Palliative care in Nigeria Journal of Palliative Medicine, 2012

1. MANAGEMENT OF DISEASE AND
PERSON – A CONTEMPORARY
ISSUE IN MODERN MEDICINE
Dr. Folaju O.Oyebola
MPhil. Pall. Med. (UCT)
Head of Dept. Pain & Palliative Medicine
Federal Medical Centre
Abeokuta, Ogun State, Nigeria
fooyebola@yahoo.com

2. Overview
• Palliative care concept
• Multidisciplinary Team Care Approach
• Journey so far … 2002 - 2011
• Day Care Hospice Project – The concept
• Sharing experiences – 2 stories
• Tributes

3. Posers
• What exactly do we manage in patients, is it the
disease / the person ?
• How effectively do we manage both?
• What are the best way to effectively manage both the
disease and the person?
• Curative Vs. Care or / Curative and Care ?
• Palliative Care # End-of- Life Care?

4. Disease & the Person
Disease Person
Cure: Care – compassion, hope etc.
• Surgical - Need Assessment along at
• Medical least 4-5 domains
Both applicable in Cancer - Care and Support

5. WHO Views
• “Health is not just the absence of disease, it is a state of
physical, psychological, social and spiritual well being”
(World Health Organisation,1948).
• “Until recently the health professions have largely followed a
medical model, which seeks to treat patients by focusing on
medicines and surgery, and gives less importance to beliefs
and to faith. This reductionism or mechanistic view of
patients as being only a material body is no longer
satisfactory. Patients and physicians have begun to realize
the value of elements such as faith, hope and compassion in
the healing process. The value of such ‘spiritual’ elements in
health and quality of life has led to research in this field in an
attempt to move towards a more holistic view of health that
includes a non-material dimension, emphasizing the
seamless connections between mind and body.”
(World Health Organization (WHO), 1998)

6. The Person (mind)

7. 2006 FMCA Study
FMCA Experience Desire for a company
• Forty-six (85.2%) of patients • .
were of the opinion that the
hospital staff do not spend
time with them.
• While 27(50%) of the
respondents affirmed that
they did not enjoy a close
relationship with the staff.

8. Care & Support for the Soul
FMCA Experience Not my business
a). 29 (53.8%) of the
respondents were not satisfied
with the hospital “spiritual
care “
b). 18 yr. old, had Chronic
scrotal swelling ? tumor,
uncontrollable pain
(morphine).
Further assessment- Identified
spiritual distress – Had a strong
desire to be baptized. Rev. Fr. + 2
Godmothers intervened & was
baptized. Pain subsided & family
was very happy

9. .
Duty of Health professionals
•• . To cure sometimes
• To relieve often
• To comfort always
(Hippocrates)
CURE & CARE - Too often forgotten

10. Care & Cure
• Up to the 19th century, most medical care related to
amelioration of symptoms while the natural history of
the disease took its course toward recovery or death.
By 1900,doctors & patients alike had turned to a search
for root cause & ultimate cure. Therapy directed at the
symptoms was denigrated & dismissed as merely
symptomatic …………(Pain & Symptom control)
• [Yet] the immediate origins of misery & suffering need
immediate attention while the long time search for
basic cure (disease specific) proceeds. The old method
of care and curing had to be discovered.
Wall P.D Twenty-five volumes of Pain 25:1-4,1986

11. PC Definition
• Is an approach that improves the quality of life of
patients and their families facing the problems
associated with life threatening illness.
• through the prevention and relief of suffering by
means of
• Early identification and impeccable assessment
and treatment of pain and other problems,
physical, psychosocial and spiritual.
(WHO2002)

12. PC Definition
• PC means patient and family-centered care
that optimizes quality of life by anticipating,
preventing, and treating suffering.
• Palliative care throughout the continuum
of illness involves addressing physical,
intellectual, emotional, social, and spiritual
needs and to facilitate patient autonomy,
access to information and choice.
73FR 32204, J UNE 5, 2008
• Medicare Hospice Conditions of Participation-Final Rule

13. Old concept of. Palliative Care
• .
.
Curative Palliative
care care
Diagnosis Death

14. Continuum of care- Not End-of Life
.
Care
• .
Curative care
Chemo, Radio
HAART.
Palliative Care for Cancer Individual
& HIV/AIDS /Family
care
Bereavement
diagnosis death care

15. . Outcome of introducing PC early after
diagnosis
• “Among patients with metastatic non-small
cell lung cancer, early palliative care led to
significant improvements in both quality of
life & mood. As compared with patients.
receiving standard care, patients receiving
early palliative care had less aggressive care at
the end of life but longer survival”
Jennifer S.Temel, et al (2010), N Engl J Med 2010;363:733-42

16. Multidisciplinary/ Interdisciplinary
• “THE DAYS of lone-ranger clinician are over.“
“The parallel play” model of health care, with
each discipline structuring cross-sectional
interventions in silo, is terminally ill and on firm
do-not-resuscitate status ---- The modern patient
with chronic illness needs a group of multidomain
experts who work together longitudinally to
collectively orchestrate chronic care”
Vyjeyanthi S. Periyakoli (2008)

17. PC & other Hospital Community
Multidisciplinary Team (MDT) Approach:
• Open minded
• Team work
• Mutual respect
• Rx. Both the disease/ person - Cure /Care
• • Cooperative / Collaborate Teams
Small win – HIV/AIDS MDT Project
Failing - Oncology MDT

18. Collaboration
• Debunk rivalry, never supplanting physicians
as each of us needs other.
• Strengthen existing referral network.
• Education, Training & Research collaboration.
• Essence is to jointly manage advanced disease
patients to improve their quality of life &
improve FMCA health care service delivery.

19. Palliative care is holistic & inter-
. care.
disciplinary
• .

20. Journey so far ………
Unusual responsibility to model the WAY & start
new service without pre-existing structure !!!!
• Strategic Planning
Define –
- Mission,
- Vision,
- Values

21. Inspiration
FMCA hospital Mission Statement
• Provide quality and timely clinical and other
support services to patients and clients at a
reasonable cost within its jurisdiction. “In
doing so, we shall adopt a
multidisciplinary team approach for
the provision of prompt, excellent and cost
effective Health care services in Ogun
state………….”

22. Strategies
Vision Mission Statement
• To improve quality • To integrate palliative
of life of clients and care services into the
their families and existing health care
system using
establish a Centre for
multidisciplinary
education , training
team care approach
and research.

23. VALUES
• Client first • Sacrifice
• Team spirit • Hardworking
• Mutual respect • Honesty
• Empathy
• Accountability

24. Modest achievements
Small wins
• Morphine – Introduce by PC team against Pentazocine
• We introduced MDT to cancer /HIV/AIDS services
• First 2 Palliative Care Physicians in Nigeria
• Paper presentations-Local, Region & World events
• Assisting other sister hospitals to start PC services
• Education & Training with our UK Partners
2005,2008,2011
• Interdepartmental Seminars -
Target patients – Cancer, HIV/AIDS, End-stage Cardiac,
Metabolic, Renal and Neurological conditions

25. Focus Services
• Pain / symptom control
• Care and support
• Bereavement care
• Geriatric services – New project
• Community outreaches – Home visit – certifying
dead at home.
• Palliative Care Education and Training/ UK
Partners
• Day Care Hospice

26. Day Care Hospice Concept
AIM- Refer patients for: Inaugurated Jan.2011
• Longer consultation time Facilities –
• Holistic Care and support
• TV
• Clients sharing challenges and
successes. • Games
• Identify Pt. problem & refer to • Drawing & Painting
appropriate MDT group.
• Collectively strategized on • Kitchen facility
clinical & non-clinical problems. Future facilities
• Skills & empowerment for • Massage
clients.
• Social networking with peers • Salon
• Temporary stay & stabilization • Bigger Day Care Hospice
of clients

27. Day Care Unit
• .

28. Challenges
• Inadequate Manpower - No annual leave
since 2007
• Lack of funding
• Local resistors – Non-referral of patients by
some department to PC team

29. Inadequate Manpower(only 4 core staff)
• .

30. Our Clients
January-May 2011 MALE FEMALE TOTAL
Day Care Hospice Clients 1 13 14
Retroviral Clinic 76 317 395
Home Visit/ Bereavement 2 8 10
Ward Admission 7 31 38

31. Palliative/ Pain Clinic consults received
.
from march 2008 to June 2011
• 70
.
60
50
40
30
20
10
0
2008 2009 2010

32. .
Cancer Case – Story 1
•• . A 24 year old lady with history of recurrent breast
lump. Had excisional biopsy and histology which
confirmed adenocarcinoma.
• Had some radiotherapy but defaulted .
• Re-appeared 4 months later with metastatic extension
to the axillary region.
• Had some CHEMO but also defaulted
• Presented 4 months later with severe chest pain
, pulmonary metastasis and minimal pleural effusion
(Surgical + Palliative Care).
• A month later, she was admitted to the emergency for
attempted suicide.

33. Problems &. Intervention
. .
Problems Solution
• • . Physical • • . Jointly managed – MDT
- Ulcerated metastatic Breast Ca. - Pain - Opioids(Morphine) +PCM
- cough and mild difficulty in - Wound dressing- Metronidazole
breathing powder
• Family meeting –
• Psychosocial – Suicidal
- Care and Support
Depression, inadequate support
- Patient find meaning to illness
& rejection by family
- Family Cohesiveness
• Spiritual –
• Escaped from the
- Religious conflict incarceration
- Family requested Parole • Pastor, UCH

34. Story 2 – HIV/AIDS Continuum of Care
• A 30yr old graduate, teacher married 8years ago with
two kids.
• Lost second child few month after birth.
• Husband died of HIV/ AIDS 3years ago
• Two year ago she was diagnosed RVS positive and placed
on HAART.
• last year she lost her 7year old boy to head injury.
2nd Relationship
• She was lonely/ depressed - this prompted her to search for
another relationship.
• Pregnant for sero - discordant man (non-disclosure).
• Resigned her job &abandoned home to follow new man

35. PROBLEMS . INTERVENTION
• Got to know of other 4
• -. • Strategy/ counselling;
women & 7 Kids, • - . Advised to be independent & relocate
• jobless and was starving, - To re-apply & get her former job .
• abandoned by her man Spiritual care & support
friend . - We contacted our volunteer her who
offered her spiritual care & support
- lonely & depressed, wanted Intervention - Outcome
to terminate pregnancy/
- Found meaning to her life
commit suicide.
- Became closer to God.
• Problems; • Already secured back her Job and
- Emotional, returned to her personal home .
- Socio-economic & • She was discouraged not to terminate
the pregnancy.
- Spiritual
• Today she is living happily ,Civil
servant, part-time
hairdresser, attending PMTCT and
coping well with the pregnancy.

36. Tributes – Encouraging the Hearts
• Consultants , Units & Departments - Refer
patients to us for consultation & collaborate
• Palliative Care MDT
• Volunteers – Time, resources etc.
- support, strategize together with us

37. THANK YOU
• THE HARVEST IS RIPE
BUT THE LABOURERS
ARE FEW – PRAY THE
GOD OF HARVEST TO
SEND DOWN
LABOURERS.
Matt. 9, 37-38
Pls. Join us today !!!!!!