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(WP)NCD/ICP/NCD/003-E English only Report Series No.: RS/98/GE/02(JPN)

REPORT

WORKSHOP ON STRENGTHENING HEALTH PROFESSIONAL EDUCATION IN CANCER PAIN RELIEF AND DEVELOPMENT OF PALLIATIVE CARE EXPERTISE

Convened by: WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC Saitama. Japan

23-26 March 1998

Not for sale

Printed and distributed by the

World Health Organization Regional Office for the Western Pacific

Manila, Philippines

September 1998

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CONTENTS

SUMMARY................................................................................................................................. i

I. INTRODUCTION ................................................................................................................. I

2. PROCEEDINGS ................................................................................................................... 2

3. SUMMARY OF DISCUSSION ......................................................................................... 9

4. CONCLU Sl ON S ................................................................................................................. I I

ANNEXES:

ANNEX I - LIST OF PARTICIPANTS, CONSULTANTS, TEMPORARY ADVISERS. OBSERVERS AND SECRETARIAT ................................ 15

ANNEX 2 - AGENDA ................................................................................................. 21

ANNEX 3 - OPENING REMARKS BY THE REGIONAL DIRECTOR ................... 23

ANNEX 4 - TECHNICAL DISCUSSIONS ............................................................... 25

ANNEX 5 - GROUP REPORTS ................................................................................. 29

ANNEX 6 - DRAFT CURRICULUM GUIDELINES FOR CANCER PAIN RELIEF AND PALLIATIVE CARE ....................................... 33

Key words

~eoplasms I Pain I Palliative Care I Education, Medical I Education, Nursing I Japan

NOTE

The views expressed in this report are those of the participants in the Workshop on Strengthening Health Professional Education in Cancer Pain Relief and Development of Palliative Care Expertise and do not necessarily reflect the policies of the World Health Organization.

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for the participants in the Workshop on Strengthening Health Professional Education in Cancer Pain Relief and Development of Palliative Care Expertise, held in Saitama, Japan, from 23 to 26 March 1998.

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SUMMARY

The WHO Regional Workshop on Strengthening Health Professional Education in Cancer Pain Relief and Development of Palliative Care Expertise was held from 23 to 26 March 1998 in Omiya. Japan. in close collaboration with the WHO Collaborating Centre in Cancer Pain Relief and Quality of Life at the Saitama Cancer Centre, Japan.

Objectives

(I) To develop approaches for implementation of the WHO guidelines of cancer pain relief and to update current knO\vledge and skills in cancer pain and palliative care;

(2) to develop appropriate ways of integrating palliative care and cancer pain relief into medical and nursing curricula in undergraduate education and postgraduate training; and

(3) to develop strategies for the establishment of palliative care expertise in developing countries in the Region.

The Workshop was attended b~ 12 participants from II countries in the Region, 2 temporary advisers. 2 WHO consultants. 3 WHO staff. and 5 observers. A total of 25 people took active part in the deliberations. Dr Koo Wen-Hsin (Singapore) was elected Chairman. supported by Professor You Jo Ro (Republic of Korea) as Vice Chairman and Dr Marilyn A. Pajei-Calilung (Philippines) as Rapporteur.

Mr Yuzo Narita. Deputy Executive Director and superintendent for Prefecture Hospitals, Department of Public Health, Saitama Prefecture. welcomed participants on behalf of the Saitama Prefecture. The workshop was opened by Dr S.T. Han, the WHO Regional Director for the Western Pacific.

The workshop reviewed current understanding of cancer pain relief. the availability of opioid analgesics for cancer pain relief in the countries of the Region, the important role of national drug regulations and regulators, the WHO method on cancer pain relief and approaches to changing the regional practice of cancer pain management. WHO activities in cancer pain relief and palliative care were also reviewed. Participants from the II countries presented reports on the current situation of cancer control in each country with a specific emphasis on development of a cancer pain relief programme. palliative care education, opioid availability. and drug regulatory issues. A field visit to the Saitama Cancer Centre was arranged. In a series of three small group sessions. the participants considered how they could bring to their own national situations improvements in the implementation of WHO methods for cancer pain relief, strengthen palliative care education at undergraduate and postgraduate levels, and support the establishment of palliative care expertise. Each of the three small groups gave a report at the final plenary session of the workshop and offered a series of conclusions.

The workshop concluded that:

(I) Member States of the Region should give priority to the further implementation ofthe WHO Method on Cancer Pain Relief and the development of palliative care services.

(2) National focal points for the development of national policies and programmes on cancer pain relief and palliative care should be identified.

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(3) Appropriate national cancer pain relief and palliative care policies and programmes should be developed and should involve drug regulators, medical and nursing schools. h,,;;pitals and pharmacies. professional organizations and societies and the volunteer sectors :\national palliati,·e care expert committee may be an appropriate advisory body to otTer techn1cal support for planning. implementati.Jn and evaluation of the cancer pain and palliati\ e care programme.

( 4) Education and training of health professionals in cancer pain relief and palliative care should be strengthened. The important role of medical and nursing schools in each country was recognized. National curricula in palliative care within both undergraduate and postgraduate programmes should be prepared

(5) National efforts to eliminate the barriers to appropriate medical use of opioids should include comprehensive availability of morphine in multiple formulations; correction of disproportionate controls on prescription pads. and elimination of the awkwardness and expense involved in obtaining forms for opioid prescription. Pharmacy restrictions which prevent pharmacists from storing and dispensing opioids should be eliminated.

(6) No upper limit exists for the dose of morphine and other opioids. Morphine doses may be increased progressively to alleviate pain in the absence of limiting. uncontrolled adverse effects. This "ell-established point should be understood both by officials controlling opioid use and by all physicians.

( 7) Efforts should be made to translate the WHO publications and other education materials into the major languages of the Region and widely disseminate them and other useful materials to health professionals and the general public.

( 8) Establishment of national demonstration projects in cancer pain rei ief and palliati\·e care should take place in countries of the Region.

( 9) The status of nurses and pharmacists should be strengthened and multidisciplinary education and professional teamwork should be promoted.

(I 0) An electronic nel\\ork for cancer pain relief and palliative care should be established. Existing \\orld pain relief and palliative care websites should be linked and fully utilized. The further development of regional links will provide an important measure for strengthening information exchange.

(I I) WHO collaborating centers and active regional and international expert groups in the field of cancer pain relief and palliative care should be encouraged for further strengthening their collaboration and development in the cancer pain relief and palliative care throughout the Region.

( 12) Awareness should be raised among the public, patients and their families that pain can be controlled and quality of life can be improved. national and community advocacy initiatives should be supported.

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I. INTRODUCTION

The WHO Regional Workshop on Strengthening Health Professional Education in Cancer Pain Relief and Development of Palliative Care Lpertise was held on 23-26 March 1998 in Omiya. Japan in close collaboration with the WHO Collaborating Centre in Cancer Pain Relief and Quality of Life at the Saitama Cancer Centre. Japan.

1.1 Objectives

(I) To develop approaches for implementation of the WHO guidelines of cancer pain relief and to update current knowledge and skills in cancer pain and palliative care;

(2) to develop appropriate ways of integrating palliative care and cancer pain relief into medical and nursing curricula in undergraduate education and postgraduate training; and

(3) to develop strategies for the establishment of palliative care expertise in developing countries in the Region.

1.2 Participants and resn11rce persons

The Workshop was attended by 12 participants from II countries in the Region. 2 temporary advisers. 2 WHO consultants. 3 WHO staff. and 5 observers representing the International Association for the Study of Pain; the WHO Collaborating Centre in Cancer Pain Relief and Quality of Life. Saitama Cancer Centre. Japan: the WHO Collaborating Centre for Policy and Communications in Cancer Care. University of Wisconsin. U.S.A.: the WHO Collaborating Centre in Supportive Care. MD Anderson Cancer Centre, U.S.A.; and the National Cancer Centre, Japan. A total of 25 people took active part in the deliberations. The full list is given in Annex I. Dr Koo Wen-Hsin (Singapore) was elected Chairman, supported by Professor You Jo Ro (Republic of Korea) as Vice Chairman and Dr 1\larilyn A. Pajel-Calilung (Philippines) as Rapporteur.

1.3 Organization

The workshop was conducted in four major parts:

(I) Plenary talks delivered by the consultants, temporary advisers, some observers, and WHO staff. reviewed current understanding of cancer pain relief. models for the provision of palliative care education and services. the availability of opioid analgesics for cancer pain relief in the countries of the Region. the important role of national drug regulations and regulators. and approaches to changes in the regional practice of cancer pain management. The current status of WHO activities in cancer pain relief and palliative care in the Region were reviewed.

(2) Participants from the I I countries presented reports on the current situation of cancer control in each country with specific emphasis on development of cancer pain relief programmes, palliative care education, opioid availability. and drug regulatory issues.

(3) A field visit to the Saitama Cancer Centre allowed participants to observe the implementation of WHO methods for cancer pain relief in one major centre, to interview patients whose pain was being controlled by adequate administration of opioid drugs, and to visit a model in-patient unit and hospital pharmacy.

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( 4) In a series of small group sessions, participants considered how they could, in their own national situations, bring improvements in the_implementation of WHO gUideh~es for

1 cancer pain relief. strengthen palliative care educatiOn _at underwadua~e an~ postgra uate eve s, and support the establishment of palliative ca~e experttse. !hetr constderatto~s were ~utded by a brief paper: "Technical suggestion on enhancmg cancer pam reltef and palhattve care prepared b\ c:-.perh of this \\orh.shop. (Anne:-. 4). Each of the three small groups gave a report at the final plenar) session at the "orkshop and offered a sertes of cone lus10ns (Annex 5 ).

1.4 Opening ceremonv

Mr. Yuzo Narita. Deputy E:\ecutive Director and Superintendent for Prefecture Hospitals, Department of Public Health. Saitama Prefecture, welcomed participants on behalf of the . Saitama Prefecture. The \vorkshop was then declared open by Dr S.T. Han. the WHO Reg10nal Director for the Western Pacitic. In his remarks. Dr Han noted the rising regional incidence of cancer. and emphasized that Western Pacific Regional Office places a high priority on the implementation of cancer pain relief and palliative care programmes. The full text of Dr S.T.Han's talk is contained in Annex 3.

' PROCEEDINGS

2.1 Adoption of the \\Orkshop agenda

Dr Han Tieru. Regional Ad\ iser, Noncommunicable Diseases in the WHO Regional Office for the Western Pacific. re\·ie\\ed the workshop objectives, introduced the workshop agenda and details of the workshop programme with the participants (Annex 2). The meeting agenda \\as adopted by the participants.

2.2 Plenarv presentations

2.2.1 Dr Neil MacDonald (Canada) outlined the history of the WHO Cancer Pain Relief and Palliative Care Initiative. In most countries of the world, including the majority of nations in the Western Pacific Region, cancer patients usually present with advanced disease, and their only practical therapeutic option is pain relief and palliative care.

Dr MacDonald outlined the WHO Method for Cancer Pain Relief. presented evidence for the international success of the programme, and provided an update on modern cancer pain management, stressing the importance of pain assessment. He emphasized, as reflected in recent WHO publications, that programmes for cancer pain relief should be organized as part of a national cancer control programme .

.., ' ' Dr I an Maddocks (Australia) provided a comprehensive overview of palliative care. using the WHO definition of palliative care as a base for his discussions. He outlined the history of the palliative care movement, emphasizing the seminal role of Dame Cicely Saunders. and traced its development in the countries of the Western Pacific Region.

Dr Maddocks had consulted in several nations of the region and commented on the influence of culture on palliative care organizations and the use of opioids for symptom relief. Barriers to palliative care progress in the Region are similar to those in other parts of the world. However, the lower status of the nursing profession and of other health professionals (which impedes professional teamwork, a fundamental principle of palliative care) is a particular

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regional problem. Physician ignorance and disinterest in palliative care, often compounded by a ~ispropo~ionate interest in futile methods of cancer treatment, frequently hamper the mtrod~1ct10n of successful programmes. In Asia, fears of adverse opioid effects, notably addiCtion. and concerns about drug diversion are particularly noticeable.

Later in the plenary sessillns. Dr Maddock~ presented an overview of curriculum development. He presented a series of practical approaches. based on available instructional material, for improving regional palliative care education.

2.2.3 Dr Fumikazu Takeda (Japan) discussed the current status of cancer pain relief in the Western Pacific Region and presented the results of a WHO-supported multinational study (involving China. Japan. the Philippines. Singapore and VietNam) on the approaches of physicians and nurses to cancer pain treatment, and their knowledge of the WHO method for cancer pain relief. His study highlighted a number of problems which should be brought to the attention of national governments and medical leaders.

2.2.4 Dr Han Tieru (Regional Adviser in Noncommunicable Diseases). presented an overview of World Health Organization/Western Pacific Regional Office activities in cancer pain relief and palliative care. He introduced the historical development of the WHO cancer pain relief and palliative care programme. and summarized the situation on implementation of WHO methods on cancer pain relief and palliative care programme in different countries of the Region. The major obstacles were analyzed and the approaches and indicators for development of the programme were provided to the workshop. The cancer pain relief programme had been well developed in Australia. Japan and Nevv Zealand and was available with different coverage and effectiveness in more than 13 developing countries and areas. WHO had actively collaborated with more than 12 countries to promote the development of the palliative care and pain relief programme. He stated his expectations that, following successful completion of the workshop. a palliative care network would be structured to take forward prioritized projects. Dr Han stressed the importance of energy and impetus at the country level. and the need to identify credible national leaders who could liaise with local government officials. medical leaders. Western Pacific Regional Office and with international resources. The noncommunicable diseases programme of the Regional Office would act as a coordinating centre to support national and regional programmes. However. efforts must first be started and prioritized at the national level.

2.2.5 Dr David Joranson. Head of the WHO Collaborating Centre for Policy and Communication in Cancer Care. University of Wisconsin. U.S.A., presented information on the current use of morphine throughout the Region. While progress has been noted in some countries. notably Australia. China. Hong Kong. Japan. New Zealand. the Philippines, and Singapore limited or no access by cancer patients to morphine is noted in most countries of the Region. He offered data on the major impediments to morphine availability. Disproportionate fear of addiction and drug diversion clearly lead the list of barriers to morphine use. He described the ironic situation wherein limits on the dose and duration of use of morphine is, in many countries, a government decision. not, as it should be, a medical decision. Indeed, physicians are often unduly fearfuL hesitating to prescribe necessary opioids lest their actions are misunderstood, with dire consequences for themselves.

2.2.6 Dr Charles Cleeland, Head of the WHO Collaborating Centre in Supportive Care, MD Anderson Cancer Centre. U.S.A .. summarized existing barriers and matched this summary with a cogent series of proposals to break down barriers and create practical country programmes. He emphasized that the availability of credible external support for a national programme is an important factor.

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Curricular standards are important. national guidelines for pain manageme~t need to be adop!ed. and protocols for pain management must be agreed upon. However, whtle ~he above. work can be successfully completed by national authorities in pain manageme~t, thetr work wtll be for nauoht unless national institutions support their efforts, national professtonal ,, 12antzati~ns. give their full backing. and governments recognize barriers and act to remove th~m. Dr Cleeland stressed the primary role of assessment in a cancer pain control programme.

2.2. 7 Dr Ruth Stark. Regional Adviser in Nursing. WHO Regional Office for the Western Pacific. gave a presentation on nursing services in the Region and provided particular insights on the status of nurses and current limitations on professional team developments. Dr Stark and her colleagues have recently published a monograph entitled "Nursing Care of the ~)ick: A Gutde for Nurses Working in Small Rural Hospitals" which could be usefully linked with existing and future WHO publications on cancer pain relief and palliative care.

2.2.8 Ms Y. Kimoto. Head Nurse. the Saitama Cancer Centre. Japan, outlined the current status of nursing education in Japan. She was able to call upon her own experience at the Saitama Cancer Centre (illustrated clearly in the field trip to the Centre) to offer a model for successful nursing participation in a cancer pain relief programme.

2.3 Countrv reports

A total of 11 country reports were submitted. Discussion of country reports covered a variety of topics. It is evident that \\hile several countries are not troubled by opioid restriction, undue societal concerns about the risk of drug addiction and opioid diversion are universal.

Cancer patients in many countries. however. continue to suffer from lack of access to necessary analgesic therapy. In all countries. palliative care continues to struggle for a place in the medical curriculum. in quali(ying examinations. and in continuing education programmes.

All the country reports noted a continuing rise in cancer incidence and mortality, and in most it is clear that the majority of cancer patients. for some years to come. will present with advanced disease. The majority of these patients will experience severe pain, and, as Dr S.T. Han. Regional Director of the WHO Regional Office for the Western Pacific, stated in his opening remarks. for patients\\ tth incurable cancer. palliative care and pain relief remain the important human and pragmatic option.

Aside from the common!) recognized problems stated above, features of individual country reports included:

2.3.1 Cambodia

There are no formal guidelines on cancer pain relief or palliative care. Surgery remains the mamstay of cancer treatment; each physician uses his best judgement in treating terminal pat1ents: as in other Asian countries, patients often use traditional methods.

A WHO consultant visited Cambodia in 1997 and conducted a workshop on cancer prevention and control with an emphasis on cancer pain relief. He advised the Government to develop national guidelines on the various phases of cancer control and to facilitate the implementation ofthe WHO method for cancer pain relief and palliative care. He stressed the importance of placmg morphine on the country list of essential drugs and making it available within Cambodia.

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. Although these initiatives ~re not yet in place, the Ministry of Health has developed a pol.tcy docum~nt. on the Cambodtan Cancer Control Programme which includes cancer pain rehef and palltattve care as an essential component.

2.3.2 China

In 1990. with support from the Ministry of i-Iealth, WHO and Canada, the first National Cancer Pain Relief and Palliative Care meeting was held in Guangzhou. This meeting was attended by Chinese medical professionals and by senior officials in the Ministry of Health.

Subsequently. a series of national workshops have been held based on the "train the trainers" concept. The WHO Cancer Pain Relief Method is available in Mandarin as are a set of teaching slides describing WHO guidelines.

Morphine consumption continues to im:rease slowly in China, but as reflected in the study presented by Dr Takeda. Chinese physicians are not yet comfortable with its use. Other barriers to cancer pain relief include the reluctance of Chinese patients to report pain.

Revised guidelines for cancer pain relief and palliative care have been issued by the Ministry of Health ( 1997). Further workshops. including another national workshop in 1998, are going forward. Leaders in oncology research are carrying out studies on palliative care education. Recently, research has included study of the so-called "fourth phase of the WHO ladder" for patients with refractory pain, the role of traditional Chinese methods for pain control, and the broader role of analgesics other than morphine.

2.3.3 Fiji

Cancer is the second leading cause of death in Fiji. Recently, the Government has established the Fiji Cancer Control Programme which includes palliative care as a component part. The Government policy statement specifically calls for the implementation of the WHO Method of Cancer Pain Relief. and states that "the programme shall ensure the accessibility to the required drugs. particularly oral morphine tablets, at medical institutions and at home". It also states that appropriate education on palliative care should be provided.

A National Cancer Prevention and Control Task Force manages the cancer control programme. The initial phase of the programme is to be introduced over a five-year time span (1996- 2000). Recently. the Essential Drug List has been reviewed in accordance with WHO guidelines. Morphine tablets ( 10 mg and 20 mg) are available. Fiji does not have specialized clinics for cancer patients, nor hospice programmes. However. on the whole, care providers are familiar\\ ith WHO pain relief guidelines. Palliative care training is needed which will "train the trainers" who will then take forward national initiatives.

Major constraints include: (1) lack of a designated person to manage the cancer control programme; and (2) lack of a clinical oncologist.

2.3.4 Lao People's Democratic Republic

A national cancer control programme is contemplated but not yet in place. It is clearly needed in view of the rising incidence and mortality of cancer. Most cancer patients present with far advanced disease. Surgery is the only means available for the treatment of cancer.

Recently, a pain relief clinic has been established in Mittiphab Hospital, Vientiane, with support from a pharmaceutical firm (UPSA-France). It is expected that the clinic will be a focal point for pain treatment and education but, to date, limited resources curtail its activities.

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If the role of the Mittiphab Pain Clinic can be expanded through collaboration with . international colleagues. an impetus for implementation of the WHO method for cancer pam reltef and promotion of palliative care may develop.

2.3 .5 Malaysia

As in other countries. the incidence and mortality of cancer continues to rise. Palliative care was initiated in !992 by Hospice Malaysia and the National Cancer Society (Pe.nang Branch). These are nongovernmental organizations. Currently there are II dornac.allary .care •10spice programmes in Malaysia. with services provided by volunteers. The first m-pataent palliative care unit was started in East Malaysia in 1995.

Currently. the Ministry of Health has stated its intention to set up palliative care units in

all state hospitals.

Palliative care education remains modest. The East Malaysian palliative care unit provides the only structured course. although a module of palliative care instruction is contained in the Familv Medicine curriculum and in certain basic nursing courses. The WHO guidelines are not'' ideh· known although the situation is improving. M)1hs and misperceptions about morphine are shared by lay people and the medical and nursing professions alike.

Malaysia recommend> a major emphasis on palliative care training at all levels. Education ,,ill be advanced as more palliative care units are started and with formal development and acceptance of a palliative care curriculum.

2.3.6 Mongolia

The professional organization working against cancer is the National Oncological Research Centre. In addition. there are oncological departments in each district and aimag (province).

Cancer morbidity and mortality continues to rise. with 75-80% of patients presenting with advanced disease. In 1990. the government passed a palliative care bill allowing free palliative care therapy. A formal National Anti-Cancer Programme was launched by the Government in 1997. This programme designates responsible figures for palliative care at all levels of the health system. A WHO-sponsored training course on cancer pain relief was held in 1996. Starting from that year. oral liquid morphine has been increasingly utilized.

Currently. increased emphasis on pain and palliative care is noted in the curriculum of the Medical School and College and one nurse is training in Japan. However, importation and distribution of opioids remain a major problem. oral morphine supplies are insufficient and expensive. and professional expertise is not adequate.

2.3.7 Papua New Guinea

Cancer probably is increasing as the average age of the population increases. and improvements in control of infectious disorders occur. However, an accurate count is not available as complete registration may be a problem. and hematologic malignancies are not included in the National Cancer Registry.

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Current practice in cancer pain relief is limited as:

(i) few physicians and nurses are trained in cancer pain control techniques;

(ii) plans for a national pain clinic. which could serve as a focal point for training and education. have been made. but never implemen;ed:

(iii) access to opioids remain limited: and

(iv) cancer pain relief is only a small part of the National Health Plan

As in other countries. opioid availability and health professional education are major problems. In Papua New Guinea. fear of opioid abuse is less problematic, but proper distribution. storage, and disposition of opioids is difficult.

2.3.8 Philippines

The Philippines has a National Cancer Control Programme which includes cancer pain relief as a component part. The Programme is supported by key health professional groups and the Philippine Cancer Society. a volunteer group. Recently. a booklet entitled "Caring at Home". designed to support care-givers in providing comfort to patients in a home setting. has been published and wide!)' distributed.

The partners in the Philippine Cancer Control Programme have:

(i) organized a yearly "National Cancer Consciousness Week" which includes an emphasis on palliative care:

(ii) formed a National Hospice Coordinating Council:

(iii) sponsored training courses in pain control and palliative care: and

(iv) published a monograph on "How to break bad news"

The government has acted to increase the annual importation of morphine, and to approve new morphine formulations. However. as in other countries. limitation of opioid availability and distribution, and adequate palliative care education continue to present problems.

2.3.9 Republic of Korea

As in all other countries in the Region. cancer incidence is rising. with an increase in mortality from 9th ( 1950) to 2nd place ( 1986). behind cardiovascular disorders.

There is no statistical material available which shows the extent to which the WHO Method for Cancer Pain Relief is implemented nationally. However. a recent telephone survey of oncologists in Seoul suggests reasonable understanding and application of the method by these physicians. A recent survey of nursing colleges ( 49 out of I 08 respondents) shows that 5 I% have lectures on palliative care and 35% specifically on pain management. There are no separate palliative care courses in the medical colleges.

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In addition to morphine. fentanyl is available in Korea. A h~spice system for palliative care. including specific home care programmes, is gradually evolvmg.

In 1995. the Catholic University College of Nursing in Seoul, was designated as a WHO Collaborating Centre for Palliative Care. The College has established a 360-hour course offered

to 45-50 students a year.

Problems include:

( 1) a lack of national standards and curricula for education in palliative care;

(2) the absence of a national policy on palliative care: and

(3) restrictive la\~S which still hamper patient access to opioids. Both society and health professionals remain unduly concerned about the risk of addiction.

While problems exist. the Republic of Korea continues to make progress in implementing WHO guidelines for pain relief and palliative care.

2.3.10 Singapore

PalliatiYe care ,tarted in 1985 \~hen St. Joseph's Home set aside 16 beds for terminally-ill cancer patients. In 1987. the Singapore Cancer Society started a volunteer home care service. By 1989. the need for more full-time professional involvement was recognized and a new charitable organization. the Hospice Care Association, was formed. One of its aims is to promote palliative care education. Current!). there are five charitable palliative care organizations \Vho coordinate their activities through the Singapore Hospice Council. The access for patients to Council services is increasing (42 patients in 1987. 1159 patients in 1997). The Hospice Council runs regular training courses.

In 1996. Singapore hosted the Second Asia/Pacific International Hospice Conference.

Regular teaching programmes in palliative care are in place at both the undergraduate and graduate levels. A major eff011 to develop palliative care research is underway. The Singapore Cancer Centre has recently been established. It is expected that palliative care education and research will advance under its aegis. The lack of trained personnel remains the major barrier to palliative care progress in Singapore.

:; . 3. 1 1 VietNam

Most cancer patients present with advanced disease. Facilities for offering chemotherapy and radiotherapy are limited. The WHO Method for Cancer Pain Relief was introduced into VietNam in 1988.

While a foothold has been established, wide implementation of the WHO Method for pain control and palliative care will depend on continued support from WHO and international agencies.

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3. SUMMARY OF DISCUSSIONS

3 .I Prioritization of palliati\·e care bv Ministries of Health and other involved government agenc1es

Governments must be informed of the reality of the suffering of increasing numbers of cancer patients. and the lack of response to this reality in government policies and professional education. Because of ignorance of the reality. and misconceptions about opioid use and pain management, national focal points are often not identified or given opportunities to advance the care of suffering cancer patients.

Development of national cancer control policies and programmes which give cancer pain relief and palliative care priority are critical. Essential for the success of these programmes is the involvement, both in planning and implementation. of senior officials in the Ministries of Health (not their delegates). the heads of medical and nursing schools. the heads of major professional and volunteer organizations and national drug regulators.

Funding issues inevitably arise. It is strongly believed, however, that activities may be funded if a country recognizes a need and constructs its national initiatives with the help of available regional and international resources.

National palliative care expert committees in each country could be an appropriate advisory body for technical support to the development and implementation of palliative care and pain relief programmes.

3.2 Enhancement of palliative care education throughout the Region

3.2.1 Excellent educational material from both WHO and other sources is available. but is often unknown to professionals and the public. Efforts should be made to make this material available by:

(I) Preparing and updating a catalogue to include:

* WHO publications:

* other Pain and Palliative Care textbooks:

* relevant general textbooks:

* family self help guides:

* leading cancer control and palliative care journals:

* helpful websites and e-mail linkages:

* newsletters; and

* assessment protocols.

(2) Expanding the programme for translating monographs into different languages of the Region to help countries access other helpful educational materials which may be

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available in languages other than English. The example of helping Cambodia and Laos to obtain educational material prepared in French was noted.

3.2.2 The important role of medical faculties in each country was recognized. The introduction and use of the materials described above are dependant upon the interest and support of medical and nursing schools. While S(•me medical and nursing schools have already incorporated specific educational modules on carocer pain relief and palliative care within both undergraduate and graduate programmes, most health professionals in the Region recei~e .only limited. if any, exposure to the essential attitudes, skills and knowledge relevant to palhat1ve care. Specific actions to be considered by medical faculties include:

(I) preparation of national curricula in palliative care and establishment of national standards for implementation of the curricula: and

(~) modification of qualifying examinations to recognize that evidence of preparation in palliati\e care is regarded as an essential component of physician learning.

3.~.3 Even where members of medical faculties and national professional organizations recognize the importance of palliative care, change will not occur without:

(I) establishment of academic positions for physicians charged with responsibility for taking forward the proposals I is ted above:

(2) support for the formation of national palliative care advisory groups which will link the medical faculty and palliative care leaders in common purpose: and

(3 l support for continuing education programmes which introduce the modern concepts of palliative care into current medical practice. It was recognized that most doctors in the Region are products of a medical educational system that gave scant attention to pain relief and palliati\ e care trainings.

3.2.4 It \\as agreed that health-professional team\\Ork provides the essential foundation for palliative care. Nurses and pharmacists. in particular, are key elements of the care team. Teamwork is inhibited in many countries because of a relative dominance of physicians and inadequate training and low status of other health professionals. The status of nurses and pharmacists should be enhanced and multidisciplinary education and professional teamwork in palliative care should be promoted. This is a culturally sensitive area, but one which deserves thoughtfu I attention.

3.2.5 Complex and difficult to establish, but ultimately very influential in bringing about change are the establishment of national demonstration projects. In these projects, the impact of the WHO approach can be observed. From them. the experiences for development of palliative care programme are disseminated throughout a country. The Saitama Cancer Center Demonstration Project stands as an excellent example.

3.3 Drug regulatory issues

National palliative care educational projects are futile unless national drug regulations and opioid distribution systems allow effective use of analgesics. Awareness produced by palliative care education can influence attitudes towards opioid use. Ultimately, however, education is only fully beneficial when matched with enlightened drug regulatory policies.

* Concerted national efforts to eliminate the barriers to appropriate medical use of opioids should be made in order to promote the comprehensive availability of morphine in

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multiple formulations (parenteral: short-acting; long-acting), plus the availability of at least one alternate strong opioid.

* Physicians should have the authority to judge the dose and timing of individual opioid prescriptions. Recognition of this must be promoted.

* It needs to be recognized that no upper limit exists for morphine and other opioid dosage. Morphine doses may be steadily increased to alleviate pain in the absence of limiting, uncontrollable adverse effects. A bureaucratic burden creates a climate of fear and avoidance amongst physicians. It includes disproportionate controls on prescription pads, together with awkwardness and expense in obtaining forms for opioid prescriptions, and these must be redressed.

* Pharmacy restrictions that make it impossible for pharmacies to store and dispense opioids should be removed.

3.4 Enlistment of Community Support

Given the frugal resources available in many countries of the region, the burden of care will inevitably fall on patients and on their families. Usually, they have poor understanding of cancer and its effects, and there is much denial and prejudice concerning cancer and the use of opioid drugs to relieve p~in. Measures which raise public awareness and provide basic information throughout the community are needed.

Palliative care advocacy groups may be organized in cooperation with National Cancer Societies. Sometimes, Cancer Societies have shied away from a recognition that patients die. If that situation exists in a country. independelll community advocates should be supported.

Publicizing successful examples of volunteer agency work and collaboration with governments will be helpful. The joint production of a Family Manual by the Philippine Cancer Society and the Philippine Government is a model which should be brought to the attention of other countries throughout the Region.

3.5 Communication network

A regional electronic communication network on palliative care which also connects with the global palliative care network is suggested as a useful way of continuing the impetus provided by this workshop.

4. CONCLUSIONS

The Workshop identified clear national palliative care needs, correctable national barriers to progress, and realizable projects to improve the care of cancer patients with advanced disease. Participants look forward to working together for the development of a palliative care network.

(I) Member States of the Region should give priority to the further implementation ofthe WHO Method on Cancer Pain Relief and the development of palliative care services. A national cancer control programme which recognizes palliative care and cancer pain relief as a priority should be developed.

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(2) Individuals and committees within national health authorities which can act as focal points for the development of national policies and programmes on cancer pain relief and palliative care should be identified.

(3) Appropriate national cancer pain relief and palliative care policies and programmes are required. which should involve drug regulators, medical and nursing schools, hospitals and pharmacies. professional organizaticns and societies and the volunteer sectors. A national palliative care expert committee may be an appropriate advisory body to offer technical support for planning, implementation and evaluation of the cancer pain and palliative care programme.

( 4) Education and training of health professionals in cancer pain relief and palliative care should be strengthened. The important role of medical and nursing schools in each country was recognized. National curricula in palliative care within both undergraduate and postgraduate programmes should be prepared and national standards for implementation of the curricula should be established. (Curriculum guidelines on cancer pain relief and palliative care are attached as Annex 6) Cancer pain relief and palliative care should receive proportionate importance on qualifying examinations.

All teaching hospitals and cancer hospitals should establish palliative care expertise and adopt WHO guidelines on cancer pain relief.

(5) National palliative care educational projects are futile if national drug regulations and opioid distribution systems remain counterproductive. National efforts to eliminate the barriers to appropriate medical use of opioids should include comprehensive availability of morphine in multiple formulations: correction of disproportionate controls on prescription pads. and elimination of the awkwardness and expense involved in obtaining forms for opioid prescription. Pharmacy restrictions which prevent pharmacists from storing and dispensing opioids should be eliminated.

(6) Excellent educaticmal materials from both WHO and other sources are available. Ho\\ever. efforts should be made to translate the WHO publications into the major languages of the Region and \\idcly disseminate those WHO publications and other useful materials to health professionals and the general public.

( 7) The Saitama Cancer Centre demonstration project in Japan stands as an excellent example of the WHO method in cancer pain relief in action. Establishment of national demonstration projects in cancer pain relief and palliative care should take place in other countries of the Region.

(8) It was recognized that no upper limit exists for the dose of morphine and other opioids. Morphine doses may be increased progressively to alleviate pain in the absence of limiting. uncontrolled adverse effects. This well-established point should be understood both by officials controlling opioid use and by all physicians.

(9) Health professional teamwork provides the essential foundation for palliative care. Nurses and pharmacists in particular, are key elements of the care team. Teamwork is inhibited in many countries because of a relative dominance of physicians and inadequate training and low status of other health professionals. Therefore, the status of nurses and pharmacists should be strengthened and multidisciplinary education and professional teamwork should be promoted.

(I 0) An electronic network for cancer pain relief and palliative care should be established. The Internet provides a unique opportunity for advancement of WHO and national

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cancer pain and palliative care initiatives. Existing world pain relief and palliative care websites should be linked and fully utilized. The further development of regional links will provide an important measure for strengthening information exchange.

(II) WHO collaborating centers and active regional and international expert groups in the field of cancer pain relief and palliative care should be encouraged for further strengthening their collaboration and development in the cancer pain relief and palliative care throughout the Region.

(12) Awareness should be raised among the public, patients and their families that pain can be controlled and quality of life can be improved. Due to poor understanding of cancer and its effects, and denial and prejudice concerning cancer and the use of opioids to relieve pain, national and community advocacy initiatives should be supported.

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ANNEX I

LIST OF PARTICIPANTS, CONSULTANTS, TEMPORARY ADVISERS. OBSERVERS AND SECRETARIAT

CAMBODIA

CHINA

FIJI

LAO PEOPLE'S DEMOCRATIC REPUBLIC

l. PARTICIPANTS

Dr Kheang Yana Deputy Director Preah Bat Norodom Sihanouk Hospital 19 Street 205. Tuol Svay Prey II Khan Chamkar Mon Phnom Penh

Dr Liu Shu Jun Professor of Medicine Beijing Cancer Hospital No. 52 Fu-Cheng Road Hai-dian District Beijing 100036 Fax: 86 10 68122437 Tel: 86 10 68121122 ext 2067

Dr Sun Yan Professor Department of Medical Oncology Cancer Institute and Hospital Chinese Academy of Medical Sciences Beijing I 00021 Fax: 8610 67734107 Tel: 8610 67781331-8519

Mrs Lola Pofa Tuiloma Assistant Director (Hospital) Ministry of Health and Social Welfare Headquarters Kaunikuila House. Flagstaff Box 2223. Government Bldgs. Suva Fax: 306 163 Tel: 306 177

Dr Vongphrachanh Fongsouvanh Chief of Medical Department Responsible for Medicine and Neurology Mittaphab Hospital Vientiane Tel: 216 847

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Annex 1

MALAYSIA Dr Joseph Kaniantra Joseph Ongkology Medical Specialist Hospital Kuala Lumpur Jalan Pahang 50586 Kuala Lumpur Fax: (603) 298 9845 Tel: (603) 291 6969

MONGOLIA Dr Ravjir Sanduijav General Consultant National Cancer Center Enkhtaivan Street - 2 Ulaanbaatar Fax: 976 I 358189 Tel: 976 I 342682 (H)

PAPUA NEW GUINEA Dr Gertrude Didei Acting Chief Anaesthetist Department of Anaesthesia Port Moresby General Hospital Free Mail Bag Boroko. N.C.D. Fax: 325 0342 Tel: 324 8257

PHILIPPINES Dr Marilyn A. Pajei-Calilung Programme Manager Prevention of Blindness Programme/ Philippine Cancer Control Programme Noncommunicable Disease Control Service Department of Health San Lazaro Compound Manila Fax: 842 35 25, 711 62 97 Tel: 0918 850 3708, 711 62 97

REPUBLIC OF KOREA Dr Ro You-Ja, R.N. Professor The Catholic University of Korea College of Nursing 505 Banpo-Dong, Socho-Gu Seoul. 137-701 Fax: 02 590 1297 Tel: 02 590 128111295

SINGAPORE

VIETNAM

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Dr Koo Wen-Hsin Consultant Departmen• of Medical Oncology Singapore General Hospital Outram Road Singapore 169608 Tel: (65) 275 0098

Dr Truong Van Quy Deputy Director of Nursing Care Department Hanoi Medical College No. I Ton That Tung Street Hanoi Tel: 8524712

2. CONSULTANTS

Dr Neil MacDonald Director. Cancer Ethics Programme Centre for Bioethics Clinical Research Institute of Montreal 110 Pine A venue West Montreal. Quebec. H2W 1R7 Canada Fax: 514 987 5695 Tel: 514 987 5620

Annex l

E-mail: mccanncl@IRCM. UMontreai.CA

Dr Ian Maddocks Professor of Palliative Care The Flinders University of South Australia International Institute of Hospice Studies 700 Goodwood Road Daw Park SA 5041 Australia Fax: 618 277 4957 Tel: 618 275 1751 E-mail: ian. maddocks@flinders .edu. au

Annex 1

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3. TEMPORARY ADVISERS

Dr Fumikazu Takeda President/Director Saitama Cancer Centre 818 Komoru, Ina Saitama 362 Japan Fax.: (0)48-832-1664/(0)48-722-1129 Tel: (0)48 722 1111

Ms Y oshie Kimoto Head Nurse. Department of Nursing Saitama Cancer Centre 818 Komoru. Ina Saitama 362 Japan Fax.: (0)48-832-1664/(0)48-722-1129 Tel (0)48 722 1111

4. OBSERVERS

Professor Charles S. Cleeland Representative of the International Association for the Study of Pain, Professor of Medicine Director. Pain Research Group University of Texas MD Anderson Cancer Centre, Texas Medical Centre 1515 Holocombe Boulevard. Houston Texas 77030 United States of America Fax: I 713 745 3475 Tel: 1 713 745 3470 E-mail: cleeland@utmdacc.mda.uth.tmc.edu

Dr Jiro Uki Chief Neurosurgeon Associate Director of the WHO Collaborating Centre for Cancer Pain Relief and Quality of Life Saitama Cancer Centre, 818 Komoru, Ina Saitama 362 Japan Fax.: (0)48-832-1664/(0)48-722-1129 Tel (0)48 722 111 1

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Dr Y osuke Uchitomi Director Psycho-Oncology Research Division National Cancer Centre Branch Research Institute 6-5-1 Kashiwanoha, Kashiwa 277 Chiba Japan Fax: 81 471 34 7026 Tel: 81 471 34 7013

Dr David E. Joranson Senior Scientist/ Director Pain and Policy Studies Group University of Wisconsin Comprehensive Cancer Centre WHO Collaborating Centre for Policy and Communications in Cancer Care 1900 University Avenue Madison. Wisconsin United States of America Fax: I 608 263 0259 Tel: I 608 263 7662 E-mail: Joranson@facstaff. wisc.edu

Dr Xin-Shelley Wang Medical Coordinator

Annexl

WHO Collaborating Centre in Supportive Care Pain Research Group, Department of Neuro­Oncology University of Texas MD Anderson Cancer Centre Box 221. HMB, 1100 Holocombe Boulevard Houston. Texas 77030 United States of America Fax: 7137453475 Tel: 713 745 3504 E-mail: swang@utmdacc.mda.uth.tmc.edu

Annex 1

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5. SECRETARIAT

Dr Han T:eru (Operational Officer) Regional Adviser in Noncommunicable Diseases WHO Regional Office for the Western Pacific Manila Philippines Fax: (632) 526 0279, 526 0362, 521 1036 Tel: (632) 5289986 E-mail: tieruh@who.org.ph

Dr Ruth Stark Regional Adviser in Nursing WHO Regional Office for the Western Pacific Manila Philippines Fax: (632) 526 0279, 526 0362. 521 1036 Tel: (632)5288001 E-mail: starkr@who.org.ph

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ANNEX2

AGENDA

I. Opening ceremony

2. Adoption of agenda

3. WHO methods in cancer pain relief

4. Concepts, principles. basic skills and progress of palliative care

5. Current status of cancer pain relief and palliative care services in the Western Pacific Region

6. Overview of WHO programmes and activities in palliative care and cancer pain relief in the Region

7. Availability of opioid analgesics for cancer pain relief

8. Changing the practice of cancer pain management

9. Field trip to Saitama Cancer Centre

I 0. Country reports

II. Development of approaches for further strengthening implementation of WHO methods in cancer pain relief

12. Strengthening health professional education in cancer pain relief and palliative care

13 Development of strategies for establishment of palliative care in developing countries

14. Conclusions

15. Closing ceremony

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ANNEXJ

OPENING REMARKS BY THE REGIONAL DIRECTOR AT THE WORKSHOP ON STRENGTHENING HEALTH PROFESSIONAL EDUCATION IN CANCER PAIN

RELIEF AND DEVELOPMENT OF PALLIATIVE CARE EXPERTISE 23-26 MARCH 1998, SAlT AMA, JAPAN

LADIES AND GENTLEMEN:

I am very pleased to welcome you all to this workshop on Strengthening Health Professional Education in Cancer Pain Relief and Development of Palliative Care Expertise.

Cancer is now a major health problem, not only in developed countries but also in developing countries. In 1996, more than I 0 million people worldwide were newly diagnosed as suffering from cancer. In the Western Pacific Region, it is estimated that some 3.5 million cancer cases occur each year. Every year cancer causes 6 million deaths globally. It now accounts for about 20% of all deaths in developed countries and about I 0% of all deaths in developing countries. Although numerous advances have been made in combating cancer, the majority of patients with cancer, especially in developing countries, are diagnosed very late, when they are already incurable. For patients \~ith incurable cancer, palliative care and pain relief have become the only humane and pragmatic options. Such care has a great impact on the quality of life of patients and their families.

Palliative care is still a neglected area. It is often ignored or regarded as something that comes at the very end of the list of treatment options. Major obstacles to the development of palliative care and pain relief programmes include inadequate public policies, inappropriate drug regulations, and poor supply and distributions of pain relieving drugs. Lack of appropriate education and training for health workers and shortages of well-trained health professionals are two of the key issues. A recent WHO study on physicians' and nurses' attitudes to and knowledge of cancer pain relief in China. Japan. the Philippines. Singapore and VietNam showed that health workers often had an inadequate insight into the nature and severity of pain suffered by patients. Underestimation of the patient's pain, undue fear of addiction, and inappropriate goal-setting for pain management were the most common problems identified.

Development of palliative care requires sufficient numbers of well-trained health professionals. They are important not only for the delivery of care but also for advising policy­makers and educating the general public to create a supportive political and social environment for development of palliative care.

WHO is encouraging medical and nursing schools and teaching hospitals to provide substantial support to palliative care in terms of human resources, facilities, funding and teaching time. As an important measure, palliative care programmes should be established in major teaching hospitals and all cancer hospitals. Professional associations and societies can play critical roles in technical training of doctors and nurses, and examining for certifications and licences.

As the next step in this process, this Workshop has been organized to develop approaches to implement WHO guidelines on cancer pain relief, and to strengthen education and training. In particular, you will be examining how to integrate palliative care and WHO methods on cancer pain relief into medical and nursing curricula. Developing palliative care expertise in developing countries in the Region is also a major theme of the workshop.

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Annex 3

During this meeting. you wi II exchange information and share your experiences. I am confident that. having updated your skills. you'' ill take the lead in development of palliative care and pain relief programme in your own countries.

In 1990. a successful WHO workshop on cancer pain relief was held here with great support from Saitama Cancer Centre and the WIIO Collaborating Centre for Cancer Pain Relief and the Quality of Life. Once again. I would like to extend my sincere thanks to this Centre for their hard work. enthusiasm. thoughtful arrangements and dedication in preparing this meeting.

Finally. I would like to thank all of you for coming to this workshop. I wish you very successful discussions and a pleasant stay in Japan.

Thank you.

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ANNEX4

TECHNICAL SUGGESTIONS FOR ENHANCING CANCER PAIN RELIEF AND PALLIATIVE CARE

I. Adoption of Rational Drug Policies to Facilitate the Implementation of the WHO Guidelines on Cancer Pain Relief

(a) National drug regulations control the availability of opioids. In many countries that control severely limits the delivery of effective pain relief. Common constraints are:

* limitations on the amount which may be prescribed on a single prescription

* limitations on duration of use which a prescription allows

* lack of availability of particular formulations (eg. liquid, immediate release, sustained release, trans-dermal, parenteral) access to alternate opioids (eg. oxycodone, fentanyl, hydromorphone, methadone) At least one alternative opioid and one alternative NSAID should be available in recognition of individual drug sensitivities and the occasional need to switch opioids when drug side-effects occur.

* restrictions on the numbers and locales of pharmacies able to dispense opioids

*absence of needed analgesics on national Essential Drug List

(b) Restrictive policies reflect a lack of knowledge about opioids which leads to undue fear of opioid addiction by decision-makers, including confusing tolerance and physical dependence with drug addiction. Effective training will need to include national drug authorities, leading physicians and national decision-makers.

II. Develop Methods for the Integration of Palliative Care into Undergraduate Education and Postgraduate Training

(a) Proposal to Strengthen education in palliative care and cancer pain relief will include:

development of national curricula on pain and palliative care;

*introduction of these curricula into health professional educational programmes;

* giving cancer pain relief and palliative care receive proportionate importance on qualifying examinations;

* conducting hospital audits which include reviews of cancer pain management and of in­house training in cancer pain and palliative care.

(b) Leadership positions in medical and nursing faculties are strongly recommended, and the individuals appointed should be given responsibility for implementing training programmes.

(c) WHO collaborating centers in the field have undertaken pioneering work, but still cancer pain and palliative care have received a low priority in most countries and few individuals have received training in palliative care. Further support for the WHO centers should enable them to expand their training programmes to health professionals throughout the Region.

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Annex 4

(d) Demonstration projects where the success of WHO approaches to palliative care can be clearly observed are an essential component of policy and attitude change.

(e) include:

There is no lack of educational material. Readily available WHO publications

Cancer Pain Relief, 1986 (edition I)

Cancer Pain Relief and Palliative Care (including a Guide to Opioid Availability) ( 1991)

Cancer Pain Relief, 1996 (edition 2)

Manual on prevention and control of common cancers (WPRO publication)

Nursing Care of the Sick (a WHO/WPRO publication)

Family training manuals (both WHO and national publications are available that can serve as templates for others)

To ensure the availability. translation and wide distribution of these essential manuals, Governments and national professional organizations might invite support from. multinational organizations.

(f) A number of other educational aids have been developed or proposed.

These include:

An international journal on cancer control (a potential WHO-IARC project)

Teaching slide sets and overheads

(g) Simple assessment methods for identifying and monitoring pain and other symptoms have been developed and are available, some in a range of languages.

Because the severity of a patient's pain is often not recognized by health professionals, the use of quantitative assessment methods, using forms filled in by patients or family members is recommended.

III. The Conduct of National Workshops and Enlistment of the International Community in Support of WHO Palliative Care Initiatives

(a) National workshops offer an excellent medium for linking international organizations, government authorities, drug regulators, professional organizations, volunteer groups, and international consultants in common purpose and resolve. Information can be shared on the vital importance of cancer pain relief and palliative care and on the means at hand to address those issues.

The publication of workshop conclusions and plans for follow-up provide a blue-print for further collaborative planning and for auditing progress.

(b) International consultant services support national governments and organizations with their planning activities for cancer pain relief and palliative care. A consultant visit may usefully lay the foundation for a successful national workshop.

- 27-

Annex 4

(c) Many physicians and groups through the Region are already active-

their good work should be encouraged and supported.

IV. Internet communication

The Internet provides a unique opportunity for advancement of WHO and national cancer pain and palliative care initiatives. Existing international pain relief and palliative care websites should be collected and fully utilized and the further development of regional links will be important to strengthen information exchanges.

V. Team Building and Family Support

(a) Cancer pain relief and palliative care are dependent upon health professional team work. It is recognized that there is a widespread lack of understanding and respect between physicians. nurses and other health professionals which hinders the advancement of health goals for the people. Improvement in joint ph) sicians-nursing interaction should be made.

(b) Ultimately. patients and families wish to be in a position to care for themselves. with professional support. when required. Often they are in situations where they must care for themselves with little access to professional care.

Manuals representative of national culture can be simply produced based on existing templates. They must emphasize the safe use of drugs and allay fears about morphine.

VI. Strategies for Establishment of Expertise and the Implementation of Policies

(a) Words are empty and little will happen without the understanding and support of health leaders in each country. Ad\ocacy effort should be made for the promotion of cancer pain relief and palliative care.

(b) Identification of a focal point in the Ministry of Health or a national committee for cancer pain relief and palliative care programme.

(c) Further strengthening of links with international experts opioid regulatory issues.

(d) Development of public educational material in concert with local cancer societies.

(e) Circulation and promotion of WHO publications- the method in each land to be depended upon national situations.

(f) Development of an assessment programme for monitoring advances in the countries.

(g) Formation of a Network in Palliative Care with specific emphasis on collaborative efforts on the areas of national policies. drug regulations and education.

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ANNEX 5

Group reports

Group I (Leader: Dr Koo, Singapore)

Representatl\ cs of Cam hndia. \' ietnmn. Lws, Singapore. Japan.

Consultant: Dr MacDonald

1. Dissemination of lnti.mnation

Recommendations need to come to the attention of decision-makers. Although the dissemination of relevant information is important at all levels, particular care should be taken to reach the policy makers.

Many appropriate educational materials are available. but not always in the language that is useful. French materials may be more useful than English texts in Vietnam. Laos and Cambodia.

::?.. Issue of Priority

Many countries have major problems with malaria. TB. HIV. If resources are limited. they may be unwilling to diYert resources to cancer prevention and control- whether primary, secondary or tertiary. These concerns should be respected. but advocacy for individuals with the suffering of advanced cancer remains important.

3. Individual Etrorts

If policy makers are not interested. even if informed, individual efforts nevertheless can facilitate change. Support from experts from overseas. support from volunteers and NGOs in running workshops at local and nationalle\el requires only modest effort. They can help individuals organise and strengthen their work and gradually influence higher authorities.

Group II (Leader: Dr Joseph, Malaysia)

Pa11icipants: China. Mongolia. Japan. Malaysia

Consultants: Dr Takeda. Mr Jorgansen

The participants recognised their different levels of affluence and tradition. There are. for example, obvious problems for Mongolia in the a..ailability of any oral morphine, but all nations need to improve the range of preparations a\ ailable or the amount permitted.

Key texts in pharmacology. medicine and surgery which embody relevant information on cancer pain control and palliative care are available, helping advocates publicize the information that (for example) there is no correct or upper level dose for morphine and have it seen as authoritative.

The exposure of medical and nursing students to palliative care needs support from the heads of the cancer services and the hospice organisations. Deans of Medical Schools should be lobbied to introduce hands-on training of students so that they observe the good effects of pain management.

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Annex 5

Education for the drug regulators and administrators is necessary. It is frustrating if health professionals ,,ho kno'' how to use morphine do not have access to adequate suppl.Jes. It wdl be useful to include representati\es of the drug regulatory authonttes 111 natiOnal meetmgs on cancer pain managem~nt (this has happened in 1\lalaysia)

The availabilitv in rele,·ant languages ofth·~ second edition of the WHO manual on Cancer Pain is a great help. ;nd these should be ~idely a.ailable. In Mongolia there is an intention to translate and circulate WHO Guidelines to all large hospitals.

Three salient points should be highlighted in reports to governments:

* In general. morphine consumption in the region is very low

* No such thing as a ceiling dose

* Demonstration projects arc readily implemented and are effective means for training

Group III (Leader: Dr Maril~n Pajel Calilung, Philippines)

Participants: Korea. Fiji. Papua Ne'' Guinea. Fiji. Philippines

Consultants: Dr Maddocks. Dr Cleeland. Ms Stark

I lm oh ing Go\ ernment

Go,ernment plays an important role. and should be involved in major ways. It is necessary to identify indi\ iduals in government'' ho can influence opioid availability and cancer pain relief. They should be enwuragcd to undertake roles in organisations advocating cancer pain relief. and gi\en chairman roles in educational meetings.

Particular ,occasions alkm strong ad\tJCaC) - eg. Cancer Pain Relief week, public meetings "ith participation cf government and NGO agencies. special meetings of professional societies. An initial focus on cancer pain relief rather than palliative care may attract stronger official interest.

Demonstrations projects in hospitals or in community care can be used to influence government officers. leading specialists and key persons. and the) provide a focus for education. They should be ad\ocated with government and NGO bodies.

Testimonies by patients. \\hether in the media. as slides or videos. demonstrating benefit from effective cancer pain control with opioids are very useful. and need to be presented repeatedly to maintain community and government interest.

Research can also be an effective assistance with advocacy. It raises the academic status of cancer pain relief and palliati\·e care. im·ites the interest of specialists.

2. Integrating Palliative Care into Training

The group suggested that WHO should accept a major role in this area. Foreign consultants, in collaboration with local experts. should be invited to conduct training in cancer pain relief, followed by training of the trainers, leaving behind sufficient expertise to continue training locally.

- 3 I -

Annex 5

It is important to identify personalities in Government Organisations. NGOs and Academic Institutions '' ho influence decisions and'' ith ''hom personal contact can be de\·elopcd.

Pharmaceutical companies \\ill often sponso• professional meetings thr~u.gh ~he spec_ialist societies. and support outreach from major centers to doctors. nurses even tamliJes 111 outlymg

areas.

Heads of colleges of medicine and nursing need to be encouraged to include Cancer Pain Relief in the curriculum Presenting testimonies to the faculties which demonstrate the need for cancer pain relief throughout the c~mmunity. and which affirm the benefit for patients and staff of good acute and chronic pain control may be persuasive.

3. Developing Palliative Care Expe1tise

Each countn will need to dc\ elop its own strategies. based in WHO principles. Constant evaluation should be done. both inside and from outside the country.

Final Plenary Discussion - points raised included the following:

* It ''as noted that the second edition of the WHO manual is already translated into Japanese and Vietnamese. and that a Chinese \ersion should be soon available.

* The addition of basic education materials to influence patient and family was strongly supp01ted.

* Some countries ha\e greater difficulties and start further behind than others- eg Laos. Cambodia. Which program deserves most support'.' A start with the training of health professionals ''as suggested. pro\'iding access to knowledge and skills so that there is stronger support for change at government level.

* Through this workshop many persons ha\ e established communication with the WHO office. and with experts. This could be the basis for a networJ.; providing information exchange. There may be paths for funding de' eloping country aspirations to continue the exchange. (eg through foreign embassies. aid organisations. NGOs). Curriculum development could be supported by sending consultants to review the medical and nursing curricula.

* Consultants are readily available and money to support them can often be found in developed countries if appropriate proposals are received. Many French speaking consultants can be located in Canada.

* Many countries have very hard and fast laws. Teaching about palliative care and cancer control in the absence of avai !able opioids causes frustration. but may gradually lead to greater pressure on opioid availability. Highlight the fact that most countries require that opioids are available, and this example can become an avenue for change. with advocacy by the narcotic contro I staff.

" - _)_) -

ANNEX6

Cancer Pain Relief and Palliative Care Draft Curriculum Guidelines for the Western Pacific Region

I Introduction

Education is a process for encouraging change - in attitudes, knowledge and skills.

A curriculum is a tool for education, which:

Defines the area to be considered and the target population Lists the aims - as specific as possible Outlines the content - as detailed as practicable

It may include also the strategies to be used for achieving change, including:

1. Consideration of basic educational approaches • Didactic • Opportunistic • Problem-based • Learning contract

2. The modes of study and the methods for presentation of material, including:

a) factual material

Individual stud written recorded interactive

Classroom teachin lecture tutorial debate etc.

b) prnctical application and skills • Apprenticeship • Demonstration

Case discussion Reflective practice

Distance stud study guide & notes articles and textbooks tele conference

3. The methods of evaluation to be used, including: written - essay, short answer, MCQ, analogue scale oral - face-to-face, tele-rnedicine, tape, video

• demonstration - model, bedside, laboratory group presentation

With regard to Cancer Pain Relief and the Development of Palliative Care within the Western Pacific Re ion of WHO:

1. A need for change is widely recognised

Many governments have no stated policy for cancer control or do not include in their policy statements the relief of suffering caused by advanced cancer. There is widespread, though variable, limitation on the supply, availability and distribution of strong analgesics. Funding specifically for palliative care is unusual, with cancer funding focussing predominantly on radiotherapy and chemotherapy. There is poor professional understanding of cancer pnin nnd the methods available for its relief, and limited awareness of the attitudes, knowledge and skills involved in the provision of palliative care There is widespread community fear of and denial of cancer and fear also of opioid drugs, with reluctance to use them and belief that usc of opioid drugs will lead to addiction.

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Annex 6

2. Education in Cancer Pain Relief and Palliative Care deserves to be encouraged at every level, including:

Policy-makers and decision-makers in government Senior officials charged with implementing government policy Professionals responsible for dav-to-dav care of patients with advanced cancer The general public

3. Education is promoted by demonstration more than by precept, and demonstration of effective cancer pain relief and palliative care in model wards or hospice programs is a vital part of any national educational initiative.

!\II levels of relevant personnel bcndit from practical demonstration of the attitudes, knowledge and skills which are basic to the provision of cancer pain relief and palliative care, and this is facilitated by the establishment of model projects. whether bv hospital consulting teams, community and home care programs or dedicated hospice units.

Such demonstrations may be initiated by non-government bodies, but they will also require governrm:nt approval of, for example, opioid drug availability.

4. A curriculum is a necessary component of that education.

It will be directed particularly at health professionals, recognising that they have a strong potential to influence government policy and its implementation. The targets for the curriculum wiil include:

Specialist physicians Family physicians Medical students Senior nurses Practising nurses Trainee nurses Other health professionals - pharmacists, physiotherapists, social workers, etc. Community groups with potential to offer volunteer support in palliative care.

Note:

There is great variation across the Western Pacific Region in policy, practice and awareness of cancer pain relief and palliative care. One single curriculum will not be appropriate for all countries.

Some countries, which enjoy a high standard of living and generous government support in he<tlth car<', may readily <~dopt curricula written for other developed countries - eg the Canadian Currirulurn. ln other situatjons more modest aims will he appropri<ttc, and the curriculum adopted should refle<"t the financial. professional and cultural realities which exist.

I Curriculum Guidelines

These guidelines for the development of curricula for the Western Pacific Region are presented acknowledging the need for modest flrst steps, but offering a vision of later progress towards the effective education of all key persons.

l. The development of appropriate curricula for education in cancer pain relief and palliative care should be: included in government cancer control policies

• encouraged by professional organisations implemented by medical, pharmacy and nursing educational institutions

2. Recognising that most health professionals were not exposed to consi(kration of cancer prun relief and palliative care in their trruning, curricula should be developed for the three mr'as of: undergraduate education, postgraduate education and continuing education of health professionals.

3. Curricula should include recommendations concerning attitudes, knowledge. and skills desirable for effective cancer pain relief and palliative care.

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Annex 6

GENERAL AIMS FOR A CANCER PAIN RELIEF AND PALLIATIVE CARE CURRICULUM

I ATTITUDES

1. The comprehensive nature of illness

To recognise that discomfort arising from illness, and particularly from advanced illness, includes physical, psychosocial and spiritual components.

2. Respect

a) "Patient-centredness" To show respect for the patient's expression of discomfort ("believe the patient~)and the patient's expression of priority of need, and to demonstrate encouragement of the patient's role in decision-making and in the control of management.

b) Family involvement To understand the impact of illness on the family, and show respect for the role of family members in management and provision of care.

c) Culture and religion To recognise the importance of culture, race, religion. language and gender issues on individual and community approaches to illness and show respect for their influence on management.

d) Fellow professionals To understand the need for cooperation in the provision of care and to demonstrate respect for the knowledge and skills of the various health professions who may contribute to care, and for the contribution by family members.

3. Inter-disciplinary teamwork

To demonstrate understanding of the particular contributions made by specialist and family physicians, nurses, other health professionals and family members to the comprehensive care which patients with advanced and terminal illness require.

4. Continuity of Care

• To understand the need for an early attention to the effective management of symptoms in the treatment of cancer and other potentially-terminal illness.

• To recognise the nee~! for care to continue uninterrupted throughout the course of a terminal illness, wherever that care is being delivered.

• To reject the concept that "nothing more c::~n be done" when active treatment or cancer or other advanced illness is suspended, and to advocate instead that "there is always something which can be done".

• To accept that palliative care extends into the bereavement period

5. Attitudes to Opioids

• To understand that opioids are indispensable for relief of pain and suffering • To reject a fear of opioids based in misunderstanding that:

- opioid use in pain will lead to addiction - medical use of opioids will increase drug abuse - opioid usc in pain will cause respiratory depression

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Annex 6

I KNOWLEDGE

1. Mechanisms of discomfort

• To describe the ways in which pain and other symptoms are caused by cancer and other advanced illness.

• To understand the ways in which the use of medications and of other techniques (including complementary and traditional methods of treatment) may modify the effect of illness and combat symptoms.

2. Management of Pain

• To understand the rationale of the WHO approach to cancer pain management. In particular, to advocate the use of morphine according to the precepts:

By mouth- using oral opioids and other analgesics wherever appropriate By the clock- anticipating and preventing pain, and using breakthrough doses as well as regular doses of analgesics By the ladder- moving from weak analgesics to strong analgesics as necessary and recognising that there is no correct dose or upper limit to the dose of morphine in cancer pain

• To understand the possible routes of administration of analgesics • To understand and prevent the side effects of analgesics

3. The Organisation of Care

To identify the various settings within which cancer pain relief and palliative care is offered, and to describe the resources available to contribute to the comprehensive care needed in each setting.

4. The Psychosocial Aspects of Care

To describe the effects of terminal and advanced illness on the emotional reactions of patients and of family members, including the impact of grief and bereavement on well-being.

!sKILLS

1. Individual patient care To accurately assess the cause of major symptoms of advanced cancer and other illness, and to plan appropriate comprehensive approaches to combat those symptoms

2. Family Care To counsel and support patients and families and assist their growth in understanding, confidence and ability to face the threat of terminal illness.

:ro advocate the fullest appropriate disclosure to the patient and to the family of mformation concerning diagnosis and prognosis.

3. Delivery of Care To access the range of resources which can contribute to the care of advanced cancer and other illness, including community as well as hospital resources.

4. Education and Advocacy To be confident and effective in:

• presenting information concerning care to patients, family members and colleagues

• identifying barriers to effective management • outlining deficiencies in current practice in regard to cancer pain relief and

palliative care • advocating and promoting change in practice.

; ! I