Page 0121

access on a progressive basis.8

Some of the core obligations noted in Table 2 are equally

important in palliative care, such as adequate nutrition,

shelter, sanitation and safe, potable water. It is also

important to focus on prevention of illness such as

immunization against HPV to prevent cervical cancer and

healthy lifestyle to limit non-communicable diseases. We

need to recognize that child health care should include

paediatric palliative care when necessary.

WHO public health strategy for palliative care

In 2002, Stjernswärd described the Ugandan success in

integrating palliative care into the country's health system

through engaging a government public health approach.11

Drawing on this success WHO recommends four "low-cost

foundation measures" for integrating palliative care into a

country's health system. These are 1) developing and

implementing policies for palliative care; 2) educating health

care workers in palliative care and creating awareness of

palliative care services within communities; 3) ensuring drug

availability, in particular essential analgesic medication; and

4) developing palliative care services within the public health

sector.12

Barriers to palliative care

Doyle and Woodruff, writing for the International

Association of Hospice and Palliative Care Manual of Palliative

Care13 describe a number of barriers to palliative care that

they classify as physician factors, patient factors, social

factors and access factors. Lack of education in palliative

medicine translates into lack of understanding of the role of

palliative care and lack of integration of palliative care into

clinicians' practice. One of the physician barriers described is

the lack of communication skills to address end-of-life issues.

There are a number of difficult conversations that doctors

may need to have as a patient's disease progresses and it is

important the doctors become skilled in having these

conversations so that patients and family members can be

fully informed about the illness and can make choices that are

appropriate to their circumstances and preferences.14

Doctors may be reluctant to refer patients to palliative care if

they do not have an understanding or belief in the discipline.

They may also be reluctant to hand over care to another

doctor and unfortunately may also be guided by a fee for

service structure and concerns about loss of income. Patient

factors that are a barrier to palliative care include denial in

patients that often hope or believe that the prognosis is

better than what they are told; they may have an unrealistic

expectation of the disease's response to treatment; there

may be disagreement about treatment options between

patient and family members; there is frequently a lack of

advanced care planning. Lack of informational access may be

as a result of patients or family members not being receptive

to the information or choosing to ignore the information

about palliative care services.13 Social factors that may be

barriers to accessing palliative care include poverty; living in

a rural community; being part of disempowered or

marginalized groups such as refugees, prisoners, the

homeless. Dissonance between the patient's culture and the

culture of the care service may be a barrier. Western

palliative care started with a strong Christian foundation and

many organizations still use Christian symbols that may deter

patients from other religions using the services. Palliative

care workers are trained to be sensitive to these social and

cultural issues and involving carers from the patient's social

and cultural community can help to overcome these barriers.

The role of the health care professional in improving

patients' access to palliative care

In terms of human rights, governments have three levels of

obligation: to respect, protect and fulfil these rights. But

people are not simply passive recipients of the benefits of

human rights, they can demand that their rights are fulfilled

and upheld. London describes agency as "critical to a human

rights approach"

15 and states that: "Rights alone are not

enough, but need to be coupled with community

engagement".16 Who leads this community engagement and

who encourages and supports the agency of the vulnerable

individual requiring palliative care? Chochinov eloquently

expressed the lack of agency afforded vulnerable individuals

requiring palliative care when he addressed the Canadian

Senate Standing Committee on Social Affairs, Science and

Technology: ''Unfortunately, in end-of-life care, we do not

have a vocal constituency: The dead are no longer here to

speak, the dying often cannot speak, and the bereaved are

often too overcome by their loss to speak''.17

Patients living with cancer and their family members are

very powerful advocates when they are encouraged and

supported to speak about their needs and demanding their

human rights. A particularly powerful series are the Life

Before Death (www.lifebeforedeath.com)

18 and Treat the

Pain (http://treatthepain.org)19 videos series setting out the

imperative for good palliative care and pain management.

Communities are also often quiet on the imperative for

good end-of-life care. Death is not a comfortable topic of

conversation or discussion and communities choose not to

consider the need for palliative care or ignore information

about palliative care because of this discomfort. These

PALLIATIVE CARE

120 CANCER CONTROL 2014

Index

  1. Page 0001
  2. Page 0002
  3. Page 0003
  4. Page 0004
  5. Page 0005
  6. Page 0006
  7. Page 0007
  8. Page 0008
  9. Page 0009
  10. Page 0010
  11. Page 0011
  12. Page 0012
  13. Page 0013
  14. Page 0014
  15. Page 0015
  16. Page 0016
  17. Page 0017
  18. Page 0018
  19. Page 0019
  20. Page 0020
  21. Page 0021
  22. Page 0022
  23. Page 0023
  24. Page 0024
  25. Page 0025
  26. Page 0026
  27. Page 0027
  28. Page 0028
  29. Page 0029
  30. Page 0030
  31. Page 0031
  32. Page 0032
  33. Page 0033
  34. Page 0034
  35. Page 0035
  36. Page 0036
  37. Page 0037
  38. Page 0038
  39. Page 0039
  40. Page 0040
  41. Page 0041
  42. Page 0042
  43. Page 0043
  44. Page 0044
  45. Page 0045
  46. Page 0046
  47. Page 0047
  48. Page 0048
  49. Page 0049
  50. Page 0050
  51. Page 0051
  52. Page 0052
  53. Page 0053
  54. Page 0054
  55. Page 0055
  56. Page 0056
  57. Page 0057
  58. Page 0058
  59. Page 0059
  60. Page 0060
  61. Page 0061
  62. Page 0062
  63. Page 0063
  64. Page 0064
  65. Page 0065
  66. Page 0066
  67. Page 0067
  68. Page 0068
  69. Page 0069
  70. Page 0070
  71. Page 0071
  72. Page 0072
  73. Page 0073
  74. Page 0074
  75. Page 0075
  76. Page 0076
  77. Page 0077
  78. Page 0078
  79. Page 0079
  80. Page 0080
  81. Page 0081
  82. Page 0082
  83. Page 0083
  84. Page 0084
  85. Page 0085
  86. Page 0086
  87. Page 0087
  88. Page 0088
  89. Page 0089
  90. Page 0090
  91. Page 0091
  92. Page 0092
  93. Page 0093
  94. Page 0094
  95. Page 0095
  96. Page 0096
  97. Page 0097
  98. Page 0098
  99. Page 0099
  100. Page 0100
  101. Page 0101
  102. Page 0102
  103. Page 0103
  104. Page 0104
  105. Page 0105
  106. Page 0106
  107. Page 0107
  108. Page 0108
  109. Page 0109
  110. Page 0110
  111. Page 0111
  112. Page 0112
  113. Page 0113
  114. Page 0114
  115. Page 0115
  116. Page 0116
  117. Page 0117
  118. Page 0118
  119. Page 0119
  120. Page 0120
  121. Page 0121
  122. Page 0122
  123. Page 0123
  124. Page 0124
  125. Page 0125
  126. Page 0126
  127. Page 0127
  128. Page 0128
  129. Page 0129
  130. Page 0130
  131. Page 0131
  132. Page 0132
  133. Page 0133
  134. Page 0134
  135. Page 0135
  136. Page 0136
  137. Page 0137
  138. Page 0138
  139. Page 0139
  140. Page 0140
  141. Page 0141
  142. Page 0142
  143. Page 0143
  144. Page 0144
  145. Page 0145
  146. Page 0146
  147. Page 0147
  148. Page 0148
  149. Page 0149
  150. Page 0150
  151. Page 0151
  152. Page 0152
  153. Page 0153
  154. Page 0154
  155. Page 0155
  156. Page 0156

powered by PageTiger