Dr Twycross taking time to speak with delegates at the conference

Anger in Compassion: Dr Robert Twycross addresses IAPCON 2012

Many of us have come to see anger as a negative emotion. But, can it have any positive effect? Let us tell you how the question came up.

Dr Robert Twycross is the palliative care guru of India. He taught almost all the first generation palliative care physicians in India and through them, the subsequent generation. (See the writeup about our Bruce Davis Training Centre to see how his pioneering work continues to inspire.)

He has retired now, but came back to India and took part in the annual conference of the Indian Association of Palliative Care (IAPCON 2012) organized by Dr Arundhati Chakraborty, held in Kolkata last month. In a moving event, his students gave him a plaque of honor. We strongly recommend that you take half an hour to see and to listen to his entire lecture.

If you can’t spare half an hour (we pity you!) here are some gems from his talk:

1. You need to be angry. Do you not have enough to be angry about?  

• 99% of the needy in India do not have access to pain relief;
• Most of some 300 odd medical colleges in the country (except for some five or six) fail to teach pain management and palliative care.

These facts alone may make “anger in compassion” well up in you, forcing you in to action. If so, let that anger be a catalyst for change!

2. It’s time to redefine what constitutes a medical emergency.
It should include, for example, someone with a limited life span who has not had a good night’s sleep in three months.

3. Miminise formality, maximise humanity.
The bigger your organization becomes, the more formal it becomes. It takes effort to retain humanity.

Dr Twycross ended his lecture by quoting Pallium India newsletter of March 2009. He asked all the young people in the audience to take down the quote, put it on a plaque and to keep it on their wall:

“We should not permit the growth and routinization of palliative care to take away its soul. It will be a happy day when palliative care reaches most of the needy in the country; but it will be a sad, sad day, if in the process palliative care comes to be delivered just with the brain, and the ‘eyes of the heart’ do not open any more!”

View on their website or download the pdf here:

Download Preconference CME Brochure

Dear Colleague,

As you are aware, Palliative Care is in infancy in INDIA and nearly nonexistent in the Eastern part of India.

In an effort to initiate it and make it available to everybody who needs it, the Indian Association of Palliative Care have decided to call upon professionals from all the specialties to gather in one platform and spread awareness in the region.

Also, it has an objective to provide moral support to those who are already working towards it.

Cancer Centre Welfare Home & Research Institute, Kolkata is going to organize the PRECONFERENCE CME of the 19th International Conference of IAPC on the 9th of February 2012.

You are invited to register for the preconference and make it a grand success.

• Download the brochure and registration form which can be filled up and sent/faxed to the following address/fax number: +91-33-24678002, +91-33-24536711

Dr. Sanghamitra Bora
Joint organizing Secretary
Preconference CME (IAPCON 2012)
Cancer Centre Welfare Home & Research Institute
Mahatma Gandhi Road, Thakurpukur, Kolkata – 700063

NEW: View flyer or download pdf

From Dr. Nagesh Simha, President, Indian Association of Palliative Care:

I am delighted to inform you that the 19th International Conference of the IAPC will be held in Kolkata, 10-12 February 2012.

The theme is “Education, Training and Research in Palliative Care”.

• Abstract submission deadline: 31 November 2011

Registration fees:

• Doctors: Member, INR 2,000 / Non-member, INR 3,000
• Post graduates: INR 1,500
• Nurses & Volunteers: INR 1,000
• Spouse/children: INR 1,500

Full details & registration forms are available at the IAPC Kolkata 2012 website…

“42% of the world’s countries have no palliative care services”

WPCA Mapping report 2011

A quote from the Worldwide Palliative Care Alliance (WPCA) 2011 update of the global mapping of palliative care provision.

In 2006, Professor David Clark and Dr Michael Wright from the International Observatory on End of Life Care (IOELC) presented a report (pdf) that measured palliative care development in all countries of the world and classified them according to levels of palliative care development.

The IOELC 2006 report used a four-part typology:

1. No known hospice-palliative care activity (Group 1 Countries)
2. Capacity building activity (Group 2 Countries)
3. Localised hospice-palliative care provision (Group 3 Countries)
4. Countries where hospice-palliative care services were reaching a measure of integration with the mainstream healthcare system

The mapping exercise has been repeated in 2011 with some new criteria.

Within the typology, changes have been made to the criteria for level of palliative care development in groups 3 and 4 and these have been subdivided to produce two additional levels of categorisation: Groups 3a, 3b and Groups 4a, 4b.

India has been upgraded from Group 2 to Group 3b. This shows progress from “Isolated provision” to “Generalised provision” characterised by:

• the development of palliative care activism in a number of locations with the growth of local support in those areas
• multiple sources of funding
• the availability of morphine
• a number of hospice-palliative care services from a community of providers that are independent of the healthcare system
• the provision of some training and education initiatives by the hospice organisations.

We should rejoice!

The growth is definite and more widespread, though we wish the change was more visible in terms of opioid consumption or some such indication of significant rise in the percentage of needy population accessing palliative care.

Links

• WPCA Report: “Mapping levels of palliative care development: a global update 2011″ (pdf)
• Indian Association of Palliative Care press release (pdf)
• The Hindu: Study calls for more palliative care facilities

From Dr. Nagesh Simha, President, Indian Association of Palliative Care:

I am delighted to inform you that the 19th International Conference of the IAPC will be held in Kolkata, 10-12 February 2012.

The theme is “Education, Training and Research in Palliative Care”.

• Registration deadline: 31 July 2011
• Abstract submission deadline: 31 November 2011

Registration fees (50% reduced rates before 31 July 2011):

• Doctors: Member, INR 2,000 / Non-member, INR 3,000
• Post graduates: INR 1,500
• Nurses & Volunteers: INR 1,000
• Spouse/children: INR 1,500

Full details & registration forms are available at the IAPC Kolkata 2012 website…

Dr Sukdev Nayak

Dr Sukdev Nayak, the palliative care pioneer from Cuttack, Orissa, has been appointed the director of Acharya Harihar Regional Cancer Centre.

This is the first time that a palliative care physician has been appointed in such a prestigious post. Naturally, this carries with it enormous potential in terms of integration of palliative care in cancer treatment and also in terms of outreach.

Dr Sukdev Nayak had his palliative care training from Oxford and then set up the first palliative care service in Orissa in 1994.

Under his leadership, Orissa became one of the first states in the country to simplify the narcotic regulations. He has always been an active member of the Indian Association of Palliative Care and was its president in 2006-2008.

Pallium India joins the palliative care fraternity in the country in wishing Dr Sukdev Nayak all the best!

Supreme Court of India

Dear Friend,

The Indian Association of Palliative Care‘s (IAPC) public interest litigation came up for hearing in the Supreme Court of India on 12 November 2010.

For those of you who are not aware of this, this was admitted by the Supreme Court of India in February 2007. The petitioners had asked for, among other things:

• a palliative care policy by Central and State Governments
• inclusion of palliative care in medical and nursing curricula
• simplification of narcotic regulations
• adoption of standard operating procedures by all State Governments

The court was very sympathetic to our cause. The Medical Council of India (MCI) was represented by counsel and the court asked MCI to file an affidavit.

We shall have to wait and see what transpires when the case comes up for hearing again.

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Pallium India-USA joins Coalition for Compassionate Care of California

Pallium India-USA has been accepted as a member of the Coalition for Compassionate Care of California, a state wide organization promoting quality end-of-life care for Californians.

Pallium India-USA plans to increase awareness and use of Advance Health Care Directives in the South Asian population as well as address end-of -life issues in a culturally sensitive manner.

Please see our new Partners page.

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Please Reflect… We Need Your Narratives

In relation to illness, what was the worst incident of pain and suffering or the impact of relief that you ever came across – as a health care professional, volunteer, patient or a relative or on-looker?

If you would like to write about it, we would like to offer you a platform to tell it to the World.

Why should you?

If you are a health care professional or volunteer, writing your experience down has the potential to improve your self-awareness and your awareness of your patients’ humanity through recording their stories.

There is also the pleasure of contributing to a body of knowledge that can be a powerful tool in advocacy and may some day help to change institutional or Governmental policies. You will also get a publication in an international scientific, peer reviewed, indexed (Medline/PubMed, EMBASE, CINAHL and others)  journal, the Journal of Pain and Palliative Care Pharmacotherapy (JPPCP) published from the UK.

If you are interested in sharing your experience, please contact us here…

You may find the instructions for authors on the journal website helpful.
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IAHPC Needs YOU!

If you are not a member of the International Association for Hospice and Palliative Care (IAHPC), please consider becoming one.

Membership gives you free access to several palliative care journals online, and also makes you eligible to apply for traveling scholarships.

Fees are graded, based on location and GDP, making it extremely affordable for Indians and our colleagues around the World.

India comes in Middle/Low category according to the World Bank list.

Click Here to Join IAHPC…

On behalf of every one from developing countries, Pallium India thanks IAHPC for the graded membership structure based on GDP. With this gesture, you convey a powerful message to the global community.

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One Month Certificate Course in Pain and Palliative Care at MNJIORCC, Hyderabad

This four-week course will be conducted by MNJ Institute of Oncology, Hyderabad, as part of the activities of the collaborative training center which was developed by MNJIO with INCTR, American Cancer Society and PALLIUM INDIA.

It aims to provide doctors, nurses, social workers and volunteers with practical “hands-on” training in palliative care supplemented by theoretical background information. Dr. Stuart Brown, Director of INCTR’s PAX Program, will be part of the external faculty.

Course dates: December 6th 2010 – January 1st 2011.

For more information, please contact: mnj.palliative@gmail.com

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Reducing Suffering During Nasogastric Intubation

A tube through the nose into the stomach sometimes becomes necessary in advanced disease when the patient is unable to swallow food or medicines. This is particularly relevant to India because of its large burden of head and neck cancers.

But even the thought of such a thing is terrifying to patients and many opt not to have it, resulting in inability even to take pain medication, or horrible unsatiated pangs of hunger. And in the presence of active disease, the process of the tube insertion may be particularly painful.

Dr Ya-Wen Kuo et al from Taiwan have published a Systematic Review in the Journal of Pain and Symptom Management (Vol 40, No.4, October 2010) on the use of nebulised lidocaine (lignocaine) prior to nasogastric tube insertion. it appears that nebulised lidocaine can reduce the pain by as much as 57.7%.

Reducing the Pain of Nasogastric Tube Intubation with Nebulized and Atomized Lidocaine: A Systematic Review and Meta-Analysis

Abstract – Nasogastric tube (NGT) intubations occur frequently in clinical practice and can be a painful procedure for patients. A systematic review of current knowledge concerning the use of nebulized lidocaine to reduce the pain of NGT insertion was conducted in order to develop evidence-based guidelines. In addition, a meta-analysis of appropriate randomized controlled trials (RCTs) was performed.

[...]

Five RCTs with 212 subjects were identified. A total of 113 (58%) subjects were women. The mean age of treatment and control groups was 59.6 and 55 years, respectively. The countries of studies were the United States, United Kingdom, Australia, Canada, and Thailand.

In the treatment groups, the use of lidocaine concentration was 4% and 10%. The pooled effect size was 0.423 (95% confidence interval: 0.204-0.880; Z=−2.301; P=0.021), indicating that the use of nebulized lidocaine before NGT insertion can decrease pain by 57.7%.

There is insufficient evidence to recommend the dosage, concentration, or delivery method. Further research is needed to articulate a comprehensive clinical guideline.

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Ethics: When the Patient and Family Members Disagree

An article by Dr Robert L Fine from Dallas, Texas, USA in the Journal of Pain and Symptom Management (Vol 40, No.4, October 2010) highlights the importance of patient-centered care.

He asks, what would you do when the patient who has gone through dialysis for many years, at the end of his life expresses a wish not to be resuscitated and then becomes too weak to argue, and the family insists on resuscitation for “religious reasons”?

The obvious answer would be to go by the patient’s wishes, but it is not an easy thing for the team to do, when faced with the angry family. (In India, often, the family would simply take the patient away to a high-tech hospital in the face of such confrontation).

Dr Fine suggests that often physicians “acquiesce to the most insistent voice in the room”. The patient is weak and is less liable to be heard any longer!

He says, ‘among the rationalizations… for such avoidance behaviors are, “I’m getting paid to do the wrong thing, but that’s the system we live in and it’s not my problem to fix”, or the more cynical, “The patient should have chosen a better family”. Another common excuse….is “Dead patients don’t sue, but angry relatives do”.

The author goes on to explain the importance of keeping the focus on the patient. Taking decision-making away from individuals to “ethical committees” can help resolve the problem. Indeed!

Keeping the Patient at the Center of Patient- and Family-Centered Care

Abstract – The practice of palliative care typically refers to the focus of treatment as the patient and family. Tending to the needs of both patients and their families is usually good, but what should clinicians do when they perceive the best interests, needs, or treatment preferences of the patient are in conflict with those of the family or other surrogate?

Physicians may be able to suppress the inevitable moral cognitive dissonance of such circumstances, write orders, and walk away, but other health care professionals, especially nurses, may not have it so easy. This article suggests practical steps to obviate conflict in such circumstances before offering an ethical analysis focusing on notions of autonomy, beneficence, and true caring for patients, especially those near the end of life.

The limitations of surrogate decision makers are considered and legal liability concerns are briefly explored, ultimately leading to the conclusion that keeping the patient at the center is sine qua non of patient- and family-centered care.

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New Guidelines for Cardiopulmonary Resuscitation (CPR)

CPR gets instituted less in palliative care than in other medical streams, but it might still become necessary at times.

The American Heart Association has published new guidelines (Circulation. 2010;122:S640-S656, doi:10.1161/CIRCULATIONAHA.110.970889).

The following are some of the key elements of the revised guidelines:

• The AHA has rearranged the A-B-Cs (Airway-Breathing-Compressions) of CPR to C-A-B (Compressions-Airway-Breathing).
• Chest compressions are therefore the first step for lay and professional rescuers to revive an individual with sudden cardiac arrest.
• This change in CPR sequence applies to adults, children, and infants, but excludes newborns.
• “Look, Listen and Feel” has been removed from the basic life support algorithm.
• Rate of chest compressions should be at least 100 times a minute.
• The ratio of chest compression and chest inflation should be 30:2.
• Rescuers should push deeper on the chest, resulting in compressions of at least 2 inches in adults and children and 1.5 inches in infants.
• Between each compression, rescuers should avoid leaning on the chest so that it can return to the starting position.
• Rescuers should avoid stopping chest compressions and avoid excessive ventilation.
• Injection of atropine is no longer recommended in the treatment of asystole.

Read the full guidelines here – [PDF version]

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Parting shot…

Dr Amit Sood, chief of Integrative Medicine in Mayo Clinic, in his book “Train your mind, Engage your heart,Transform your life” (Morning Dew Publications, LLC, 2009) recommends that you should see yourself with your pet’s eyes.

“You are what your dog thinks you are, kind, caring and compassionate”, Amit says. “Your pet does not care about your financial net worth, job, health, fame etc. All it cares about is your love and your ability to express it. The loving you is the transcendental you that no one can rob. Peg your self-esteem on how loving you are, not on your material accomplishments.”

The Rain Gods Helped Us!

Our celebrations for World Palliative Care Day on 9th October 2010 in Trivandrum were a phenomenal success. It was raining cats and dogs for several days – very unusual for this time of the year – and all the weather pundits were predicting continued rain! But, the sky cleared by noon and rain kept off until midnight, giving us lovely weather for the program.

The musicians also gave their best. “Old is Gold“, the troupe led by Padmasree Udayabhanu, included such noted singers as Suseela Devi.P, Srikanth.N, Arundhathi, Kallara Gopan, Bhavana Radhakrishnan, Preetha P.V, Radhakrishnan, Sriram, Ravisankar, Rakesh Brahmanandan and Kavalam Srikumar – all of whom gave their services free. [click here for pictures]

There were several luminaries from the literary and public fields at the program (including the famous poet and environmentalist, Smt Sugathakumari), but the real dignitaries were our patients for whom the musicians performed.

The lilting melodies from the past melted every heart.  One of the performers was our own young volunteer, Sarat! The program was jointly organized by Pallium India and Rajeswari Foundation.

The organizing team led by our volunteer Brigadier Oommen John deserve congratulations!

Volunteers Recognized

One of the highlights of the World Palliative Care Day celebrations was the recognition given to two of our volunteers: Sri K Sivadasan who is the chief organizer of Nanniyode Palliative Care Centre and the other Mrs Patricia Paul Fernandez (fondly called Lijo by everyone) who provides exemplary care to patients at Murukkumpuzha.

Mr. Sivadasan and Mrs Lijo, we are proud of you!

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World Palliative Care Day in Srinagar

Dr Yousuf Tak from Srinagar writes,

It is a really tough time Kashmir is going through at the moment.

But, we managed to organise a seminar on the eve of World Hospice and  Palliative Care Day in the lawns of Pulwama District Hospital to raise awareness on the subject.”

Most of us living in safe zones in the world cannot even begin to understand the struggle of people like Yousuf Tak in Kashmir.

Kudos to you, Yousuf. You still manage to do your bit despite all the difficulties!

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Pallium India-USA Launched in California!

Initiated by Dr Jerina Kapoor (Founder & President), Pallium India-USA will work towards improving access to palliative care in India, but will also provide information to the Indian community in USA on matters relating to Advanced Care Directives and available services for their relatives back in India.

At a function held on September 26th, 2010 in the India Community Center, Milpitas, California, Dr Vyjeyanthi Periyakoil from Stanford University, Dr M.R. Rajagopal (Chairman, Pallium India), Ms Sandy Stokes from the Chinese American Coalition for Compassionate Care and Dr Jerina Kapoor addressed a gathering of more than 130 members, the vast majority of them from the Indian community.

The theme of the meeting can be summarized as answering the questions:

God forbid that something like that should happen to you, but…

• If a relative of yours has incurable cancer in India, where can that person access pain management or palliative care?
• How can you ensure that the person lives with dignity during the last few months of his life?
• What can you do to improve access to people like him?

Or, if you get an advanced incurable disease… Where would you like to spend your last few weeks or days? In an intensive care unit or in your home? How can you ensure that your wishes are respected?

The attendees took a general decision to support initiation of palliative care services in as many places in India as possible and decided on an action plan for the same.

For the USA based population, Advanced Care Directives was recommended, as a way to have a say in the care that people would receive in case they are not able to speak for them selves because of an illness.

Also, decision was taken to form Speaker Forums to go out in the community to talk about end-of -life issues, and there were many people volunteering for that. People expressed interest in looking at the resources in their home towns in India for palliative care and work to improve that. So, it was a meeting that inspired people to work to improve things in their own community, whether here in the US or in India.

There was a ‘can do’ spirit in the room. A decision was taken to have a follow up meeting to organize ourselves.

India West Reports on Pallium India-USA

The recent Pallium India-USA launch has been reported in India West, the “USA’s Most Honored Indian Newspaper Published From California”. View and download the report…

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Another step forward for Project Hamrahi

Project Hamrahi is a mentoring program for Indian palliative care programs jointly initiated by Australia Palliative Link International and Pallium India. Its pioneer, Dr Odette Spruyt was the first person to make a visit for this purpose to Patna in Bihar earlier this year. Odette has subsequently been following up with Patna.

The second visit under the project happened this month (October 2010) at Thiruvalla, a town in Kerala about 130 kilometres north of Trivandrum. In a prestigious medical school and hospital (Pushpagiri), Dr P.T.Thampi started a palliative care program five years back. He works with a dedicated team of volunteers and staff.

Dr Sok-Hui Goh from project Hamrahi spent a week with the team recently, walking with the team on home visits, seeing patients, discussing problems and solutions, and conducting educational programs. Her husband Dr.Andrew Chew taught surgery residents. Sok-Hui and Andrew hope to continue their friendship with the Thiruvalla team.

Thank you Sok and Andrew.

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Love Really is Like a Drug

The Guardian reports on a Stanford University School of Medicine study which finds that love not only blocks pain, it also seems to stimulate the same parts of the brain as morphine:

Intense spells of passion are as effective at blocking pain as cocaine and other illicit drugs, a team of neuroscientists say. Tests on 15 American students who admitted to being in the passionate early stages of a relationship showed that feelings for their partner reduced intense pain by 12% and moderate pain by 45%.

In the study, researchers at Stanford University showed eight women and seven men photographs of their partners while delivering mild doses of pain to their palms with a hot probe. At the same time, the students had their brains scanned by a functional magnetic resonance imaging machine. At the end of each test, the students were asked to rate how much pain they felt.

Feelings of love, triggered by a photo of their partner, acted as a powerful painkiller. Brain scans revealed that these feelings caused more activity in parts of the brain that are also triggered by morphine and cocaine. Looking at an image of an attractive friend rather than their partner had only a mild analgesic effect.

Read more at The Guardian…

Download the study from Plosone.org: Viewing Pictures of a Romantic Partner Reduces Experimental Pain: Involvement of Neural Reward Systems [pdf]

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Care and Share

Care and Share is an American non-profit organization created in 1990 by a handful of professionals based in USA. They have been staunch supporters of Pallium India’s palliative care efforts.

Youtube: Brief description of Care and Share’s activities, in particular their “Ganolsavam 2009″ – Ganolsavam 2010 was held on October 9th…

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Reader’s Digest: A Good End

There is a fantastic article on Palliative Care and End-of-Life issues in the October 2010 issue of Reader’s Digest Australia by Helen Signy:

A Good End

Each year half a million Australians experience the impact of a terminal illness as patients, carers or family members – yet talking about dying is not something that comes naturally to the majority of us.

Facing up to death is difficult, but for the individual who knows his or her life is drawing to a close, being able to communicate openly and honestly with family and friends is often of immeasurable comfort.

“For terminally ill people it’s a very lonely, isolated experience because no-one else really can know what it’s like to know that time is limited,” says Suzanne Clementi, a counsellor at Brisbane’s Karuna Hospice Service, which offers home-based palliative care. “Everyone tries to protect themselves by not talking about it. Often I find it’s the people who are more honest and talk about it openly who are the ones who cope better.”

Medical intervention can often control pain, yet the lack of awareness about how to die well that troubles health advocates.

Palliative Care Australia CEO Donna Daniell says many Australians are unsure what to expect at the end of their lives: they don’t know where to find support, and they fail to plan in advance. “We need to get the conversation going so we can work towards a better death,” she says.

Here, four people who are facing death talk about their experiences:

• Catherine, 62, Sydney, New South Wales
• Julian, 74, Melbourne, Victoria
• Kerrie, 28, Maitland, New South Wales
• Dr Eng, 73, Melbourne, Victoria

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Focus on Palliative Care in Developing Countries

Nancy Hinds is a palliative care pioneer in Fresno, California. She founded the Hinds Hospice which leads palliative care delivery in the region.

It would have been easy for Nancy to do the job in Fresno and to be satisfied with that. But she chose to look beyond her territory and to look at suffering elsewhere. Last month saw her leading a conference, “Hospice and Palliative Care in the Global Community“, which focused on palliative care in developing countries.

Participants from developed and developing countries worked together to share experiences and to develop an action plan for future action.

Nancy’s gang, as the group was fondly nicknamed at the conference, is set to go places. Thank you Nancy and gang, for all that you have set out to do.

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A Child In Pain… A Mother’s Suffering

For those who attended the palliative care conference in Fresno last month, it was indeed a powerful experience to listen to a talk by Dianne Gray from the Elisabeth Kübler Ross Foundation.

She talked about how her son was diagnosed with an incurable progressive neurological disease at the age of four, how the family’s lack of communication destroyed her marriage and changed her whole life, how her child suffered because her son’s pediatric sub-specialists were misinformed on the topic of hospice/palliative care and fearful of giving the child morphine.

Eventually, when a palliative care team got involved and gave the child morphine, life became a bit more bearable for the family. But towards the end, he went into intense muscle spasms and agonizing pain. He suffered for 8 days without getting pain relief, or if that was not a possibility, palliative sedation.

A lack of education and communication left the family and some care providers involved feeling inept and saddened by the persistent suffering as they knew this did not need to be the case.

Dianne’s talk was at a conference for developing countries. It left the audience feeling anger at the fact that these things were permitted to happen in a developed country where such practices would not be expected.

Some problems seem to be common to the whole World, developed or not.

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We all love children, right? Yet we are so cruel to them.

When a child is in agonizing pain, if you have the means at your disposal to relieve that pain safely, yet refuse to use them, is that not tantamount to torture?!

If you think the following story from Kenya is not relevant to India or to the rest of the developing world, sorry, you are mistaken.

Here are a couple of quotes from the British Medical Journal article “Restrictive government policies leave Kenyan children dying in pain” (BMJ 2010; 341:c4864 doi: 10.1136/bmj.c4864, 9/9/10):

One doctor treating children with cancer in Nairobi told researchers, “People have no problems with relieving pain in adults with morphine, but when it comes to children there is always some reservation. Putting a child on morphine is always a big issue.”

and,

A nurse from Bondo district hospital said, “We have no pethidine, no DF118 [dihydrocodeine], and no morphine. We have children here with advanced HIV; some are in severe pain. The pain management for children with advanced HIV is not enough.”

The BMJ article refers to a 78-page report by Human Rights Watch “Needless Pain: Government Failure to Provide Palliative Care for Children in Kenya”.

You can read the complete HRW report online or download a PDF

Accompanying the report, HRW has two powerful videos from Kenya telling the story of Jethro and Sammy, WATCH them here…

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Malaysia’s Pain Management Guidelines

Dr Richard Lim from Malaysia writes to introduce their new Evidence Based Clinical Practice Guideline on Cancer Pain Management in Malaysia.

A large official launch by the Ministry of Health will take place sometime in December or January. They are also preparing a training module and will be starting a series of roadshows to promote this guideline.

You can download the Guidelines from the MOH website:

• Clinical Practice Guidelines – in full (PDF)
• Quick Reference for Healthcare Providers (PDF)

Dr Lim continues to write that it took them a good 2 years to get it all done and hopes that it will serve as a useful reference for all healthcare workers in Malaysia managing patients with cancer.

Having scanned through the document, we find it to be an excellent resource for India too. True, some of their drugs are not available in India, and they do not seem to have some low cost drugs that we use over here; but by and large, it will be a useful addition to the armamentarium for palliative care institutions in India.

And please make note of another important hidden message in Dr Lim’s email – his efforts do not stop with the publication of the guidelines – they are going on to a “public launch” and “road shows“.

Unless the guidelines reach the consumers, what is the use? A lesson to learn there, is there not?

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Mind-Body Medicine

Mrs. X was in tears. Her husband has gone through three cancers: a non-Hogdkin’s lymphoma, then a Hodgkins lymphoma and finally a malignant melanoma.

She herself has just gone through colonic surgery –  and she has three children to take care of.

“Is this suffering any less than the suffering from incurable diseases in India?”, Dr. Amit Sood asks.

Dr Amit Sood heads the department of Integrative Medicine at the famous Mayo Clinic in Rochester, Minnesota, USA.

The department undertakes serious research in Mind-Body Medicine and studies various complementary and alternative medicine (CAM) forms of therapy.

Amit says that meditation and acupuncture are the CAM modalities best supported by evidence. With the meditation training the department provides, Mrs. X is able to cope with her situation.

Amit runs a course at Mayo on Mind-Body Medicine and has published a book called “Train your mind, Engage your heart, Transform your life.”.

We hope to work with Amit to adapt his techniques so that they can be put to good use in India.

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Pain in Africa

Kathy Kreiter, the executive director of International Association for Study of Pain (IASP) brings our attention to another report from the Economist, Pain in Africa:

Drugs in Africa: A lot of pain
Africans need more morphine

GERARD was five years old when he died this year of AIDS. He lived in a slum in the Kenyan capital, Nairobi, and was nursed by his mother. “I could tell he was in a lot of pain,” she says. Yet Gerard received no relief except for ibuprofen, a mild painkiller.

…

The International Narcotics Control Board, a UN body that oversees controlled drugs, says 90% of the world’s morphine is administered in rich countries. By contrast, morphine and other painkillers such as pethidine and dihydrocodeine are hard to find in state systems in poor countries. So Africans with AIDS, cancer, sickle-cell disease, victims of car crashes, gunshot and machete wounds, and women in labour, suffer severe pain without relief.

Kenya is ahead of many African countries in palliative care, with its own hospice movement, but only seven of its 250 hospitals have ready access to morphine. Even when it is in stock, the annual supply is limited to some 1,500 patients. Yet 180,000 Kenyans die each year of AIDS and cancer alone. A 75mg daily dose of morphine would make all the difference.

Read the full article on The Economist website…

Not that there is any new information there; but every little bit of attention to the pain problem in the media helps the cause.

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Rural MBBS Degree in India

India has come out with a “Rural MBBS” program in which the course duration has been shortened from the conventional six years and a half (including house surgeoncy) to four years.

These doctors will have training with no frills. Their training will not include exotic surgery or too detailed basic sciences, but will be problem oriented training in ordinary ailments. They will have to sign an agreement by which they will have to practice in a rural area for a minimum of ten years.

There has been considerable debate about this new program and the medical fraternity has been generally against it. In a recent article in The Lancet entitled “Rural MBBS degree in India”, the authors Sanjay Kinra and Yoav Ben-Schlomo point out how poor the medical service in rural India is, and raise a couple of issues.

One simple question is:

• Do we know it for a fact that the current six and a half years is the optimal period of training for a doctor?
• On the other hand, are the rural and smaller hospitals competent to train these doctors?

Full text with references can be viewed on TheLancet.com (free registration required)

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18th International Conference of Indian Association of Palliative Care

Dr Piyush Gupta, organizing secretary, invites you to the 18th International Conference of Indian Association of Palliative Care at Lucknow – the historic City of Nawabs having rich cultural heritage. To be held from February 11th to 13th, 2011 (Friday – Sunday) at Sanjay Gandhi Post Graduate Institute of Medical Sciences.

Full details at the 18th International Conference of Indian Association of Palliative Care website…

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PARTING SHOT… On Hope…

A Pallium India blog on Hope (http://palliumindia.org/2010/10/hospice-care-and-hope/) made one of our readers ask, “What hope can remain in someone who knows he has only weeks to die?”

The answer could be in a quotation from Martin Luther King Jr,

“We must accept finite disappointment, but we must never lose infinite hope”.

As carers, we sometimes need to help people to bring hopes down to realistic levels. The person’s hope may not be sustainable if he wants cure and nothing but cure, but may be achievable if his hope is to see his daughter married or if he just wants to go to his favourite temple one last time.

Such a change cannot be forced; it will have to be achieved by listening to him, helping him to ventilate feelings and in short “walking with him” till he reaches the desired state of mind.

Dr Piyush Gupta, organizing secretary, invites you to the 18th International Conference of Indian Association of Palliative Care at Lucknow – the historic City of Nawabs having rich cultural heritage. To be held from February 11th to 13th, 2011 (Friday – Sunday) at Sanjay Gandhi Post Graduate Institute of Medical Sciences.

The theme of the conference is “Networking in Palliative Care“, Dr Gupta’s invitation letter says,

Our theme, “Networking in Palliative Care” shall seek an answer to:

When the hardcore criminals sentenced to death, are asked for their last wish; which is always fulfilled and all the civilized nations aim at a painless death even for them, isn’t it unfortunate that in our country; the patients getting death warrants by Cancer; have to suffer for months together in excruciating pain; cursing themselves for none of their sins; praying for an early death?

Should they not be given freedom from acute pain?

Yes! Says WHO by giving them “Oral Morphine”. Then why are they deprived of this at the cost of their sufferings, despite India being one of the largest producer of Opium?

We have to go even beyond Oral Morphine to ensure life and death with dignity.

Networking probably has some of the answers.

Find out more and register at iapcon2011.com …

• Pre-conference Workshops on Research & Publications / Communication at Chatrapati Sahuji Maharaj Medical University Lucknow February 10th 2010 (Thursday)
• Last date for Abstract Submission October 30th, 2010

Discounted registration is available before 31st October, 2010.

Full details at the 18th International Conference of Indian Association of Palliative Care website…