medicine or Ayurveda can prescribe morphine. Injection morphine and
pethidine are available in all hospitals down to divisional hospitals. Both Immediate Release and Sustatined Release
forms of oral Morphine are available in the country. But stocks are available only in Cancer Hospitals and supply of oral morphine is very often irregular. Fentanyl patches are also available in Sri Lanka, but are of limited use due to high costs. Methadone is available, but is currently used only in deaddiction centres. Tramadol is widely available.
A major practical problem is that only three days’ supply of Morphine can be issued to any patient at a time. Same prescription can be renewed three times. New prescription is needed after the third refill. This will mean that the patient or family member has to make trips to the cancer centre every other day to ensure that the patient is pain free. Sri Lanka has an essential drug list in which both injection and oral morphine are included. Tramadol is also in
EDUCATION AND TRAINING:
Palliative Care is not an accepted medical or nursing specialty in Sri Lanka. Education and training in Palliative Care has been the weakest link in palliative care in the country. College of General Practitioners of Sri Lanka has managed to offer basic training to more than 300 doctors in the country, most of them Government Doctors. There are no training facilities available for other health care professionals or community volunteers. There are no guidelines for practice/ delivery of palliative care available in the country
POLICY/ NATIONAL STRATEGY:
There is no national policy in palliative care. The National Cancer Control Plan document being formalised has a section on rehabilitation, survivorship and palliative care. National Cancer Control Program has a palliative care team to take palliative care forward at the policy and strategy front. The suggestion to establish a National steering Committee for palliative care within the National Cancer Control Program has been accepted in principle. Establishment of regional cancer control units with adequate importance to palliative care is also being planned as part of the national strategy in the management of cancer. The proposed national plan/ strategy does not link up palliative cancer care with other Non Communicable Diseases.
1. A clear national policy need to be established in palliative care with coordinated foundation measures. A national Steering Committee for palliative care is to be formed under National Cancer Control Program to initiate this. The
steering committee should also look beyond cancer and draw a strategy and action plan to link up with national plans for other Non Communicable Diseases and for the elderly.
2. Experience shows that most terminally ill patients prefer to die at home and that palliative care through home care is essential. It is recommended that establishing a policy for home care services as part of primary health care should be explored for the incurably and terminally ill patients. General Practitioners in Sri Lanka can play a major role in this area.
3. The regulations for prescription of opioids need to be reviewed so that all appropriately trained doctors have access to oral morphine, enabling pain relief to be incorporated in the primary health care system. This requires that in the future, morphine formulations be available widely.
4. It is also necessary to modify that regulations for prescription of opioids to allow at least three weeks supply of oral morphine with a prescription.
5. Training of the future trainers and first focal points for implementing pain control and palliative care should be activated in various geographical regions of the country as soon as possible. With thousands of patients in need of care and potential for offering such supportive care as part of primary health care, there is an urgent need for the health care professionals and community health workers to acquire and develop the knowledge, attitudes
and skills necessary for such care.
a. A suggested pattern of courses for doctors, nurses and community health workers follow:
i. Establish sensitizing courses (3 – 6 hrs) for maximum number of doctors, nurses and community volunteers in the country
ii. Continue the Certificate Course initiated by College of General Practitioners of Sri Lanka so that basic training in essentials of palliative care is available to maximum number of doctors
iii. Establish Certificate Courses for nurses in the same pattern as for doctors
iv. Develop Fellowship Programs and Six week courses for doctors and nurses so build national professional capacity in palliative care.
v. Develop courses for community nurses to ensure the availability of trained health care workers at grass root level
vi. Develop sensitisation and training programmes for community volunteers and family members of patients
6. It will be good to establish palliative care teams in the community linked to trained GeneralPractitioners. 3-4 pilot projects to be set up with community participation in different regions as the first step.
7. Pain relief and palliative care need to be included in the undergraduate curriculum for Medicine and Nursing and be eligible for examination. This in the long run will be the most efficient way to archive the necessary educational coverage.
8. Most of the patients in need of palliative care will in future also be looked after by health care professionals in the primary health care level. If these doctors and nurses are trained to improve their clinical and communication skills and supported a net works of trained community workers and home care nurses, it can improve the care of the majority of patients in need of palliative care tremendously. The training of GPs and doctors in rural areas in Pain relief and Palliative Care will be important as well as of Community Workers, and of future Home care Nurses. This will ultimately be most important for achieving a meaningful coverage, reaching all and for guaranteeing, together with referral institutions, continued care for patients discharged from specialist centres and for freeing expensive hospital beds from incurable patients. It will also culturally be the most important for reassuring the citizen a dignified death where they want it most, namely in the home, and thereby avoid the trend of costly institutionalizing dying.
9. Local communities can be empowered to address the Psycho social and spiritual aspects of palliative care. This can be possible through training programs for community volunteers and setting up guidelines for involvement of the community in palliative care. The strong family structure still observed in Sri Lanka will be useful if the families are empowered to give palliative care at home like spiritual support, prophylaxis for avoiding bedsores, appropriate food, changing of bandages, etc.
Dr. Suresh Kumar
nstitute of Palliative Medicine
Calicut, Kerala india
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