Palliative care is an essential component of care for individuals with tuberculosis (TB), especially multidrug-resistant TB (MDR-TB). Palliative care aims to improve patients' quality of life by preventing and treating suffering through pain management and other treatment. Most palliative care for TB should be provided in home-based settings to allow for infection control, with support from trained health workers and community groups. Palliative care can help manage TB symptoms, provide psychological and spiritual support to patients and families, and enhance quality of life even as the disease progresses.

1. Palliative Care for Tuberculosis
Facilitator : Dr.Dinesh Kumar
Presenter : Dr.Darshna Sarvaiya
1st Year resident
Community Medicine

2. Palliative care
Dr. Baulfor Mount coined the term “Palliative care” 1975
Palliative care is an approach that improves the quality of life of patients and their families
facing the problem associated with life-threatening/ limiting illness, through the prevention
and relief of suffering by means of early identification and impeccable assessment and
treatment of pain and other problems, physical, psycho-social and spiritual.
Physician – patient communication & provision of multispecialty co-ordinated care.

6. Introduction
India faced with a twin burden of communicable as well as non-communicable diseases 
bridging of infection control and modern goal of NCD prevention& management.
Tuberculosis is an infectious airborne disease
- Source of transmission : Contagious person infecting those who share air space
- Prevention : early detection of new cases and initiation of effective treatment
MDR-TB : Resistance to Isoniazid and Rifampicin
XDR-TB : Resistance to Isoniazid ,Rifampicin ,Fluoroquinolones and at least one of the three
second line injectable drugs .

7. TB Burden :Global V/S India V/S Gujarat
Estimation
of TB Burden
Global India % of Global Gujarat % against
India
Incidence of
TB Cases
100 lakhs 27.9 lakhs 27 % 1.55 lakhs 5.5 %
Mortality of
TB
13 lakhs 4.23 lakhs 34 % 5591 1.3 %
MDR-TB 6 lakhs 1.47 lakhs 27% 3422 2.2 %
TB –HIV
Deaths
3 lakhs 11000 4% 429 3.9 %
WHO Global Report 2018
TB Burden : Global V/S India V/S Gujarat

8. History
2010  Dr. Ernesto Jaramillo (MO in Stop TB programme )  partnership with Society
Foundation’s International Palliative care initiative (OSF/IPCI)
November 18-19 ,2010  37 experts attended from TB and palliative care organization 
Agreement on Palliative care needs to be included in the global response to TB
Develop education about the palliative care For TB workers  launch of a basic course
2012 Union meeting at Kuala Lumpur
2013  Union meting at Paris
2014  Barcelona , Clinical guidelines for palliative care in TB patients in Netherland
2015  South Africa , Guidelines for DR-TB and TB palliative care and support

9. Palliative care is an essential component of the provision of care for individuals with
MDR/XDR-TB patients needs to access.
Palliative care should be strengthened  provided and integrated alongside the prevention &
TX of TB.
Palliative care strengthens the Stop –TB strategy .
Improving access to care ,medications ,training , and capacity building .
Declaration

10. Hughes J, Snyman L. Palliative care for drug-resistant tuberculosis: when new
drugs are not enough. The Lancet Respiratory Medicine. 2018 Apr 1;6(4):251-2.

11. PATIENT
FAMILY
CARE-GIVER

13. Barriers
Lack of awareness and training of palliative care among the health professionals
Restrictive regulation for morphine and other medicines deny access to adequate pain relief .
National health policies and systems do not often include palliative care at all
Culture and social barriers , such as beliefs about death and dying
Misconceptions about palliative care , such as that it is only for patients with cancer or for the
last weeks of life .
Misconception that improving access to opioids analgesia will lead to increased substance
abuse .

16. WHO ‘s work to strengthen palliative care will focus on the
following areas
Integrating palliative care into all relevant global disease control and health system plans
Developing guidelines and tools on integrated palliative care
Supporting member states in improving access to palliative care medicines through improved
national regulations and delivery systems
Monitoring global palliative care access and evaluating progress made
Encouraging adequate resources for palliative care programme and research

17. Who Needs Palliative care ?
 Drug sensitive TB patients co-infected with HIV
DST TB patients with extra pulmonary TB
TB patients not being able to adhere to treatment
DR-TB treatment has failed and all the treatment option have been exhausted
M/X-DR TB patients having adverse effect due to drugs .
MDR or XDR TB patients that are unable to convert sputum negative status

18. What makes Tuberculosis a Unique Palliative Care situation ?
TB & MDR-TB is contagious disease
Not treated properly ,
Threatens surrounding people including health care worker & patients family
Patient carries infection long time before they are diagnosed  family are
possibly infected
At that time provision of palliative care to patient with TB or MDR/XDR involves
less treatment and infection control measures

19. Free
standing
hospices
Inpatient care
in general
setting
Outpatient
care
Home based
Settings

20. Settings in case of Tuberculosis
Home-based palliative care :
- NDR TBC staff can counsel and train family members or caretakers of the patient
- All health workers must receive training in palliative care .
Institution-based palliative care :
- Selected NDR TBCs
- States may identify interested NGO’s or faith-based organizations with indoor facilities
engaged through an MoU and guided by NDR TBCs
- All such facilities, airborne infection control measures as per national AIC guidelines
must be strictly implanted .
- Regular consultative visits to NDR TBC as and when medically required.

21. Most palliative care must be home-based through a trained and counselled
family member or caretaker with regular visits by health care workers and
psychosocial/spiritual support through local community-based self-help groups,
NGOs.

22. Benefits for MDR-TB patients
Provides relief from respiratory distress , pain and other symptoms
Integrates the psychological and spiritual aspects of patient care
Offers a support system to help patients live as actively as possible until death
Support family cope during the patients illness and their own bereavement
Enhance quality of life ,and may also positively influence the course of illness
Applicable early in the course of illness , in conjunction with anti-TB drugs ,to prolong life
through the care

23. End-of life supportive measures
Relief from dyspnoea :
- Morphine provides significant relief from respiratory insufficiency  offered according to
established clinical protocols .
Relief from pain and other symptoms:
- Paracetamol, or codeine with paracetamol, gives relief from moderate pain
- Stronger analgesics, including morphine, should be used when appropriate to keep the
patient adequately comfortable .
Infection control measures :
- Separate infectious patients
- Control the spread of pathogens (cough etiquette and respiratory hygiene )
- Minimize time spent in health-care facilities
- Use particulate respirators (N95)

24. Regular medical visits :
- Regular visits by health care providers
- Support team should be continued to address medical needs , infection control practices
Nutritional support:
Continuation of ancillary medicines :
- Codeine helps control cough, Bronchospasms can be controlled with a metre-dosed inhaler
Hospitalization, hospice care or nursing home care  home care is not feasible or desirable
Preventive measures :
- Oral care , prevention of bedsores
Provide psychological support & Emotional support :
- To assist patients in the planning of decisions
- Especially in settings in which strong stigma is attached to the disease.
Respect for patient’s beliefs and values during treatment, and especially at the end of life

25. References
1. Gwyther L, Krause R, Cupido C, Stanford J, Grey H, Credé T, De Vos A, Arendse J, Raubenheimer
P. The development of hospital-based palliative care services in public hospitals in the Western
Cape, South Africa. South African Medical Journal. 2018;108(2):86-9.
2. Sepúlveda C, Marlin A, Yoshida T, Ullrich A. Palliative care: the World Health Organization's
global perspective. Journal of pain and symptom management. 2002 Aug 1;24(2):91-6.
3. World Health Organization. Strengthening of palliative care as a component of integrated
treatment throughout the life course. Journal of Pain & Palliative Care Pharmacotherapy. 2014
Jun 1;28(2):130-4.
4. Sawyer JM, Asgr R, Fordham FN, Porter JD. A public health approach to palliative care in the
response to drug resistant TB: an ethnographic study in Bengaluru, India. BMC palliative care.
2018 Dec;17(1):120.
5. World Health Organization. Companion handbook to the WHO guidelines for the programmatic
management of drug-resistant tuberculosis. World Health Organization; 2014.

26. 6. Mohr E, Hughes J, Snyman L, Beko B, Harmans X, Caldwell J, Duvivier H, Wilkinson L, Cox V.
Patient support interventions to improve adherence to drug-resistant tuberculosis treatment:
A counselling toolkit. SAMJ: South African Medical Journal. 2015 Aug;105(8):631-4.
7.Jain V. Palliative care in India: Trials, tribulations, and future prospects. Journal of Mahatma
Gandhi Institute of Medical Sciences. 2018 Jul 1;23(2):55.
8.Hughes J, Snyman L. Palliative care for drug-resistant tuberculosis: when new drugs are not
enough. The Lancet Respiratory Medicine. 2018 Apr 1;6(4):251-9. 9.Connor SR, Sepulveda
Bermedo MC. Global atlas of palliative care at the end of life.

27. Thank you ….!!