Palliative Care in JordanA WHO demonstration projectGlobal Summit on International Breast Health: optimizing Healthcare Delivery June 9-11.Chicago,Illinois Mohammad Bushnaq, MD Hospice and Palliative Care Consultant Jordan Palliative Care Society, Chairman -Jordan
Palliative Care- Global perspective.WHO Palliative Care Initiative.National Palliative Care Initiative.
Palliative care is defined as:‘Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual’ WHO
Palliative care relieves suffering and improvesthe quality of life of the living and the dying. More than 30 million people sufferunnecessarily from severe pain and othersymptoms each year.In spite of all the efforts over the last 2 decades,most people who need palliative care are notgetting it. Stjernsward J, Clark D. Palliative medicine. A global perspective. In Doyle D. Oxford text book in Palliative medicine. 3rd ed. New York: oxford university press.2004. pp 1199-1224
Distribution of Palliative Care ServicesThere are 60 million person dying each year. 6million of them die in pain. Only 1 million of themreceive palliative care.It is estimated that there are 8,000hospice/palliative care services, in about 100countries around the world .86% of services world wide are located only inten countries . Journal of Public Health Policy, 2007 by Webster, Ruth, Lacey, Judith, Quine, Susan
A public health approach aims to protect and improve thehealth and quality of life of a community by translating newknowledge and skills into evidence-based, cost-effectiveinterventions.it is important that all countries integrate pain relief andpalliative care into their health care systems at all levels. Stjernswa rd J, Stanley K, Tsechkovski M. Cancer pain relief: an urgent public health problem in India. Indian J Pain 1985;1:95e97.
Palliative care became a part of the NationalHealth Plan in Catalonia, Uganda, Mongolia,and Georgia. The Indian state of Kerala hassuccessfully integrated palliative care throughcommunity approach. Palliative Medicine-The Global Perspective: Closing the Know – Do Gap, Stjernsward and Xavier Gomez-Batiste. Declan Walsh, Text book of palliative medicine, page 6
The Catalonia WHO demonstration project wasthe first to reach the long-term outcomes, havingcovered 80% of all those needing palliative care ina population of 6 million (now 7 million) and with15 years of follow-up. Palliative Medicine-The Global Perspective: Closing the Know – Do Gap, Stjernsward and Xavier Gomez-Batiste. Declan Walsh, Text book of palliative medicine, page 6
Jordan is a relatively small country covering 92,3 km2. It has a population of 6.3 million people (estimatedin 2009), 50% of whom are under 25 years of age.According to cancer registry; cancer incidence isestimated to be 4332 new cases per year.60-70% of new cancer patients in Jordan presentlate to the health care system with advanced StageIII/IV cancers.
Breast cancer in JordanAccording to the latest statistics from the JordanNational Cancer Registry, 674 females and 10 maleswere diagnosed with breast cancer in 2005, accountingfor 18.6% of the total new cancer cases. Breast cancerranked first among cancer in females, accounting for36.2% of all female cancers, and is the leading causeof cancer deaths among Jordanian women.
70% of breast cancer cases in the country arepresented at advanced stages (III-IV) during whichsurvival rates are low and the disease is less curableand only 30% of cases are diagnosed in early stages(0-II).
Palliative care in Jordan before 2003Lack of awarenessFear of opioidsLack of professionalsNo IR MorphineMorphine prescription limited for 3 days
Jordan Initiative for Pain Relief & Palliative Care
Palliative care in Jordan..From dream into actionStarted with a dream from a donor, who had adream to make Middle East free of pain.Jordan Palliative Care initiative- WHO project.National Palliative care committee.
To effectively integrate palliative care, all four components ofthe WHO Public Health Model must be addressed.1) Appropriate policies.2) Adequate drug availability.3) Education of health care workers and the public.4) Implementation of palliative care services.For each component there are short, intermediate, and long- term outcomes that must be measured. THE PUBLIC HEALTH STRATEGY FOR PALLIATIVE CARE, JAN STJERNSWA RD, MD, MAYPHD, FRCP (EDIN), KATHLEEN M. FOLEY. JOURNAL OF PAIN AND SYMPTOM MANAGEMENT. VOL. 33 NO. 5 2007
WHO palliative Care projectTHE PUBLIC HEALTH STRATEGY FOR PALLIATIVE CARE, JAN STJERNSWARD, MD, MAYPHD, FRCP (EDIN), KATHLEEN M. FOLEY. JOURNAL OF PAIN AND SYMPTOM MANAGEMENT. VOL. 33 NO. 5 2007
2003 Policy Workshop60 policy-makers & clinicians National policy Drug availability Education
2004 March 3-week Course32 participant– 9 physicians– 23 nurses
Regulations governing opioid prescribing have beenchanged to facilitate effective pain management.The national opioid quota has been increased(From 2kg to 11 kg, 2003-2007).Cost-effective, generic,immediate-release morphine produced.Intensive, interactive bedside training courses.“Champions” for palliative care have emerged who areleading the development of palliative care in Jordan andsupport neighboring countries to develop pain relief andpalliative care. Jan Stjernswärd, Frank D Ferris. Journal of Pain and Symptom Pages 628-6Management, Volume 33, Issue 5, 33, May 2007
-KHCC hired the first palliative care physician, socialworker, chaplain, and clinical pharmacist in As ofDecember 2006.-palliative care service is admitting 400 new patients peryear and caring for 60–80 patients per month (of which 30–40 receive home care).-At KHCC, opioid usage in the outpatient setting alone hasdoubled from 2.5 kg in 2005 to a projected 5kg in 2006.This is a 3.3 fold increase since 2004.-The King Hussein Cancer Center is now developing into areference center of excellence, not only nationally but forthe region. JAN STJERNSWÄRD, FRANK D FERRIS. JOURNAL OF PAIN AND SYMPTOM MANAGEMENT, VOLUME 33, ISSUE 5, PAGES 628-633, MAY 2007
National palliative care initiatives From knowledge into action
There is no palliative care service outside KHCC. theaccess to opioids is still limited by many factors like,fear of opioids among health care workers and thepeople, policies and roles limiting the duration ofprescribing opioids (10 days for cancer patients and 3days for non cancer patients), and palliative care stillnot integrated into national health strategy.
StrengthsWell established health care systemPalliative care committeeWell established program at KHCCCultureDrugs availablePolicy change
In February 10th-12th, 2010; a regional Palliative Carewas conducted in Jordan as an initiative of the worldHealth Organization - East Mediterranean Regionaloffice (WHO-EMRO). The participants werephysicians, nurses, psychologists and social workersfrom Bahrain, Egypt, Jordan, Lebanon, Morocco,Oman, Palestine and Saudi Arabia.Arabic Consortium for Palliative Care was formed toencourage collaboration among the Palliative Careteams from these countries.
As for palliative care in Jordan, the SWOT analysisshowed that the main weakness points were shortageof palliative care teams, and lack of awareness aboutpalliative care and pain among health care workers inJordan.There was a need for a society that would take theinitiative to address the challenges and helpcoordinating the efforts to implement palliative care inJordan.
Jordan Palliative Care Society To help health care workers to provide highquality pain and symptom management, forpatient with chronic disease; by training andeducation, assuring drug availability, andcreating a network for palliative care across thecountry.
Knowing that education and training is the cornerstone in changing the practice of palliative care inJordan, JPS started with a two weeks workshop thatwill be given for family medicine teams, whichincludes physicians, nurses and pharmacists. Thegoals are create palliative care teams across thecountry. This will be followed by creating a palliativecare network for sharing knowledge and preparingleaders for palliative care.
National Palliative Care Workshop A national workshop offers the most effective way to address the establishment of the four foundation measures and come up with a plan of action for integrating palliative care into the health care system; it brings together the key participants and organizations necessary to accomplish these tasks. Palliative Medicine-The Global Perspective: Closing the Know – Do Gap, Stjernsward and Xavier Gomez-Batiste. Declan Walsh, Text book of palliative medicine, page 6
In countries with relatively destructuredgovernments, nongovernmental organizations(NGOs) have had an important role in modelprograms and initial projects. their more difficultchallenge is propelling projects and resourcesinto public health services for long-term viability. Palliative Medicine-The Global Perspective: Closing the Know – Do Gap, Stjernsward and Xavier Gomez-Batiste. Declan Walsh, Text book of palliative medicine, page 6
Next stepsPalliative care workshops for family physicians, GP’s, andnurses. The goal is to train- of trainers for palliative careteams across the country.National pain meeting, next November. The meeting willinclude health care workers, decision makers, and stockholders, to address pain issues in Jordan.Arabic palliative Care Consortium.
ConclusionPalliative medicine is an essential need forpatients with chronic diseases.Many countries managed to integrate palliativemedicine into health care strategy.Jordan WHO palliative care project reflected increating a center of excellence at KHCC.There is still need to spread the culture ofpalliative medicine across the country.
"Never doubt that asmall group ofthoughtful,committed peoplecan change theworld. Indeed, it isthe only thing thatever has." - MargaretMead.