Global Palliative Care (1).pdf

Global Palliative Care Dr. Meryem ERCEYLAN 08.03.2024 Global palliative care: from need to action By 2060, an estimated 48 million people (47% of all deaths globally) will die each year with serious health related suffering, and 83% of these deaths will occur in low-income and middle-income countrie...

Global Palliative Care Dr. Meryem ERCEYLAN 08.03.2024 Global palliative care: from need to action By 2060, an estimated 48 million people (47% of all deaths globally) will die each year with serious health related suffering, and 83% of these deaths will occur in low-income and middle-income countries”. These numbers indicate that 130000 people worldwide will die every day with serious health-related suffering by 2060 Global palliative care: from need to action Palliative care and pain relief is an essential health intervention that alleviates health-related suffering. Evidence supporting investment in palliative care shows that it is effective in reducing suffering for patients and families and cost effective. Global palliative care: from need to action As the world population ages, comorbidity also increases. A shift from a health system centred in medical specialties to personcentred care is required. Palliative care and its model of holistic medicine can contribute effectively to this necessary change in health systems. Global palliative care: from need to action In fact, almost 50% of the world’s countries have no access to palliative care, whereas the development of palliative care in the remaining half of countries has been uneven, with inequalities Global palliative care: from need to action The figures presented call for urgent action: improving access to palliative care is not only key to reduce serious health-related suffering but is also a moral imperative. Our health systems are insufficiently prepared to integrate palliative care and cover the growing needs of our populations. In light of the increasing global burden of serious health-related suffering, health systems must now be strengthened to meet the current and future demand for palliative care. Global palliative care: from need to action The global health community has the responsibility and the opportunity to improve the quality of life of people living and dying with serious health-related suffering, by recognising it as a public health priority and by supporting initiatives to tackle it. Global palliative care: from need to action WHO set an example in supporting palliative care at the global level by promoting its integration in national health policies through Resolution WHA67.19 of the World Health Assembly. In 2018, WHO continued to support the cause of palliative care by including an indicator to assess progress in this field in the General Programme of Work and recognising palliative care as an essential service of primary health care. Global palliative care: from need to action One way for health systems to respond to important public health problems is by implementing and adapting globally endorsed strategies (eg, the case of HIV/AIDS, tuberculosis, or dementia). The rising burden of serious health-related suffering also requires a specific global strategy that provides countries with a roadmap to improve palliative care, which also means developing solid health indicators to evaluate outcomes. Global palliative care: from need to action At present, it is unclear which indicators will be most effective; however, a combination of indicators evaluating the numerous dimensions of WHO’s public health strategy for palliative care, along with integration into other parts of the health system, and more broadly into society itself, is likely to be the most fruitful line of development. Why is palliative care a human rights issue? The committee overseeing the International Covenant on Economic, Social and Cultural Rights (ICESCR) issued a general comment on the right to health that includes a number of core obligations of all signatory nations, irrespective of resources (2000). These obligations include access to health facilities, goods and services on a nondiscriminatory basis; the provision of essential drugs as defined by WHO; and the adoption and implementation of a public health strategy. Why is palliative care a human rights issue? In the context of palliative care it is clear that patients with lifelimiting illness should have access to appropriate health care, basic medications for symptom control and terminal care, as well as inclusion of palliative care in national health care policies. The United Nations Committee on Economic, Social and Cultural Rights stated that it is critical to provide “attention and care for chronically and terminally ill persons, sparing them avoidable pain and enabling them to die with dignity World Health Assembly Resolution on Palliative Care This resolution calls on all member states to strengthen and integrate palliative care throughout their health care systems following the WHO public health model, which includes ensuring that policies are in place, comprehensive education on palliative care is available, essential palliative care medicines are available and affordable, and that programs are funded and implemented. World Health Assembly Resolution on Palliative Care WHO’s work to strengthen palliative care focuses 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 across disease groups and levels of care, addressing ethical issues related to the provision of comprehensive palliative care; supporting Member States in improving access to palliative care medicines through improved national regulations and delivery systems; a special focus on palliative care for people living with HIV, including development of guidelines; World Health Assembly Resolution on Palliative Care WHO’s work to strengthen palliative care focuses on the following areas: promoting increased access to palliative care for children (in collaboration with UNICEF); monitoring global palliative care access and evaluating progress made in palliative care programmes; developing indicators for evaluating palliative care services; encouraging adequate resources for palliative care programmes and research, especially in resource-limited countries; and building evidence of models of palliative care that are effective in low- and middle-income settings. Palliative Care and Universal Health Coverage The 2015 UN Sustainable Development Goals are the roadmap to improving life on earth. The continuum of universal health coverage under the United Nations Sustainable Development Goal number three includes Promotion, Prevention, Treatment, Rehabilitation, & Palliative Care. There is no ‘universal’ health coverage without palliative care. All nations need to include palliative care in their plans for Universal Health Coverage. Global Atlas of Palliative Care- 2nd Edition As a point of reference, in 2017 there were 55,945,730 deaths from 195 reporting countries worldwide. The great majority of those deaths, 73.4%, were due to non-communicable diseases. (Fig 1). Global Atlas of Palliative Care- 2nd Edition The total, all age, global need for palliative care is 56,840,123 people including both decedents and nondecedents. The need for non-decedents [31.100,719] was higher than for decedents [25,739,404] (Fig 2 ). Palliative care was needed for 45.3% of all deaths in 2017. Global Atlas of Palliative Care- 2nd Edition Approximately 40% of patients in need of palliative care are aged 70 years or older, 27% aged 50-69 and, almost 26% aged 20-49 and only 7% are children (0-17 years) (Fig 3). Global Atlas of Palliative Care- 2nd Edition Among adults (aged 20 years and over), 68.9% (36.5 million people) of decedent and non-decedent palliative care need is associated with a noncommunicable disease. HIV/AIDS, haemorrhagic fever, tuberculosis, and some injuries also account for an important part of palliative care for adults (Fig 4). Total need for palliative care for adults was 52,883,093 and there was nearly equal gender distribution (female 49%). Global Atlas of Palliative Care- 2nd Edition Although the largest single disease group accounting for adult palliative care is cancer, over 70% of the need is for other conditions as shown in Figure 5. HIV, cerebrovascular diseases, and dementia are the most frequent. Global Atlas of Palliative Care- 2nd Edition The need for palliative care varies by age group (Fig 6) for all 20 diagnostic groups with younger adults suffering more from HIV, congenital conditions, injury, and inflammatory conditions. Global Atlas of Palliative Care- 2nd Edition Using the WHO Member States regional groupings, over a quarter of adults needing palliative care (26.8%) live in the Western Pacific Region, followed by the Africa region (20.2%), Europe (17.9%) and South East Asia (17.1). The figures for the Americas and Eastern Mediterranean regions are 14.1% and 4.0%, respectively (Fig. 7). Global Atlas of Palliative Care- 2nd Edition However, the Africa Region has the highest number of adults in need of palliative care per 100,000 adult population, followed by Europe and the Americas regions (Fig. 8). Global Atlas of Palliative Care- 2nd Edition To analyse by region, the need for palliative care is grouped into seven categories: cancers, HIV/AIDS, stroke, dementias, injuries, and other non-malignant diseases. In all regions except Africa the highest proportion of adults in need of palliative care have other non-malignant disease. HIV/AIDS predominates in the African Region. The proportion of adults in need of palliative care for cancer is relatively high for all regions. It ranges from 6.1% in the African Region to 41.3% in the European and 40.8% in the American Region (Fig. 9) Global Atlas of Palliative Care- 2nd Edition The great majority, 76%, of the 53 million adults in need of palliative care live in low- or middle-income countries (LMICs) (Fig. 10). Global Atlas of Palliative Care- 2nd Edition Most (67%) live in the upper and lower middle-income groups. However, the highest ratios per 100 000 adult population in need of palliative care are found in the low-income countries (Fig. 11). Global Atlas of Palliative Care- 2nd Edition The illness conditions that most often generate a need for palliative care in decedents and non-decedents differ between high income (HICs) and LMICs. There are many more non-decedents with HIV/AIDS who need palliative care in LMICs than in HICs (Figs 12 & 13). Global Atlas of Palliative Care- 2nd Edition Maximum days of suffering were calculated for each of the 16 symptoms and for each condition, by multiplying the number of patients with the possibility of having the symptom as well as the average duration of the symptom in days. The global total sum of those days of suffering adds up to over 12,100 million days for decedents (Fig. 14) and 7,600 million days for non-decedents (Fig 15). Note that this does not consider overlap if several symptoms occurred simultaneously. What are the main barriers to palliative care development? Policy Education Medication Availability Implementation Health Workforce Need Psychological, social, cultural, and financial barriers What are the main barriers to palliative care development? Policy Without policies that support the provision of palliative care it is quite difficult for any palliative care to develop. Policy is seen as the fundamental component, because without it other changes cannot be introduced. Types of policies needed include: laws that acknowledge and define that palliative care is part of the health-care system; national standards defining how palliative care programs must operate; clinical guidelines for the delivery of palliative care services; establishment of palliative care as a recognized medical specialty/sub-specialty; regulations that establish palliative care as a recognized type of health-care provider with accompanying licensing provisions; a national strategy on palliative care implementation. What are the main barriers to palliative care development? Education The vast majority of health professionals worldwide have little or no knowledge of the principles and practices of palliative care. Palliative care education is needed at three levels: Basic palliative care training for all health professionals and paraprofessionals including physicians, nurses, mental health professionals, clergy, volunteers and therapists; Intermediate training for those routinely working with patients with lifethreatening illnesses; Specialist palliative care training for patients with more complex symptom management needs and for those who will teach palliative care and do research. What are the main barriers to palliative care development? Medication Availability Most medications in the WHO Model List of Essential Medicines for Pain and Palliative Care, 21st Edition 2019, especially controlled substances namely, opioids, are required for the delivery of quality palliative care. Access to opioid medications for pain control is an enormous problem worldwide. Over eighty per cent (84.25%) of the world’s population lacks adequate access to opioid medications for pain control. Australia, Canada, New Zealand, the United States, and several European countries accounted for more than 90% of the global consumption of opioid analgesics while Low-and-Middle Income Countries (LMICs) consumed only 10% of global opioids What are the main barriers to palliative care development? Implementation Without policy support for palliative care and funding mechanisms, growth is restricted to whatever is achieved by pioneers making sacrifices to create hospice and palliative care services in their communities. To reach the huge numbers of people with palliative care needs that are not receiving the services they need will require further integration into existing health care systems, including primary care and long-term care. Home based care is especially important and should be prioritised over creating new facilities. Some inpatient care is needed but the vast majority of palliative care services can be delivered in the places people call home. What are the main barriers to palliative care development? Implementation Palliative care programme development has been very uneven internationally and is correlated with Human Development Index levels, Universal Health Coverage, and World Bank Income Group. Without policy support for palliative care and funding mechanisms, growth is restricted to whatever is achieved by pioneers making sacrifices to create hospice and palliative care services in their communities. To reach the huge numbers of people with palliative care needs that are not receiving the services they need will require further integration into existing health care systems, including primary care and long-term care. Home based care is especially important and should be prioritised over creating new facilities. Some inpatient care is needed but the vast majority of palliative care services can be delivered in the places people call home. What are the main barriers to palliative care development? Health Workforce Need Reaching over 56 million people needing palliative care globally would require a major increase in the professional and para-professional workforce trained in at least basic or primary palliative care. WHPCA has estimated that approximately 2 million health care workers would be needed to care for a daily census of over 5.6 million patients just at the end of life, including approximately 400,000 palliative care community health workers mainly in low and middle-income countries. Bridging the gap in access to palliative care will mainly require all the elements in the above public health model but especially ensuring that all health professional receive training in palliative care before graduating from professional schools. What are the main barriers to palliative care development? Psychological, social, cultural, and financial barriers The development of palliative care has been limited by additional human factors. There is often a belief that even acknowledging the possibility that one may die soon is harmful. There is no evidence to support this belief and evidence points to the possibility that palliative care may actually improve survival. However, efforts to engage the public and policy makers on the need for palliative care have met with limited success. Many cultures have expressly prohibited informing patients of their diagnosis and prognosis when life-threatening. Previously this had been the case in most cultures, but views have been changing in the past several decades to the point where there is now some acceptance of the idea that patients themselves should be given the choice as to whether to receive this information Mapping levels of palliative care development: a global update 2017 We report here on a global programme of work that has been monitoring country level development in palliative care for more than a decade, beginning in 2006, followed up in 2011 and now updated for 2017. These studies have contributed significantly to advocacy, planning and monitoring of palliative care worldwide. One goal of the research has been to improve the quality of study design at each iteration, taking account of published feedback whilst at the same time presenting an unfolding analysis of global palliative care development over time. Mapping levels of palliative care development Categorisation of palliative care development 2017, N = 198 Group 1 countries: No known hospice-palliative care activity: Although it was not possible to identify any palliative care activity in this group of countries, it is acknowledged that there may be instances where, despite best efforts, current work has been unrecognised. Mapping levels of palliative care development Categorisation of palliative care development 2017, N = 198 Group 2 countries: Capacity building activity: A country in this category shows evidence of wideranging initiatives designed to create the organisational, workforce, and policy capacity for the development of palliative care services, although no service has been established yet. Developmental activities include attendance at, or organisation of, key conferences, personnel undertaking external training in palliative care, lobbying of policy makers and Ministries of Health and emerging plans for service development. Mapping levels of palliative care development Categorisation of palliative care development 2017, N = 198 Group 3 countries: 3a) Isolated palliative care provision: A country in this category is characterised by the development of palliative care activism that is still patchy in scope and not well supported; sources of funding that are often heavily donor dependent; limited availability of morphine; and a small number of palliative care services that are limited in relation to the size of the population. 3b) Generalized palliative care provision: A country in this category is characterised by the development of palliative care activism in several locations with the growth of local support in those areas; multiple sources of funding; the availability of morphine; several hospice palliative care services from a range of providers; and the provision of some training and education initiatives by the hospice and palliative care organisations. Mapping levels of palliative care development Categorisation of palliative care development 2017, N = 198 Group 4 countries: 4a) Countries where hospice-palliative care services are at a stage of preliminary integration into mainstream service provision: A country in this category is characterised by the development of a critical mass of palliative care activism in a number of locations; a variety of palliative care providers and types of services; awareness of palliative care on the part of health professionals and local communities; a palliative care strategy that has been implemented and is regularly evaluated; the availability of morphine and some other strong pain-relieving drugs; some impact of palliative care on policy; the provision of a substantial number of training and education initiatives by a range of organisations; and the existence of a national palliative care association. Mapping levels of palliative care development Categorisation of palliative care development 2017, N = 198 Group 4 countries: 4b) Countries where hospice-palliative care services are at a stage of advanced integration into mainstream service provision: A country in this category is characterised by the development of a critical mass of palliative care activism in a wide range of locations; comprehensive provision of all types of palliative care by multiple service providers; broad awareness of palliative care on the part of health professionals, local communities, and society in general; a palliative care strategy that has been implemented and is regularly updated; unrestricted availability of morphine and most strong pain-relieving drugs; substantial impact of palliative care on policy; the existence of palliative care guidelines; the existence of recognised education Centres and academic links with universities with evidence of integration of palliative care into relevant curricula; and the existence of a national palliative care association that has achieved significant impact. References https://www.thelancet.com/action/showPdf?pii=S2214109X%2819%2930223-2 file:///C:/Users/lenovo/Downloads/WHPCA_Global_Atlas_DIGITAL_C ompress%20(2).pdf