wayforwardforhospiceinmalaysia_drranjitoommen

8/14/2019 WayForwardForHospiceInMalaysia_DrRanjitOommen

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WAY FORWARDWAY FORWARD

FOR HOSPICEFOR HOSPICE

ININ

MALAYSIAMALAYSIA

RanjitRanjit MathewMathew OommenOommen

Hospice Movement started inHospice Movement started in

the early 90the early 90ss

1992 Home programs by1992 Home programs by HospisHospis MalaysiaMalaysia

andand PenangPenang Cancer SocietyCancer Society

1993 Hospice at home program,1993 Hospice at home program,KotaKota KinabaluKinabalu

1994 Hospice Malacca and1994 Hospice Malacca and KuchingKuching CancerCancer

carecare

Since then 24 services have mushroomedSince then 24 services have mushroomed

20012001 RumahRumah HospiceHospice PenangPenang

Ministry of HealthMinistry of Health

1995 Palliative Care Unit ,Kota1995 Palliative Care Unit ,Kota

KinabaluKinabalu

Since then more then 20 units andSince then more then 20 units and

numerous support teams set up innumerous support teams set up in

MOH HospitalsMOH Hospitals

20022002 SelayangSelayang HospitalHospital

100 beds available currently/ need for100 beds available currently/ need for

1000 beds1000 beds

99thth Malaysia Plan targets to put up 6Malaysia Plan targets to put up 6

regional Palliative Careregional Palliative Care CentresCentres..

Career structure availableCareer structure available

Clinical guidelines for the practice ofClinical guidelines for the practice of

Palliative care being drawn upPalliative care being drawn up

Post basic nursing course in PalliativePost basic nursing course in Palliative

Care Nursing is being developed.Care Nursing is being developed.

HospisHospis Malaysia with over 350 to400 patients inMalaysia with over 350 to400 patients in

the community at any one time, with 4 doctors,9the community at any one time, with 4 doctors,9

Palliative Care Nurses, Occupational therapist,Palliative Care Nurses, Occupational therapist,

pharmacist and supporting staff has establishedpharmacist and supporting staff has established

the largest home care program and trainingthe largest home care program and training

facility in the country.facility in the country.

Provides foundation course and many otherProvides foundation course and many other

courses through out the year.courses through out the year.

In the process of building an educationalIn the process of building an educational

centrecentre

International recognitionInternational recognition

Increased collaboration for research andIncreased collaboration for research and

other facilitiesother facilities


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RumahRumah HospisHospis and theand the PenangPenang CancerCancer

Society Home Care Program providesSociety Home Care Program provides

seamless care in the private sector.seamless care in the private sector.

Has been instrumental in helping to set upHas been instrumental in helping to set up

home programs in the rest of the countryhome programs in the rest of the country

Has continued to provide training and isHas continued to provide training and is

there ever ready to help others to develop.there ever ready to help others to develop.

KK provides seamless care, a veryKK provides seamless care, a very

successful collaboration between an NGOsuccessful collaboration between an NGO

and MOHand MOH

Can be considered a model unitCan be considered a model unitIntroduced the concept of PCU to theIntroduced the concept of PCU to the

MOH and provided initial training to rest ofMOH and provided initial training to rest of

the country planning to set upthe country planning to set up PCUPCUss

Palliative Care in MedicalPalliative Care in Medical

SchoolsSchoolsPalliative Care has been introduced toPalliative Care has been introduced to

medical students in themedical students in the KlangKlang valley,valley,

PenangPenang, Kota, Kota KinablauKinablau etc Not given theetc Not given the

priority it should get considering the factpriority it should get considering the fact

that to be a good doctor the onethat to be a good doctor the one specialityspeciality

a young doctor needs to know is Palliativea young doctor needs to know is Palliative

Care MedicineCare Medicine

No post graduate degree or DiplomasNo post graduate degree or Diplomas

availableavailable

Palliative care is an approach that improvesPalliative care is an approach that improves

the quality of life of patients and their familiesthe quality of life of patients and their families

facing the problem associated with lifefacing the problem associated with life--

threatening illness , through the prevention andthreatening illness , through the prevention and

relief of suffering by means of early identificationrelief of suffering by means of early identification

and impeccable assessment and treatment of painand impeccable assessment and treatment of pain

and other problems, physical, psychosocial andand other problems, physical, psychosocial and

spiritualspiritual

WHO 2002WHO 2002

Palliative care cannot be confined toPalliative care cannot be confined tocancercancer

It is not only for the urban population.It is not only for the urban population.

It cannot be provided in patchesIt cannot be provided in patches

Why should those dying and sufferingWhy should those dying and suffering

just because they do not have cancerjust because they do not have cancer

be denied the proven benefit ofbe denied the proven benefit of

palliative care?palliative care?

The effectiveness of pain and symptomThe effectiveness of pain and symptom

control has been established over 30 years.control has been established over 30 years.

When clinical guidelines on pain control areWhen clinical guidelines on pain control are

followed 70 to 90% of patients withfollowed 70 to 90% of patients with

advanced cancer gain adequate pain reliefadvanced cancer gain adequate pain relief

Good communication results in improvementGood communication results in improvement

in psychological health and better control ofin psychological health and better control of

symptoms.symptoms.


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There is also preliminary evidence forThere is also preliminary evidence for

the application of models of Palliativethe application of models of Palliative

Care for people with other illness.Care for people with other illness.

A substantial body of opinionA substantial body of opinion

recognizes that this model of care nowrecognizes that this model of care nowneeds to be adapted for other patientsneeds to be adapted for other patients

on the basis of need rather thenon the basis of need rather then

diagnosis or prognosisdiagnosis or prognosis

In general the opinion now is thatIn general the opinion now is that

Palliative Care for older people mustPalliative Care for older people must

be included within health servicebe included within health service

planning at national level. Policyplanning at national level. Policymakers need to ensure that palliativemakers need to ensure that palliative

care is integral to the work of all healthcare is integral to the work of all health

services and is not seen just as anservices and is not seen just as an

add on extraadd on extra..

In UK BaronessIn UK Baroness IlloraIllora FinlayFinlay got through a Palliativegot through a Palliative

Care Bill on 23Care Bill on 23rdrd for Febfor Feb07 which called for equity of07 which called for equity of

access to palliative care for all patients.access to palliative care for all patients.

This bill addresses the issue of:This bill addresses the issue of:

*Inequity of access to Palliative Care*Inequity of access to Palliative Care

*Patchy spread of Palliative Care*Patchy spread of Palliative Care

The PC bill hopes to address this with strategicThe PC bill hopes to address this with strategic

planning and sustainable funding. To make sure thatplanning and sustainable funding. To make sure that

there is public accountability for how vulnerablethere is public accountability for how vulnerable

patients get the care they need to be able to livepatients get the care they need to be able to liverather then wait to dierather then wait to die..

Two documents brought out byTwo documents brought out by

WHOWHO

Active aging :a policy framework 2003 andActive aging :a policy framework 2003 and

Palliative care solid facts 2004Palliative care solid facts 2004

These documents clearly bring out someThese documents clearly bring out some

facts which need to be taken intofacts which need to be taken intoconsiderationconsideration

The knowledge and experience gainedThe knowledge and experience gained

through Palliative Care must be integratedthrough Palliative Care must be integratedinto every day clinical practice.into every day clinical practice.

Community surveys consistently find thatCommunity surveys consistently find that

pain is an important symptom in around onepain is an important symptom in around one

third of the older people. Older people withthird of the older people. Older people with

dementia are a particular risk of poor paindementia are a particular risk of poor pain

controlcontrol

A BMJ poll acknowledges theA BMJ poll acknowledges the

importance of Palliative Care for nonimportance of Palliative Care for non

malignant diseases.malignant diseases.

More then 40,000 people voted on lineMore then 40,000 people voted on line

and a large majority voted forand a large majority voted for

palliative care for all at end of lifepalliative care for all at end of life..


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Palliative care Australia :Palliative care Australia :

Priorities for the 2008Priorities for the 2008--09 budget.09 budget.

Health care and other services do notHealth care and other services do not

always perform well for people whoalways perform well for people whoare dying. People with terminalare dying. People with terminal

condition often facecondition often face crippling financialcrippling financial

burdens as a consequence of theirburdens as a consequence of their

terminal conditionterminal condition..

KeralaKerala Government in India announcedGovernment in India announcedPalliative Care PolicyPalliative Care Policy

The government ofThe government ofKeralaKerala announced itsannounced itsPalliative Care Policy and thus becomesPalliative Care Policy and thus becomes

the first government in the developingthe first government in the developingworld to officially declare a Palliativeworld to officially declare a PalliativeCare policy. The government hopes toCare policy. The government hopes todevelop community based palliate caredevelop community based palliate careservice with effective communityservice with effective communityparticipationparticipation

Direction of Palliative CareDirection of Palliative Care

We all dieWe all die --the right of every man to diethe right of every man to die

peacefullypeacefully

To be able to live rather then wait to dieTo be able to live rather then wait to die

No longer the responsibility of NGONo longer the responsibility of NGOss

The benefits of Palliative Care have beenThe benefits of Palliative Care have been

provenproven

THE WAY FORWARDTHE WAY FORWARD

Palliative Care has to be integrated intoPalliative Care has to be integrated into

the mainstream medicine and it has to bethe mainstream medicine and it has to be

a part of the health care system anda part of the health care system and

deliverydelivery

NGONGOs can only be supportives can only be supportive

Delivery of Palliative Care is theDelivery of Palliative Care is the

responsibility of the MOH. Supportingresponsibility of the MOH. SupportingNGONGOs must be adequately supported ands must be adequately supported and

fundedfunded

Training modules have to beTraining modules have to be

developed at various levels.developed at various levels.

Even now it is possible to use existingEven now it is possible to use existing

facilities in Hospice Malaysia ,facilities in Hospice Malaysia ,PenangPenang

etc to train people at all levels. Everyetc to train people at all levels. Every

health care facility must have somehealth care facility must have some

one trained in basic palliative careone trained in basic palliative care

Delivery of Palliative careDelivery of Palliative care aa

modelmodel

All patients to be channeled through PCUAll patients to be channeled through PCU

Pain and symptom control/family conferencePain and symptom control/family conference

all to be done in PCU before discharge toall to be done in PCU before discharge to

districts or home programdistricts or home program

Liaise with trained personnel at district levelLiaise with trained personnel at district level

Work with family physiciansWork with family physicians

Tele medicine may be usefulTele medicine may be useful


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PCU should have a person in chargePCU should have a person in charge

to follow up patients referred out fromto follow up patients referred out from

PCUPCU

Provide regular training to a doctorProvide regular training to a doctorand nurse from all districtand nurse from all district

hospitals/family physicians and theirhospitals/family physicians and their

teamsteams

PCU should be accountablePCU should be accountable

A supportive palliative care environmentA supportive palliative care environment

does not necessarily mean the constantdoes not necessarily mean the constant

availability of professional people. Onlyavailability of professional people. Only

supervision and occasional consultationsupervision and occasional consultation

is required when the whole supportis required when the whole support

system works well. This support systemsystem works well. This support system

needs well trained nurses andneeds well trained nurses and carerscarers

experienced in Palliative Care. Theseexperienced in Palliative Care. These

people are the front line for providingpeople are the front line for providing

Palliative care at homePalliative care at home

STRATEGY TO TRAINSTRATEGY TO TRAIN

SPEICALISTSSPEICALISTSKK ExperienceKK Experience

Attempt to introduce PC as a PGAttempt to introduce PC as a PG

training program at UMS in vaintraining program at UMS in vain

Doctors who got interested in PC haveDoctors who got interested in PC have

fallen by the sidefallen by the side

Doctor who started PC in KK nowDoctor who started PC in KK now

heads Palliative Care Service inheads Palliative Care Service inBrisbaneBrisbane

Palliative Care has to be separate fromPalliative Care has to be separate from

Oncology or any form of curative medicineOncology or any form of curative medicine

Palliative Care cannot be taken for granted.Palliative Care cannot be taken for granted.

It is a philosophy that has to develop on its ownIt is a philosophy that has to develop on its own

and allowed to bloom by itself not under theand allowed to bloom by itself not under the

shadow of Oncology or any other specialty.shadow of Oncology or any other specialty.

The effect of Palliative Chemo on survival isThe effect of Palliative Chemo on survival ismodestmodest

Generally accepted guidelines about offering ofGenerally accepted guidelines about offering ofpalliative chemo are lackingpalliative chemo are lacking

The wish of the a patient to be treated plays aThe wish of the a patient to be treated plays arolerole

A SYSTEMATIC COUNSELING PROCEDUREA SYSTEMATIC COUNSELING PROCEDUREMAY BE NEEDED TO PREPARE PATIENTMAY BE NEEDED TO PREPARE PATIENTAND FAMILY FOR DECISION MAKINGAND FAMILY FOR DECISION MAKING

* Finances have to be balanced* Finances have to be balanced

Palliative Care calls for investing inPalliative Care calls for investing in

personnelpersonnel

*The benefits far out weigh the*The benefits far out weigh the

investmentinvestment

* It will be money well spent. It will* It will be money well spent. It will

reduce suffering across the board.reduce suffering across the board.


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WE HAVE TO ACT FASTWE HAVE TO ACT FAST

We need to lobby with the Health Minister, theWe need to lobby with the Health Minister, the

MOH, the cabinet and all in powerMOH, the cabinet and all in power

Those involved have to be to be passionateThose involved have to be to be passionate

We need to be smart, statistics and proof has to beWe need to be smart, statistics and proof has to beprovided, quote WHO other countriesprovided, quote WHO other countries

We need to educate the peopleWe need to educate the people

The elderly and those with incurable diseases mustThe elderly and those with incurable diseases must

be made aware of their rightsbe made aware of their rights

Unfortunately the dead do not speak aboutUnfortunately the dead do not speak about

the benefits they have had fromthe benefits they have had from

Palliative CarePalliative Care

People requiring Palliative Care are on thePeople requiring Palliative Care are on the

increase. Our population is aging.increase. Our population is aging.

Why at the beginning of the 21Why at the beginning of the 21stst century, docentury, do

we need a grass root movement to help uswe need a grass root movement to help us

learn something as basically human as howlearn something as basically human as how

to die?to die?

We need to relearn death because of theWe need to relearn death because of the

excellent job done by the MOH people todayexcellent job done by the MOH people today

die in a different way from our forbears: Wedie in a different way from our forbears: We

tend to die older, from different causes andtend to die older, from different causes and

in different environment.in different environment.The Health System has to adapt to thisThe Health System has to adapt to this

changechange

In 1900 people died at home surrounded byIn 1900 people died at home surrounded by

family ,physicians routinely comforted thefamily ,physicians routinely comforted the

dying and their families.dying and their families.

In the past century medical and pubic healthIn the past century medical and pubic health

advances have almost doubled the averageadvances have almost doubled the average

life expectancy.life expectancy.

People who die in old age now tend toPeople who die in old age now tend to

experience a long period of functionalexperience a long period of functional

decline before death, thus require intensivedecline before death, thus require intensive

care giving and well coordinated medicalcare giving and well coordinated medicaland palliative care.and palliative care.

On the world hospice scene are we are getting leftOn the world hospice scene are we are getting leftbehind? Other developing countries are fast catching upbehind? Other developing countries are fast catching upand moving forward at a much faster rate.and moving forward at a much faster rate.

We need to move into fast gearWe need to move into fast gear

We need to have a visionWe need to have a vision

To make Palliative Care accessible to all Malaysians whoTo make Palliative Care accessible to all Malaysians whorequire itrequire it

It was DrIt was DrKhashiwagiKhashiwagi who rightly saidwho rightly said

regardless of the differences in the conceptregardless of the differences in the conceptof death, socio economic and religiousof death, socio economic and religiousbackgrounds and medical and nursingbackgrounds and medical and nursing

situations a common hope for all people allsituations a common hope for all people allover the world is to die peacefully. Thereforeover the world is to die peacefully. Therefore

the need for Palliative Care Services inthe need for Palliative Care Services inevery part of the world is a considerationevery part of the world is a considerationthat reaches beyond the boundaries ofthat reaches beyond the boundaries of

countries and nationalitiescountries and nationalities


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We need to have targets toWe need to have targets to

achieveachieve

Set target datesSet target dates

To cover all cancer patients by 2013To cover all cancer patients by 2013

All people requiring Palliative Care byAll people requiring Palliative Care by20202020

Work together to achieve these targetsWork together to achieve these targets--

All those involved the MOH and NGOAll those involved the MOH and NGOss

In Palliative care we are patient , we listen,In Palliative care we are patient , we listen,

we never argue our cause. It is watchfulwe never argue our cause. It is watchful

waiting and symptom controlwaiting and symptom control

This approach will not work in introducingThis approach will not work in introducingPalliative Care into this country. May bePalliative Care into this country. May be

this is why we have not been successfulthis is why we have not been successful

The Hospice philosophy has come to stayThe Hospice philosophy has come to stay

The pioneers have done their part inThe pioneers have done their part in

establishing the Hospice Philosophy andestablishing the Hospice Philosophy and

proved to the country the difference it canproved to the country the difference it can

make to people who are sufferingmake to people who are suffering

The bottom to top approach has worked soThe bottom to top approach has worked so

farfar

Now it has to be the top to bottom approachNow it has to be the top to bottom approach

We have to try and make Palliative CareWe have to try and make Palliative Care

become a government policybecome a government policy

A part of mainstream medicineA part of mainstream medicine

An important part of the delivery of healthAn important part of the delivery of health

carecare

Working together with the existing NGOWorking together with the existing NGOs wes we

can prove that we are truly a nation thatcan prove that we are truly a nation that

carescares

If we act now the MOH working with all theIf we act now the MOH working with all theNGONGOS we can set target and achieve them.S we can set target and achieve them.

Palliative Care for all incurable cancer byPalliative Care for all incurable cancer by

20132013

Palliative Care for all those requiring itPalliative Care for all those requiring it atleastatleast

by 2020by 2020

Only then can we call ourselves a caringOnly then can we call ourselves a caring

nation a developed nationnation a developed nation

THANK YOU

wayforwardforhospiceinmalaysia_drranjitoommen

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