Palliative Care

More than any other aspect of cancer control, palliative care can bring relief from pain and suffering and improve quality of life more immediately. Globally most cancer is incurable when diagnosed, and even in developed countries up to 50% of patients overall will die of their disease. Palliative care thus can impact all forms of cancer. Compared to cancer treatment methods palliative care is relatively simple and inexpensive. It should have a high priority in cancer control where it will be required in up to 80% of cases in some countries. Indeed in the developing setting where there are not enough doctors, nurses and resources to deal with the existing load of cancer patients, palliative care becomes an essential part of a national strategy in this kind of situation. Strong political motivation and leadership is needed to correct the situation without high expenditure.

Although inexpensive methods for relief of pain exist, cancer pain relief is still much neglected in the daily care of the more than four million cancer patients worldwide who suffer cancer pain. The current failure to achieve adequate pain relief in advanced cancer has several contributing factors: inadequate education of physicians and medical students on the proper treatment of pain; the fear that patients will become drug dependent so that opioids are underprescribed and underused; a general lack of awareness that pain can be relieved; and misguided drug legislation leading to poor availability of appropriate drugs.

Governments can undertake a number of initiatives that will have a major impact on the quality of life of cancer patients. In addition to establishing national policies and programs for cancer pain relief and palliative care, governments can ensure that these programs are incorporated into their existing health care systems. Health care workers, especially physicians, medical students, nurses and pharmacists can be trained for their respective appropriate roles in palliative care and cancer pain relief. Equitable support can be provided for palliative home care programs as part of national health policy. Governments can also assure that hospitals can offer back-up support for home care, and that opioid (especially oral morphine) and nonopioid analgesics are readily available.

WHO has done considerable work in this area of cancer control. Its program calls for the dissemination of knowledge of what can be done to relieve cancer pain through a global network. The awareness of patients and families that pain can almost always be controlled should be increased. Doctors and nurses should be trained to treat cancer pain, and this information should be in standard textbooks of cancer medicine. Cancer pain should be treated not just in specialized cancer centres, but also in general hospitals, health centres and at home. National drug legislation should be revised to make analgesics readily available to patients. Public and private fund-raising can be undertaken to support local and national programs for relief of cancer pain.

WHO has produced publications on policies and guidelines for cancer pain relief and palliative care. Some of these describe its successful three-step "ladder" for cancer pain relief, which has proven effective in clinical studies. The first step uses oral nonopioids (aspirin and paracetamol). One moves on to mild opioids like codeine in the second step and then to strong opioids like oral morphine in the third step until the patient is pain free. Adjuvant drugs are used for anxiety and to handle special situations such as bone or neuropathic pain. Drugs are given by the clock every 3 – 6 hours rather than on demand to assure that the right drug is given in the right dose at the right time to achieve an 80-90% efficacy that is cost-effective. Specialized procedures by anesthetists and neurosurgeons can be provided at cancer centres for the remaining few patients who require them.

WHO guidelines can be distributed to all involved health care workers, and some of this material can be adapted for family members and non-medical staff involved in palliative and terminal care. Physicians and allied health workers can be trained in the WHO cancer pain ladder and the elements of symptom relief and palliative care. Drug regulators can amend regulations that inhibit or discourage the use and availability of analgesics, especially opioids like oral morphine. The importance of home care for patients with advanced cancer needs to be recognized with hospital back-up and support provided.

Implementation for palliative care requires several steps:

• Treatment policies need to be adapted to the predominant patterns of malignant disease in the country and to available resources in a flexible way that responds readily to changes, especially in resources.
• Patient groups are identified that are suitable for the pain and symptom management of palliative therapy.
• A National Committee is established to generate guidelines for palliative care for particular cancer sites, and to recommend on facilities such as hospices and programs such as for pain or for home care.
• An information system will also be needed to allow for monitoring and evaluation of the program, including measurement of narcotic consumption and periodic surveys of the adequacy of pain and symptom control.

The basic model of education, legislation and national leadership is modified for palliative care as follows:

• Education
  Mass public education on need for and effectiveness of palliative care
  Educate health care professionals such as physicians, nurses and
  pharmacists on the value and techniques of pain and symptom
  management.

Educate other stakeholders such as health-care policy makers,
administrators and drug regulators on the importance of providing
palliative care.
In all cases stress the humanitarian imperative of the relief of suffering
Utilize the influence of the mass media
Consider a survey to assess the current effectiveness of pain and symptom
relief.

• Drug Availability
  Alter health care regulations and legislation to make drugs, especially opioids,
  available

Implement improvements in the prescribing, distributing, dispensing and
administration of drugs, especially opioids.

• Governmental Policy
  Promote collaboration across disciplines and ministries
  Establish national or state policy that enables the alleviation of chronic cancer
  pain.(WHO, 1995)
  

Process, impact and outcome measures are used to monitor and evaluate palliative care programs. Examples might include (WHO,1995):

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