Palliative Care in JordanA WHO demonstration projectGlobal Summit on International Breast Health

1. Palliative Care in Jordan
A WHO demonstration project
Global 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

2. Palliative Care- Global perspective.
WHO Palliative Care Initiative.
National Palliative Care Initiative.

3. 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

4. Palliative care relieves suffering and improves
the quality of life of the living and the dying.
More than 30 million people suffer
unnecessarily from severe pain and other
symptoms each year.
In spite of all the efforts over the last 2 decades,
most people who need palliative care are not
getting 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

5. Distribution of Palliative Care Services
There are 60 million person dying each year. 6
million of them die in pain. Only 1 million of them
receive palliative care.
It is estimated that there are 8,000
hospice/palliative care services, in about 100
countries around the world .
86% of services world wide are located only in
ten countries .
Journal of Public Health Policy, 2007 by Webster, Ruth, Lacey, Judith, Quine, Susan

6. A public health approach aims to protect and improve the
health and quality of life of a community by translating new
knowledge and skills into evidence-based, cost-effective
interventions.
it is important that all countries integrate pain relief and
palliative 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.

7. Palliative care became a part of the National
Health Plan in Catalonia, Uganda, Mongolia,
and Georgia. The Indian state of Kerala has
successfully integrated palliative care through
community 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

8. The Catalonia WHO demonstration project was
the first to reach the long-term outcomes, having
covered 80% of all those needing palliative care in
a population of 6 million (now 7 million) and with
15 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

9. Palliative Care in Jordan

11. Jordan is a relatively small country covering
92,3 km2.
 It has a population of 6.3 million people (estimated
in 2009), 50% of whom are under 25 years of age.
According to cancer registry; cancer incidence is
estimated to be 4332 new cases per year.
60-70% of new cancer patients in Jordan present
late to the health care system with advanced Stage
III/IV cancers.

12. Breast cancer in Jordan
According to the latest statistics from the Jordan
National Cancer Registry, 674 females and 10 males
were diagnosed with breast cancer in 2005, accounting
for 18.6% of the total new cancer cases. Breast cancer
ranked first among cancer in females, accounting for
36.2% of all female cancers, and is the leading cause
of cancer deaths among Jordanian women.

13. 70% of breast cancer cases in the country are
presented at advanced stages (III-IV) during which
survival rates are low and the disease is less curable
and only 30% of cases are diagnosed in early stages
(0-II).

14. Australia ≈ 60 mg
US ≈ 50 mg
Global 5.44 mg

15. Palliative care in Jordan before 2003
Lack of awareness
Fear of opioids
Lack of professionals
No IR Morphine
Morphine prescription limited for 3 days

16. Jordan Initiative for
Pain Relief &
Palliative Care

17. Palliative care in Jordan..From dream into action
Started with a dream from a donor, who had a
dream to make Middle East free of pain.
Jordan Palliative Care initiative- WHO project.
National Palliative care committee.

18. To effectively integrate palliative care, all four components of
the 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

19. WHO palliative Care project
THE 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

20. 2003 Policy Workshop
60 policy-makers & clinicians
National policy
Drug availability
Education

21. 2004 March 3-week Course
32 participant
– 9 physicians
– 23 nurses

22. Regulations governing opioid prescribing have been
changed 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 are
leading the development of palliative care in Jordan and
support neighboring countries to develop pain relief and
palliative care.
Jan Stjernswärd, Frank D Ferris. Journal of Pain and Symptom Pages 628-6Management, Volume
33, Issue 5, 33, May 2007

23. -KHCC hired the first palliative care physician, social
worker, chaplain, and clinical pharmacist in As of
December 2006.
-palliative care service is admitting 400 new patients per
year and caring for 60–80 patients per month (of which 30–
40 receive home care).
-At KHCC, opioid usage in the outpatient setting alone has
doubled 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 a
reference center of excellence, not only nationally but for
the region.
JAN STJERNSWÄRD, FRANK D FERRIS. JOURNAL OF PAIN AND SYMPTOM MANAGEMENT,
VOLUME 33, ISSUE 5, PAGES 628-633, MAY 2007

25. National palliative care initiatives
From knowledge into action

26. There is no palliative care service outside KHCC. the
access to opioids is still limited by many factors like,
fear of opioids among health care workers and the
people, policies and roles limiting the duration of
prescribing opioids (10 days for cancer patients and 3
days for non cancer patients), and palliative care still
not integrated into national health strategy.

27. Strengths
Well established health care system
Palliative care committee
Well established program at KHCC
Culture
Drugs available
Policy change

28. In February 10th-12th, 2010; a regional Palliative Care
was conducted in Jordan as an initiative of the world
Health Organization - East Mediterranean Regional
office (WHO-EMRO). The participants were
physicians, nurses, psychologists and social workers
from Bahrain, Egypt, Jordan, Lebanon, Morocco,
Oman, Palestine and Saudi Arabia.
Arabic Consortium for Palliative Care was formed to
encourage collaboration among the Palliative Care
teams from these countries.

29. As for palliative care in Jordan, the SWOT analysis
showed that the main weakness points were shortage
of palliative care teams, and lack of awareness about
palliative care and pain among health care workers in
Jordan.
There was a need for a society that would take the
initiative to address the challenges and help
coordinating the efforts to implement palliative care in
Jordan.

30. Jordan Palliative Care Society
To help health care workers to provide high
quality pain and symptom management, for
patient with chronic disease; by training and
education, assuring drug availability, and
creating a network for palliative care across the
country.

31. Knowing that education and training is the corner
stone in changing the practice of palliative care in
Jordan, JPS started with a two weeks workshop that
will be given for family medicine teams, which
includes physicians, nurses and pharmacists. The
goals are create palliative care teams across the
country. This will be followed by creating a palliative
care network for sharing knowledge and preparing
leaders for palliative care.

32. 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

33. In countries with relatively destructured
governments, nongovernmental organizations
(NGOs) have had an important role in model
programs and initial projects. their more difficult
challenge is propelling projects and resources
into 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

34. Next steps
Palliative care workshops for family physicians, GP’s, and
nurses. The goal is to train- of trainers for palliative care
teams across the country.
National pain meeting, next November. The meeting will
include health care workers, decision makers, and stock
holders, to address pain issues in Jordan.
Arabic palliative Care Consortium.

35. Conclusion
Palliative medicine is an essential need for
patients with chronic diseases.
Many countries managed to integrate palliative
medicine into health care strategy.
Jordan WHO palliative care project reflected in
creating a center of excellence at KHCC.
There is still need to spread the culture of
palliative medicine across the country.

36. "Never doubt that a
small group of
thoughtful,
committed people
can change the
world. Indeed, it is
the only thing that
ever has." - Margaret
Mead.

37. Thank you