The World Health Organization estimates that 7.

6 million people died of cancer in

2005 and 84 million people will die in the next 10 years if action is not taken. Cancer Control
More than 70% of all cancer deaths occur in low and middle income countries,
where resources available for prevention, diagnosis and treatment of cancer are Knowledge into Action
limited or nonexistent.
WHO Guide for Effective Programmes
Yet cancer is to a large extent avoidable. Over 40% of all cancers can be prevented.
Some of the most common cancers are curable if detected early and treated. Even with
late cancer, the suffering of patients can be relieved with good palliative care.

Cancer control: knowledge into action: WHO guide for effective

programmes is a series of six modules offering guidance
on all important aspects of effective cancer
control planning and implementation.

Worldwide, millions of cancer patients could be relieved from pain and unnecessary suffering if they had
timely access to good palliative care.

This module explains how to develop an effective palliative care programme within the context of a
national cancer control programme. It is based on the Planning module, which provides a comprehensive
understanding of the overall cancer control planning process.

Although this Palliative care module focuses on cancer and does not specifically address other diseases,
it recognizes the need for developing palliative care with a public health approach that targets all age
groups suffering from diseases or conditions in need of palliative care. These conditions include HIV/AIDS,
congestive heart failure, cerebrovascular disease, neurodegenerative disorders, chronic respiratory
diseases and diseases of older people, among others.

The principles guiding the development of palliative care within a cancer control programme are very
similar to those needed in providing palliative care for people with other chronic diseases.

ISBN 92 4 154734 5

Palliative Care
Cancer Control
Knowledge into Action
WHO Guide for Effective Programmes

Palliative Care
WHO Library Cataloguing-in-Publication Data

Palliative Care.
(Cancer control : knowledge into action : WHO guide for effective programmes ; module 5.)
1.Palliative care – organization and administration. 2.Palliative care – utilization. 3.Neoplasms – therapy. 4.Hospice care – organization and administration. 5.Health
planning. 6.National health programs – organization and administration. 7.Guidelines. I.World Health Organization. II.Series.
ISBN 92 4 154734 5 (NLM classification: QZ 266)

© World Health Organization 2007

All rights reserved. Publications of the World Health Organization can be obtained from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
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or for noncommercial distribution – should be addressed to WHO Press, at the above address (fax: +41 22 791 4806; e-mail: [email protected]).
The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of the World
Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries.
Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization
in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial
capital letters.
All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is
being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no
event shall the World Health Organization be liable for damages arising from its use.

The Cancer Control Palliative Care module was produced under the direction of Catherine Le Galès-Camus (Assistant Director-General, Noncommunicable Diseases and
Mental Health), Serge Resnikoff (Coordinator, Chronic Diseases Prevention and Management) and Cecilia Sepúlveda (Chronic Diseases Prevention and Management,
coordinator of the overall series of modules).

Kathleen Foley was the coordinator for this module and Cecilia Sepúlveda provided extensive editorial input.

Editorial support was provided by Anthony Miller (scientific editor), Inés Salas (technical adviser) and Angela Haden (technical writer and editor). Proofreading was done
by Ann Morgan.

The production of the module was coordinated by Maria Villanueva and Neeta Kumar.

Core contributions for the module were received from Kathleen Foley, Memorial Sloan-Kettering Cancer Center, USA.

Valuable input, help and advice were received from a number of people in WHO headquarters throughout the production of the module: Caroline Allsopp, David Bramley,
Raphaël Crettaz and Maryvonne Grisetti.

Cancer and palliative care experts worldwide, as well as technical staff in WHO headquarters and in WHO regional and country offices, also provided valuable input by
making contributions and reviewing the module, and are listed in the Acknowledgements.

Design and layout: L’IV Com Sàrl, Morges, Switzerland, based on a style developed by Reda Sadki, Paris, France.

Printed in Switzerland

More information about this publication can be obtained from:

Department of Chronic Diseases and Health Promotion
World Health Organization
CH-1211 Geneva 27, Switzerland

The production of this publication was made possible through the generous financial support of the National Cancer Institute (NCI), USA,
and the National Cancer Institute (INCa), France. We would also like to thank the Public Health Agency of Canada (PHAC), the National
Cancer Center (NCC) of the Republic of Korea, the International Atomic Energy Agency (IAEA) and the International Union Against Cancer
(UICC) for their financial support.
 Series overview

Introduction to the
Cancer Control Series
Cancer is to a large extent avoidable. Many cancers
can be prevented. Others can be detected early in their
development, treated and cured. Even with late stage
cancer, the pain can be reduced, the progression of the
cancer slowed, and patients and their families helped
to cope.

Cancer is a leading cause of death globally. The World Health Organization

estimates that 7.6 million people died of cancer in 2005 and 84 million people
will die in the next 10 years if action is not taken. More than 70% of all cancer
deaths occur in low- and middle-income countries, where resources available for
prevention, diagnosis and treatment of cancer are limited or nonexistent.

But because of the wealth of available knowledge, all countries can, at some
useful level, implement the four basic components of cancer control – prevention,
early detection, diagnosis and treatment, and palliative care – and thus avoid
and cure many cancers, as well as palliating the suffering.

Cancer control: knowledge into action, WHO guide for effective programmes is
a series of six modules that provides practical advice for programme managers
and policy-makers on how to advocate, plan and implement effective cancer
control programmes, particularly in low- and middle-income countries.

iii
A series of six modules

Cancer Control
Knowledge into Action
WHO Guide for Effective Programmes PLANNING
A practical guide for programme
managers on how to plan overall The WHO guide is a response to the World Health Assembly
cancer control effectively,
resolution on cancer prevention and control (WHA58.22), adopted

6
according to available resources
and integrating cancer control in May 2005, which calls on Member States to intensify action
with programmes for other chronic against cancer by developing and reinforcing cancer control
diseases and related problems.
Planning
programmes. It builds on National cancer control programmes:
policies and managerial guidelines and Preventing chronic
Cancer Control diseases: a vital investment, as well as on the various WHO
Knowledge into Action
WHO Guide for Effective Programmes PREVENTION policies that have influenced efforts to control cancer.
A practical guide for programme
managers on how to implement
effective cancer prevention by Cancer control aims to reduce the incidence, morbidity and mortality
controlling major avoidable cancer of cancer and to improve the quality of life of cancer patients in
risk factors.
a defined population, through the systematic implementation
of evidence-based interventions for prevention, early detection,
Prevention diagnosis, treatment and palliative care. Comprehensive cancer
control addresses the whole population, while seeking to respond
Cancer Control
Knowledge into Action
to the needs of the different subgroups at risk.
WHO Guide for Effective Programmes EARLY DETECTION
A practical guide for programme
managers on how to implement
effective early detection of major
types of cancer that are amenable
COMPONENTS OF CANCER
to early diagnosis and screening. CONTROL

Early Detection Prevention of cancer, especially when integrated with the

prevention of chronic diseases and other related problems (such
Cancer Control
Knowledge into Action
as reproductive health, hepatitis B immunization, HIV/AIDS,
WHO Guide for Effective Programmes DIAGNOSIS AND TREATMENT occupational and environmental health), offers the greatest
A practical guide for programme
managers on how to implement public health potential and the most cost-effective long-term
effective cancer diagnosis and method of cancer control. We now have sufficient knowledge to
treatment, particularly linked to
early detection programmes or
prevent around 40% of all cancers. Most cancers are linked to
curable cancers. tobacco use, unhealthy diet or infectious agents (see Prevention
Diagnosis and
module).
Treatment

Early detection detects (or diagnoses) the disease at an

Cancer Control
Knowledge into Action
WHO Guide for Effective Programmes PALLIATIVE CARE early stage, when it has a high potential for cure (e.g. cervical
A practical guide for programme or breast cancer). Interventions are available which permit the
managers on how to implement early detection and effective treatment of around one third of
effective palliative care for
cancer, with a particular focus on cases (see Early Detection module).
community-based care.
There are two strategies for early detection:
• early diagnosis, often involving the patient’s awareness of
Palliative Care
early signs and symptoms, leading to a consultation with
Cancer Control a health provider – who then promptly refers the patient
Knowledge into Action
WHO Guide for Effective Programmes POLICY AND ADVOCACY for confirmation of diagnosis and treatment;
A practical guide for medium level
decision-makers and programme
managers on how to advocate for • national or regional screening of asymptomatic and
policy development and effective apparently healthy individuals to detect pre-cancerous
programme implementation for lesions or an early stage of cancer, and to arrange referral
cancer control.
for diagnosis and treatment.
iv Policy and
Advocacy
 Series overview

Treatment aims to cure disease, prolong life, and improve

the quality of remaining life after the diagnosis of cancer is
BASIC PRINCIPLES OF CANCER CONTROL
confirmed by the appropriate available procedures. The most
effective and efficient treatment is linked to early detection • Leadership to create clarity and unity of
programmes and follows evidence-based standards of care. purpose, and to encourage team building,
broad participation, ownership of the
Patients can benefit either by cure or by prolonged life, in cases process, continuous learning and mutual
of cancers that although disseminated are highly responsive recognition of efforts made.
to treatment, including acute leukaemia and lymphoma. This
component also addresses rehabilitation aimed at improving the • Involvement of stakeholders of all
quality of life of patients with impairments due to cancer (see related sectors, and at all levels of the
decision-making process, to enable active
Diagnosis and Treatment module). participation and commitment of key
players for the benefit of the programme.
Palliative care meets the needs of all patients requiring relief
from symptoms, and the needs of patients and their families for • Creation of partnerships to enhance
psychosocial and supportive care. This is particularly true when effectiveness through mutually beneficial
patients are in advanced stages and have a very low chance of relationships, and build upon trust and
complementary capacities of partners
being cured, or when they are facing the terminal phase of the from different disciplines and sectors.
disease. Because of the emotional, spiritual, social and economic
consequences of cancer and its management, palliative care • Responding to the needs of people
services addressing the needs of patients and their families, from at risk of developing cancer or already
the time of diagnosis, can improve quality of life and the ability presenting with the disease, in order to
meet their physical, psychosocial and
to cope effectively (see Palliative Care module). spiritual needs across the full continuum
of care.
Despite cancer being a global public health problem, many
governments have not yet included cancer control in their • Decision-making based on evidence,
health agendas. There are competing health problems, and social values and efficient and cost-
interventions may be chosen in response to the demands of effective use of resources that benefit the
target population in a sustainable and
interest groups, rather than in response to population needs or equitable way.
on the basis of cost-effectiveness and affordability.
• Application of a systemic approach
Low-income and disadvantaged groups are generally more by implementing a comprehensive
exposed to avoidable cancer risk factors, such as environmental programme with interrelated key
components sharing the same goals and
carcinogens, tobacco use, alcohol abuse and infectious agents. integrated with other related programmes
These groups have less political influence, less access to health and to the health system.
services, and lack education that can empower them to make
decisions to protect and improve their own health. • Seeking continuous improvement,
innovation and creativity to maximize
performance and to address social and
cultural diversity, as well as the needs
and challenges presented by a changing
environment.

• Adoption of a stepwise approach

to planning and implementing
interventions, based on local
considerations and needs
(see next page for WHO stepwise
framework for chronic diseases
prevention and control, as applied to
cancer control).
v
 Series overview

WHO stepwise framework

1 PLANNING STEP 1 Investigate the present state of the

6
cancer problem, and cancer control
services or programmes.
Where are we now?

2
Formulate and adopt policy. This includes
PLANNING STEP 2 defining the target population, setting

6
goals and objectives, and deciding on
priority interventions across the cancer
Where do we want to be? continuum.

3 PLANNING STEP 3

6
Identify the steps needed to implement
the policy.
How do we get there?

The planning phase is followed by the policy implementation phase.

Implementation step 1 Implement interventions in the policy that are

feasible now, with existing resources.
CORE

Implementation step 2 Implement interventions in the policy that are

feasible in the medium term, with a realistically
EXPANDED projected increase in, or reallocation of, resources.

Implementation step 3 Implement interventions in the policy that are

beyond the reach of current resources, if and when
DESIRABLE such resources become available.

vi
 Contents

PALLIATIVE CARE MODULE CONTENTS

KEY MESSAGES 2

PRE-PLANNING 6
Is a cancer palliative care plan needed? 6

PLANNING STEP 1: WHERE ARE WE NOW? 8

Assess the number of people in need of cancer palliative care 8
Assess the needs of patients, health-care providers and family caregivers 10
Assess the existing palliative care plan and activities 10
Understand the social context of the palliative care plan and activities 14
Self-assessment by countries 15

PLANNING STEP 2: WHERE DO WE WANT TO BE? 16

Define the target population for palliative care 16
Identify gaps in palliative care services 17
Set goals and objectives for palliative care 17
Assess feasibility of interventions 19
Consider ethical issues 19
Set priorities for palliative care 20

PLANNING STEP 3: HOW DO WE GET THERE? 22

Bridge the gaps in palliative care 23
Raise the necessary resources 23
Organize cancer palliative care services across all levels of care 25
Adopt a team approach 26
Understand the role of health-care providers 27
Create palliative care teams 29
Educate caregivers 32
Educate the general public and policy-makers 34
Ensure the availability of essential drugs for the management of pain and other symptoms 35
Develop palliative care standards 36
Evaluate and monitor the palliative care plan and activities 37

CONCLUSION 39

REFERENCES 40

ACKNOWLEDGEMENTS 41

1
PALLIATIVE CARE

KEY MESSAGES
p Palliative care is an urgent humanitarian need worldwide
for people with cancer and other chronic fatal diseases.
Palliative care is particularly needed in places where a
high proportion of patients present in advanced stages
and there is little chance of cure.

p Ideally, palliative care services should be provided from

the time of diagnosis of life-threatening illness, adapting
to the increasing needs of cancer patients and their
families as the disease progresses into the terminal
phase. They should also provide support to families in
their bereavement.

p Effective palliative care services are integrated into the

existing health system at all levels of care, especially
community and home-based care. They involve the
public and the private sector and are adapted to the
specific cultural, social and economic setting.

p In order to respond to the cancer priority needs in a

community and make the best use of scarce resources,
palliative care services should be strategically linked to
cancer prevention, early detection and treatment services
for both adults and children.
2
 Key messages

key definitions
What is palliative care?
Palliative care (WHO, 2002a) 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.

Palliative care:
p provides relief from pain and other distressing symptoms;
p affirms life and regards dying as a normal process;
p intends neither to hasten nor to postpone death;
p integrates the psychological and spiritual aspects of patient care;
p offers a support system to help patients live as actively as possible

until death;
p offers a support system to help the family cope during the patient’s

illness and in their own bereavement;

p uses a team approach to address the needs of patients and their

families, including bereavement counselling, if indicated;

p will enhance quality of life, and may also positively influence the course

of illness;
p is applicable early in the course of illness, in conjunction with other

therapies that are intended to prolong life, such as chemotherapy or

radiation therapy;
p includes the investigations needed to better understand and manage

distressing clinical complications.

3
PALLIATIVE CARE

Terminal cancer
Terminal cancer refers to an advanced stage when curative treatment is
no longer useful, the disease is assessed to be incurable and the patient’s
condition is progressively deteriorating.

Figure 1 illustrates the continuum of care associated with curative and

palliative care. Treatment intended to modify the disease decreases as
illness progresses, while palliative care increases as the person reaches
the end of life. Palliative care also provides support for the family during
this entire period. After the patient dies, bereavement counselling for
family and friends is important.

Figure 1. Integrated model of curative and palliative care for

chronic progressive illness

Disease-modifying therapy
(curative, life-prolonging or palliative in intent)

Palliative care
Bereavement care

Presentation/ Illness Death

diagnosis

Source: Adapted from American Medical Association Institute for Medical Ethics (1999). EPEC: education for physicians on end-of-life care.
Chicago, IL, The Robert Wood Johnson Foundation.

4
The quality-of-life dimensions of palliative care are illustrated in Figure 2.
Palliative care is concerned not only with all aspects of the patient’s needs,
but also with the needs of the family and of the health-care providers.

Figure 2. Quality-of-life dimensions of palliative care

Patients Physical
Psychological
Spiritual

Families Social
Psychological
Spiritual

Providers Psychological
Spiritual

Presentation/ Illness Death

diagnosis

Source: WHO (2002a) National cancer control programme: policies and managerial guidelines, 2nd ed. Geneva, World Health Organization.

This Palliative care module focuses on cancer and does not specifically address other
diseases, however, it recognizes the need for developing palliative care with a public
health approach that targets all age groups suffering from diseases or conditions in
need of palliative care. These conditions include HIV/AIDS, congestive heart failure,
cerebrovascular disease, neurodegenerative disorders, chronic respiratory diseases
and diseases of older people, among others.

5
PALLIATIVE CARE

PRE-PLANNING
It is estimated that, worldwide, there are millions of cancer
patients in need of palliative care. With careful planning
of cancer palliative care within a comprehensive cancer
control plan, a large proportion of advanced cancer patients
could be relieved from their suffering and the quality of their
lives could be improved significantly.
Numerous governments have already adopted national palliative care
policies, including Australia, Canada, Chile, Costa Rica, Cuba, France,
Ireland, Norway, Spain, Uganda, South Africa and the United Kingdom.
i
For examples, see http://www.who.int/cancer/modules/en/index.html
www

IS A CANCER PALLIATIVE CARE PLAN NEEDED?

Palliative care is particularly important in less developed countries where a high proportion
of cancer patients are diagnosed in advanced stages when treatment is no longer effective.
These patients can be relieved from suffering with relatively low-cost interventions.

A public health approach to palliative care is required in all countries in order to address the
needs of all advanced cancer patients and their families, ensuring universal access to the
necessary services at all levels of care within the health system.

Three measures are required as a foundation for developing palliative care with a public
health approach (WHO, 1996):
p a government policy to ensure the integration of palliative care services into the structure
and financing of the national health-care system;
p an educational policy to provide support for the training of health-care professionals,
volunteers and the public;
p a drug policy to ensure the availability of essential drugs for the management of pain
and other symptoms and psychological distress, in particular, opioid analgesics for
pain relief.

All three of these measures are necessary, along with committed leadership, to achieve an
effective palliative care programme.
6
 Pre-planning

his story
Good palliative care has changed 50-year-old Subair’s
life from a daily grind of pain and penury to an active
and pain-free independence.

Subair has long experience of palliative care. By 1994

he had undergone serial amputations of the limb,
a full course of radiotherapy and several courses
of chemotherapy, and he had started on palliative
chemotherapy with Endoxan. Although from a middle-
class family, the cost of treatment bankrupted Subair.
He could no longer afford to support his four children
and they were put into an orphanage.

Subair was having excruciating pain in the stump,

and was getting little relief with non-steroidal anti-
inflammatory drugs. As he says, “It was like a hot
metal rod being pushed into the stump and rotated”.

Searching for pain relief, Subair made the 50 km

journey from his home to Calicut to a newly opened
palliative care clinic. There, Subair was put on
regulated oral morphine, in addition to the non- Subair,
steroidal anti-inflammatory drugs. With a dose of 30 50 years old,
mg morphine 4-hourly he enjoyed total relief from pain.
Kerala, India
With effective pain relief, Subair started to explore
work possibilities so that he would be able to support
himself financially. The palliative care unit found him
a job at a coffee stall in the teaching hospital to which
the unit is attached. By working hard, he managed
to get his children out of the orphanage as well as to
support himself. The job restored his self-esteem and
had a positive effect on his quality of life.

Over the past ten years, the disease has progressed

and Subair has had further surgical interventions. His
dose of oral morphine has gone up to 100 mg 4-hourly.
But he continues to be pain-free and active. He has
been able to ensure that his children are educated and
has celebrated his daughter’s wedding. Subair’s story
is an example of what good palliative care can achieve.
SUBAIR’S STORY IS AN EXAMPLE
Source: Information provided by Suresh Kumar, Director, Institute of
Palliative Medicine, Medical College Calicut, India. OF WHAT GOOD PALLIATIVE CARE
CAN ACHIEVE.
PALLIATIVE CARE

PLANNING STEP 1
Where are we now?
The Planning module offers advice on what to assess in
relation to the overall cancer needs in both the general
population and the groups particularly at risk. It also
describes how to assess the existing cancer control plan
and the services that respond to those needs. This Palliative
care module provides more detailed guidance on how to
assess palliative care needs as well as the existing palliative
care plan and services.

ASSESS THE NUMBER OF PEOPLE IN NEED OF

CANCER PALLIATIVE CARE
Assessing cancer palliative care needs is in many ways equivalent to assessing an urgent
humanitarian need to reduce unnecessary suffering of patients and their families. It is
important to bear in mind that although – in the medium to long term – effective prevention,
early detection and treatment will reduce palliative care needs, palliative care needs will never
be eliminated, because some types of cancer will inevitably remain fatal for some patients.

If the most frequent cancer types presenting in advanced stages can be identified, then it
will be possible to provide integrated palliative care services for the specialties concerned.
For example, patients with Kaposi sarcoma and other cancers related to HIV/AIDS could have
access to a common service for palliative care.

8
 Planning step 1

Table 1 provides a template for estimating the number of children and adults in need of
cancer palliative care, based on the number of cancer deaths per year. It is assumed that at
least 80% of terminal cancer patients will require palliative care.

Table 1. How to estimate the number of people in need of

palliative care based on the number of cancer deaths
Total number
of people
Caregivers in need of
Cancer deaths Patients in need of palliative care per patient palliative care
Number % Number Number Number
(A) (B) (C = A x B) D CxD
Adults 80
Children 80
Total

To calculate the overall need for palliative care, the template in Table 1 should also include
patients dying from other chronic life-threatening diseases. Estimates of palliative care
needs based on deaths are low, in relative terms, as they reflect only terminal care. A more
realistic assessment of the number of patients actually needing palliative care would also
include those suffering from cancer or other serious illness but not dying that same year. For
example, it is estimated that 50–80% of patients with HIV/AIDS would benefit from palliative
care services.

A WHO palliative care project, conducted in five sub-Saharan African countries (Sepúlveda
et al.,2003; WHO, 2004), made a rapid assessment of palliative care needs at the end of life
based on the number of deaths from cancer and HIV/AIDS, using a method similar to that
described in Table 1. The number of people needing palliative care each year was estimated
to be at least 690 800 or 0.5% of the total population of these countries.

9
PALLIATIVE CARE

ASSESS THE NEEDS OF PATIENTS,

HEALTH-CARE PROVIDERS AND FAMILY
CAREGIVERS
An overall assessment of palliative care needs should be based on information about the
specific requirements of the patients concerned, as well as those of health-care providers
and family caregivers. The purpose of assessing palliative care needs is to organize the
services to meet those needs.

The above-mentioned WHO project (WHO, 2004) found that the greatest needs of terminally
ill patients were for:
p relief from pain
p accessible and affordable drugs for symptom management
p financial support.

Family members and relatives were the main caregivers, but they generally lacked the
knowledge and skills to perform their tasks adequately.

For examples of tools to assess the needs of

patients and caregivers, see i
http://www.who.int/cancer/modules/en/index.html www

ASSESS THE EXISTING PALLIATIVE CARE PLAN

AND ACTIVITIES
In assessing the existing palliative care plan, it is important to look at palliative care in two ways:
as a key component of a comprehensive cancer control programme; and as a subsystem of a
broader palliative care strategy that includes other health conditions besides cancer.

Table 2 lists what to assess in regard to the existing palliative care plan and activities for
cancer. These aspects are discussed in the Planning module (see pages 17 and 18).

10
 Planning step 1

Table 2. The palliative care plan and activities: what to assess

Plan and activities What to assess
Palliative care plan • Endorsement of the plan and scope (geographical area and conditions included)
• Whether or not part of a comprehensive cancer control plan
• Timeliness (updated/outdated)
• Accessibility to the written plan
• Stakeholders’ involvement in plan development
• Inclusion of critical sections of the plan (assessments, goals and objectives,
strategies, timetable, responsible persons, resources, monitoring and evaluation)
• Comprehensiveness and priorities (objectives and activities related to pain relief
and control of other symptoms)
• Integration with other related activities
• Utility of the plan (used to guide programme implementation)

Ongoing palliative care • Number and types of palliative care activities and related services offered
activities • Coverage of ongoing palliative care activities
• Quality of ongoing palliative care activities
• Evaluation of structure, outcomes, outputs and process indicators and trends
Resources of ongoing • Information systems (registries, surveillance of palliative care services)
palliative care activities • Protocols, guidelines, standards, manuals, educational materials, etc.
• Physical resources (infrastructure, technologies, list of essential drugs for
palliative care)
• Human resources (leaders, councils, committees, health-care networks, health-
care providers, partners, volunteers, traditional healers)
• Financial resources
• Regulations and legislation (insurance schemes, opioid analgesics)

Context of the palliative • SWOT analysis: strengths, weaknesses, opportunities and threats concerning the
care plan and activities performance of the palliative care programme for cancer

11
PALLIATIVE CARE

In assessing current palliative care activities, the focus should be on the gap between what
is required to address the need for palliative care and what is currently available.

Ask the following questions to begin to assess existing palliative care activities:

WHAT PALLIATIVE CARE ACTIVITIES AND OTHER RELATED SERVICES ARE

BEING OFFERED?
p Are there palliative care services (medical, psychosocial and spiritual), public and private,
at the different levels of care for advanced cancer patients? Are there services for end-
of-life care? Are there services for bereavement care?
p Are there inpatient, outpatient or home palliative care services? How are they organized?

HOW MANY PATIENTS ARE COVERED BY THE PALLIATIVE CARE ACTIVITIES?

p What percentage of the target population of patients is covered by the palliative care
activities?
p What percentage of children?
p What percentage of adults?

WHAT IS THE QUALITY OF THE PALLIATIVE CARE ACTIVITIES?

Quality can be assessed through the system model of inputs, process, outputs and outcomes
(short-, medium- and long-term). Quality assessment can also be based on the continuous
quality improvement framework, which uses a number of quality dimensions that can be
explored through questions such as:
p Are all the services of the palliative care programme accessible (to ensure coverage and
timeliness) to the target population?
p Are there drugs accessible for pain relief, in accordance with the WHO’s ladder for cancer
pain relief?
p Are there drugs accessible for the control of other symptoms?
p Are the services acceptable (ensuring providers’ and patients’ satisfaction) and
appropriate (based on established standards) for the target groups?
p Are the competences (knowledge and skills) of the providers appropriate for the services
needed?
p Is there continuity (integration, coordination and ease of navigation) in palliative care
activities for cancer and other chronic fatal diseases? Is there continuity among the
levels of care? Is there continuity between private and public institutions?
p Are the palliative care activities effective (do they improve quality of life)?
p Are palliative care activities efficient (do they provide the best results at the lowest cost)?

ARE THERE REGULAR MONITORING AND EVALUATION SYSTEMS?

p Do they include evaluation of quality of life?
p What are the process and outcome indicators used?
p What are the minimum standards applied?

12
 Planning step 1

WHAT ARE THE EXISTING RESOURCES ASSOCIATED WITH PALLIATIVE CARE

ACTIVITIES?
p Are there information systems to monitor and evaluate the palliative care services
provided?
p Are there guidelines for the management of pain and other symptoms at all levels of
care, including primary health-care and home-based care?
p Are there regulations on opioid analgesics favouring their appropriate medical use?
p Is there a list of essential drugs for palliative care, which includes oral morphine?
p Is there a national or regional coordinator responsible for overseeing the palliative care
activities? Is there a multisectoral and multidisciplinary committee to advise on the policy
and activities?
p What is the existing palliative care network? Does it include programme managers,
health-care providers, community leaders and traditional healers?
p Is there a basic palliative care package for the primary health level and for home-based
care programmes? How is it financed?

SOUTH AMERICA
Example of an evaluation of palliative care programmes using structure,
process and outcome measures
STRUCTURE PROCESS
Support of health authorities Education
Most countries in South America do not satisfy the demand for Health professionals are increasingly interested in palliative care,
palliative care: 80% do not recognize palliative care as a discipline and this interest is paralleled by increasing learning opportunities.
and it is not included in the public or private health systems. Only However, less than 15% of those that deliver end-of-life care have
Chile, Costa Rica and Cuba have national programmes that provide received specific undergraduate education on that subject. Most
palliative care nationwide. have acquired knowledge and skills after graduation, through
teaching programmes with differing formats.
Financing
Most health systems are under-funded, yet they pay for futile Research
interventions but they do not pay, or they do not pay enough, for Resources and expertise in research are limited, so little research is
palliative care. This situation jeopardizes the sustainability of carried out and it is of variable quality.
activities, which are mostly run by volunteers, with resources from
charities and nongovernmental organizations, and – where possible Care
– payments from patients. There is limited information about how and where patients die, how
many receive palliative care, and the characteristics of the caring
Opioid availability and accessibility process.
There is good availability of different opioids, but poor accessibility
because of their high cost, lack of training among health personnel Coverage
on how to prescribe and use opioids, and restrictive regulations. The availability, accessibility and affordability of palliative care are
inadequate. It is estimated that: only 5–10% of patients that need
Teams and programmes palliative care receive it; over 90% of all palliative care services are
There is limited information on the number of teams or programmes provided in large cities; and over 50% of patients cannot afford the
providing palliative care services, and the type of care they deliver. services or the medication.
The teams and programmes differ according to their development:
community- or hospital-based; with one or more disciplines; with
mixed or exclusive home, outpatient or inpatient care. Most services OUTCOME
provide care for cancer patients.
There is no available information on how effective palliative care is
National palliative care associations or which factors determine its effectiveness.
By March 2006, Argentina, Bolivia, Brazil, Colombia, Mexico,
Paraguay, Peru, Uruguay and Venezuela had national palliative care Source: Wenk R, Bertolino M (2001). Palliative care development in South
associations. America: a focus on Argentina. Journal of Pain and Symptom Management,
33:645–650. Copyright Elsevier.
PALLIATIVE CARE

UNDERSTAND THE SOCIAL CONTEXT OF THE

PALLIATIVE CARE PLAN AND ACTIVITIES
The development of a palliative care plan and activities requires a thorough understanding of
the context. One way to gain this understanding is by analysing the strengths, weaknesses,
opportunities and threats (SWOT) associated with the existing plan and activities.

During the course of the SWOT analysis, the following questions should be answered:
p What are the strengths and weaknesses associated with plan development and
implementation? These are factors affected by internal forces, such as political support,
leadership, stakeholder involvement and resources available. For example, politicians and
decision-makers often see a focus on treatment as being a more attractive approach,
and neglect palliative care. They may not understand the importance of palliative care
or may feel that by emphasizing palliative care they are somehow admitting defeat and
giving up the struggle against disease.

p What are the opportunities and threats associated with plan development and
implementation? These are factors affected by external forces, such as the international
palliative care agenda, the political and economic situation within the country, or
the existence of other pressing health priorities. For example, the fact that WHO
and international partners are advocating a public health approach to palliative care
represents an opportunity for influencing the development of national policies.

For details of international organizations working in

palliative care, and also for further resources, see i
http://www.who.int/cancer/modules/en/index.html www

14
 Planning step 1

SELF-ASSESSMENT BY COUNTRIES
WHO has developed a set of tools, of different levels of complexity, for assessing population
cancer needs and existing services. A description of the tools can be found in the Planning
module.

Self-assessment tools, which can be adapted to

country circumstances, are available from
http://www.who.int/cancer/modules/en/index.html
The WHO cancer web site also provides links to
i
sources containing more specific tools for assessing
www
palliative care needs.

Tools to assess opioid control policies (WHO, 2002b)

are available at
http://www.who.int/cancer/modules/en/index.html
http://www.painpolicy.wisc.edu/publicat
A tool to assess the barriers to opioid availability
i
(Joranson, 1993) can be found at
www
http://www.medsch.wisc.edu/painpolicy/publicat/
93jpsma.htm

15
PALLIATIVE CARE

PLANNING STEP 2
Where do we want to be?
The assessment (planning step 1) identifies the gaps in
services, as well as in data and knowledge, with regard to
the burden of cancers in advanced stages and the palliative
care services available.

The next step is to consider what could be done, given limited

resources and capacity, in order to answer the question:
Where do we want to be?

DEFINE THE TARGET POPULATION FOR

PALLIATIVE CARE
The selection of the target population for a palliative care plan will depend on where the
greatest numbers of patients (adults and children) are concentrated; the urgent needs of
those patients and of their family members and caregivers; and the resources available.

The greatest needs for palliative care are generally among cancer patients presenting with
advanced stages. However, available resources may not be sufficient to target this entire group.
Faced with this dilemma, many countries when starting palliative care within a comprehensive
cancer control plan may decide to initially focus on terminal cancer patients and their caregivers.
This group has the most pressing needs. The majority of terminal cancer patients (over 80%)
suffer from severe pain and other serious symptoms that require urgent relief.

16
 Planning step 2

Some countries may decide to have a palliative care plan with a broader scope. The plan
may include not only cancer patients but also other patients with chronic life-threatening
conditions, or geriatric patients. The target population should be selected so as to include
groups that constitute the most important health and social problems. For example, Spain
has a national cancer control strategy that includes palliative care. Building on palliative care
for cancer, Spain has recently launched a comprehensive national palliative care strategy.
In sub-Saharan Africa, where over 80% of cancer patients present in late stages and there
is a high prevalence of patients living with HIV/AIDS, joint AIDS and cancer palliative care
initiatives have been developed.

IDENTIFY GAPS IN PALLIATIVE CARE SERVICES

Based on the assessment, the gaps can be identified (present state versus desired state),
and potential corrective interventions considered.

It is important to assess both the impact of palliative care interventions previously implemented
in the target population, and the interventions that have been successfully applied elsewhere,
particularly in similar socioeconomic and cultural settings.

SET GOALS AND OBJECTIVES FOR PALLIATIVE

CARE
Objectives should be set to respond to the needs of people with advanced-stage cancer,
their family members and their caregivers. The objectives should be directly related to the
identified gaps in services. For the palliative care plan to be effective, all process and outcome
objectives need to promote the common goal of improving the quality of life of cancer patients
and their families.

Table 3 provides examples of short-, medium- and long-term objectives of a palliative

care plan. The objectives concern process (how resources are organized) and outcomes
(impact on the people participating in the activities), and are listed according to level of
resources. Core objectives can be achieved with existing resources. Expanded objectives
are feasible with a realistically projected increase in, or reallocation of, resources. Desirable
objectives are beyond the reach of current resources but could be achieved if resources
become available.

17
PALLIATIVE CARE

Table 3. Examples of short-, medium- and long-term objectives of

a palliative care plan using WHO’s stepwise approach
Component Core Expanded Desirable
Overall goal • To improve the quality of life of cancer patients and their families
• To ensure that prioritized palliative care services are provided in an integrated, equitable
and sustainable way

Short-term • To ensure that standards • To ensure that standards • To ensure that standards
process for cancer palliative care for cancer palliative care for cancer palliative care
objectives including pain relief are including pain relief are including pain relief are
(within 5 years) progressively adopted progressively adopted progressively adopted
in the target area by all nationwide by all levels of nationwide by all levels of
levels of care care care
• To provide care mainly • To provide care mainly • To provide care though
through home-based through primary health a variety of options,
services and home-based including home-based
services services

Medium-term • To ensure that over 30% • To ensure that over 30% • To ensure that over 60%
outcome of terminal cancer of advanced cancer of advanced cancer
objectives patients in the target patients nationwide get patients nationwide get
(5–10 years) area get timely relief from relief from pain and other relief from pain and other
pain and other serious physical, psychosocial physical, psychosocial
physical, psychosocial and spiritual problems and spiritual problems
and spiritual problems • To ensure that over • To ensure that over
30% of caregivers get 60% of caregivers get
adequate support adequate support

Long-term • To ensure that over 60% • To ensure that over 60% • To ensure that over 80%
outcome of terminal cancer of advanced cancer of advanced cancer
objectives patients in the target patients nationwide get patients nationwide get
(10–15 years) area get relief from relief from pain and other relief from pain and other
pain and other physical, physical, psychosocial physical, psychosocial
psychosocial and spiritual and spiritual problems and spiritual problems
problems • To ensure that over • To ensure that over
60% of caregivers get 80% of caregivers get
adequate support adequate support

Note: The terms “core”, “expanded” and “desirable” refer to the WHO’s stepwise approach (see page vi for WHO stepwise framework for
chronic diseases prevention and control, as applied to cancer control).

18
 Planning step 2

ASSESS FEASIBILITY OF INTERVENTIONS

The feasibility of palliative care for a given population depends on the skills and infrastructure
available, the knowledge and attitudes of the target population, and the motivation of the
government and the care providers.

In order for a palliative care programme to be fully effective, it should deliver good quality
services for relief of pain and other symptoms, psychosocial and spiritual support, and
bereavement care, equitably and for an indefinite duration to all members of the target
population in need, including patients, family members and caregivers.

Some resource-constrained countries, where a high proportion of patients present with

advanced stages, have invested for decades in specialized palliative care institutions that
provide excellent palliative care for only a few. In general, however, these countries have
not introduced low-cost, basic services, integrated with primary health-care services and
home-based care, which could be offered in a sustainable way to the majority of people
presenting with advanced cancer.

A good palliative care programme encompassing interventions at all levels of care, with a
particular focus on primary health-care services and home-based care, could eventually result
in a reduction in hospitalization and the use of inappropriate expensive procedures.

CONSIDER ETHICAL ISSUES

Ethical and legal issues that should be addressed in a palliative care plan and programme
include the following:
p allocation of adequate human and financial resources to palliative care;
p integration of palliative care with curative care to ensure high-quality care;
p societal, individual and professional obligations and responsibilities regarding the
provision of care;
p differing perceptions and attitudes in different cultural contexts concerning, for example,
quality-of-life versus length-of-life goals, enduring or relieving pain, and the end of life;
p autonomy of decision-making, and valid informed consent of the patient and family;
p legal and cultural barriers to accessing palliative care, in particular opioids.

19
PALLIATIVE CARE

SET PRIORITIES FOR PALLIATIVE CARE

It is essential to set priorities, because resources will never be able to meet all health needs.
Careful priority-setting is particularly relevant in resource-constrained contexts in view of
the importance of making the best use of very limited resources. The criteria for selecting
priorities for palliative care will need to be discussed by the committee steering the overall
cancer control planning process.

To set priorities among strategies for palliative care for cancer:

p First identify the patients who need palliative care and assess:
• the burden they represent in terms of mortality and morbidity;
• the proportion of cases in advanced stages;
• the urgency of their needs (pain relief, control of other symptoms, social support);
• the societal impact of the disease (for example, whether the disease affects children,
underprivileged communities and caregivers).

p Then choose the type of palliative care strategy according to:

• cost-effectiveness;
• affordability;
• sustainability;
• political attractiveness.

For information on the cost-effectiveness of some

cancer interventions, see i
http://www.who.int/choice/en www

General recommendations for setting priorities (WHO, 2002a), according to the level of
resources available, are summarized in Table 4.

20
 Planning step 2

Table 4. Priority interventions for palliative care according to

resource levels using WHO’s stepwise approach

Core Expanded Desirable

• Provide palliative care including • Provide palliative care at all levels • Reinforce the network of
pain relief with emphasis on of care with emphasis on primary palliative care services integrated
home-based care, following health-care clinics and home- with cancer care and other
national minimum standards based care, following national related services
protocols
• Ensure that legislative measures • Provide support to national and
allow access to oral morphine • Ensure availability of essential international reference centres for
and other affordable essential medications in both rural and palliative care
palliative care medicines urban centres
included in the WHO Model List of
Essential Medicines • Develop reference centres that
can provide undergraduate and
• Develop a reference centre that postgraduate training
can provide in-service training to
community health-caregivers • Develop curricula in nursing
and medical schools to teach
palliative care both at the
undergraduate and graduate
levels

Note: The terms “core”, “expanded” and “desirable” refer to the WHO’s stepwise approach (see page vi for WHO stepwise framework for
chronic diseases prevention and control, as applied to cancer control).

21
PALLIATIVE CARE

PLANNING STEP 3
How do we get there?
What can be done with available resources? Having
identified objectives for the palliative care plan, the next
step is to formulate an action plan to achieve them.
A template for developing a detailed action plan is provided at
http://www.who.int/cancer/modules/en/index.html i
www

The process of translating a palliative care plan into action requires strong
leadership and competent management. It also requires a participatory
approach to identify what needs to be done in order to bridge the gaps
identified in planning step 2. Actions need to be taken gradually, in a
feasible and sustainable manner.

Thought should be given to the appropriate sequence of actions that will

guarantee success and credibility of a palliative care programme. For
example, providing palliative care for advanced cancer patients requires
pain medication to be readily accessible. Pain relief can be provided by
adequately trained caregivers, including family members, at home. Both
non-opioid and opioid analgesics, particularly oral morphine, should be
available.

22
 Planning step 3

BRIDGE THE GAPS IN PALLIATIVE CARE

It is important to evaluate the actions to bridge the gaps from the perspective of those who
support and will eventually implement those actions, and from the perspective of any potential
opponents. Next, there is a need to identify the key person (or group) with the power to
decide on the plan, and then see how that person (or group) can be activated to make the
planned changes.

Table 5 provides examples of actions to bridge gaps in palliative care for cancer in a low-
income country where less than 50% of the population has access to health services.
The country has prioritized palliative care for terminal cancer patients, and has chosen
to implement activities gradually in terms of the location of the target population (from
patients identified through the formal health system to broad community outreach) and
the geographical scope (from a demonstration area to other areas, and eventually to the
whole country).

RAISE THE NECESSARY RESOURCES

To make sure that the necessary human and financial resources are available to implement
the strategies and actions included in the palliative care plan, the following questions will
need to be answered:
p What resources are currently dedicated to palliative care? How can current resources
be reallocated or shared to achieve plan outcomes?
p Besides resources currently being expended, what else is needed to achieve the objectives
of the plan?
p What potential sources of funding or other resources are available to meet these needs?
p How can partners work together to raise funds from the government or private sector?

The palliative care plan should be accompanied by a resource plan that outlines existing
resources, needed resources and possible strategies for acquiring the needed resources
from both governmental and nongovernmental sources.

23
PALLIATIVE CARE

Table 5. Examples of actions to bridge identified gaps in palliative

care in a low-resource country
Key actions in a selected Who has the
Gaps, strengths Level of geographical area served by the power to decide How could they be
and weaknesses interventions regional cancer centre on key actions? activated to decide?
CORE
GAPS
(difference between Using available Review and modify the regulations governing opioid The local health By providing relevant information
OBSERVED and DESIRED resources and analgesics to make them readily available authorities together on the problem and its possible
status) reorganizing the with the leading health- solutions through personal
existing services to Elaborate standards for palliative care and care professionals of interactions and meetings
OBSERVED improve palliative disseminate them to all levels of care in the public relevant sectors and with the relevant stakeholders,
It is estimated that less care and private sectors organizations, supported including testimonies of patients
than 1% of terminal by the national and health-care providers
cancer patients get Establish coordination and referral mechanisms authorities
palliative care including
pain relief Elaborate a list of essential palliative care drugs and
ensure their availability in the target area
DESIRED
To provide palliative care Include palliative care packages in health insurance
including pain relief for schemes and in home-based care programmes
at least 50% of terminal
cancer patients Identify the terminal cancer patients diagnosed at the
different levels of care

Estimate the demand for palliative care services

STRENGTHS
The government supports Identify and train a network of health-care providers
a comprehensive cancer at the different levels of care, including community
control programme and family caregivers who need to be involved in the
provision of services
There are two hospices,
and there is a palliative Ensure that essential drugs, including oral morphine,
care unit in the regional will be available to meet demand and that trained
cancer centre professionals will be allowed to prescribe these drugs

Create a basic information system to monitor and

evaluate actions at the different levels of care
WEAKNESSES
Only injectable morphine
is available EXPANDED
There are strict With some Identify partners in the community and develop joint Local authorities from By disseminating the results
regulations governing additional educational strategies for reaching terminal cancer the political, health and of the evaluation of previous
opioid analgesics resources patients who do not attend the formal health-care educational sectors, (core) activities to community
system supported by the organizations
Health-care providers are national authorities
in general reluctant to Adjust the primary health services and the By advocating in favour of
prescribe morphine specialized clinical services to meet the estimated Health-care and reaching more people in the
demand community leaders, target age group
traditional healers
Correct weaknesses identified through the
monitoring and evaluation system

Develop palliative care education for undergraduate

and postgraduate students in medical and nursing
schools

DESIRABLE
With more Develop educational strategies and low-cost media National and local By disseminating the results of
additional campaigns to reach terminal cancer patients in the leaders in the political, the evaluation of previous (core
resources wider community health and educational and expanded) activities
sectors
Monitor activities and evaluate results By advocating to increase the
Health-care and coverage of palliative care for
Start mobilizing resources to expand activities to community leaders terminal cancer patients
the rest of the country using a similar stepwise
approach if the evaluation in the target areas is Leaders of national and By advocating to expand
satisfactory local associations palliative care activities to the
rest of the country

24
 Planning step 3

ORGANIZE CANCER PALLIATIVE CARE

SERVICES ACROSS ALL LEVELS OF CARE
All countries, rich or poor, that implement palliative care with a public health approach need
to integrate the services at all levels of care in order to ensure accessibility to the whole
target population. Comprehensive palliative care includes the following services:
p management of complications of treatment and the disease
p management of pain and other symptoms
p psychosocial care for patients and caregivers
p spiritual understanding and approaches for patients and caregivers
p care of the dying
p bereavement care.

The above services can be progressively extended across all levels of care.

NORWAY
Example of a rich country that has developed palliative care within a national
cancer control programme, integrating palliative care services into the national
health system with emphasis on a community-based approach
Palliative care is a component of the Norwegian Cancer Control Programme. The Norwegian national cancer strategy
clearly identifies palliative care for cancer as an area of work to be intensified. The main policy recommendations
include the following:

• Palliative care, especially terminal care, must as far as possible be available in the patient’s local community,
coordinated by the general practitioner or municipal health service, and in line with agreed regional guidelines. This
will require increased expertise.

• Palliative care in hospital must be integrated with the ordinary treatment services and, in principle, should be
carried out in the department with the primary responsibility for treatment. Establishment of special arrangements
for care is not recommended.

• Each region must establish a designated unit for cancer palliative care under the auspices of the hospital
department with overall responsibility for cancer care for the whole region. This unit should serve as a knowledge
base and centre of expertise for the whole region and must have the main responsibility for drawing up guidelines.
The unit must be supplied with the expertise in areas that are relevant to cancer palliative care and patient support.

• The designated oncology unit in each county must serve as a source of expertise for the palliative care in the county.

• The needs of patients and their families, especially with regard to time, must be taken into account in the
organization of the unit, which should not be run on the lines of an ordinary hospital department, and must be
funded according to principles other than the ordinary performance-related funding.
Sources: Kaasa S, Jordhøy MS, Haugen DF (2007). Palliative care in Norway: a national public health model. Journal of Pain
and Symptom Management, 33:599–604 and Standard for palliative care. Norwegian Association for Palliative Medicine, 2004
(http://www.palliativmed.org/asset/32504/1/32504_1.pdf, accessed 23 September 2007).

25
PALLIATIVE CARE

When organizing cancer palliative care services, it is important to keep in mind the
following:
p Cancer palliative care services should respond to the needs of patients and their families,
and to the objectives and priorities of the cancer palliative care plan.
p The services should be accessible to a large majority of the target population, and should
be delivered in an equitable manner across all levels of care, whether services are public
or private.
p It is estimated that over 80% of advanced cancer patients will benefit from relatively
simple and low-cost interventions that can be integrated into primary health-care and
home-care services, through a community-based approach.
p It is estimated that less than 20% of advanced cancer patients will require relatively
specialized palliative care services. These specialized services can be provided by
palliative care units at district hospitals or at the tertiary level.
p Inpatient and outpatient palliative care clinics at the secondary and tertiary levels serve
mainly as training and referral centres for the management of complex cases and
supervision of the other levels of care.
p The cancer palliative care services should be integrated with services for the prevention,
early detection and treatment of cancer, as well as with other related programmes and
initiatives.

ADOPT A TEAM APPROACH

Strong leadership and overall programme management should ensure that local managers and
health-care providers work in multidisciplinary teams across the health system, and coordinate
closely with community leaders and organizations involved in the programme, in order to
achieve a common goal. The composition of the palliative care team will vary depending on
the objectives of the programme, and the health-care professionals available.

In general, palliative care requires a strong network of trained health-care practitioners,

community leaders, traditional healers, and family caregivers with specific roles and functions
across the different levels of care and within the community.

A WHO tool on team building, and additional

resources on palliative care teams, can be found at i
http://www.who.int/cancer/modules/en/index.html www

26
 Planning step 3

UNDERSTAND THE ROLE OF HEALTH-CARE

PROVIDERS
Health-care providers involved in palliative care may include physicians, nurses, social
workers, psychologists, spiritual counsellors, volunteers, pharmacists and traditional healers.
Each can play a useful role.

PHYSICIANS
Physicians play a crucial role in interdisciplinary palliative care. They must be competent
in general medicine, competent in control of pain and other symptoms, and must also be
familiar with the principles of management of the patient’s disease. Physicians working in
palliative care may be responsible for assessment, supervision and management of many of
the difficult treatment dilemmas. They may also be responsible for leading the interdisciplinary
teams. They clearly play an important educational role as they discuss medical management
decisions, and should regard research, and the critical application of research findings, as
an integral part of their work.

In countries where there are as few as one physician to 50 000 people, it is unrealistic to have
this scarce resource devoted totally to palliative care. By incorporating palliative care into
the services provided by all doctors dealing with cancer patients (gynaecologists, surgeons,
radiotherapists, paediatricians etc.), as well as including it in the undergraduate curriculum,
wider, but less expert coverage can be obtained.

NURSES
The nurse is the team member who will typically have the greatest contact with the patient.
This prolonged contact gives the nurse a unique opportunity to know the patient and the
caregivers, to assess in depth what is happening and what is of importance to the patient,
and to assist the patient to cope with the effects of advancing disease. The nurse’s expertise
in providing physical and emotional care to the patient, symptom management, patient and
family education, and in organizing the patient’s environment to minimize loss of control,
is critical to palliative care. Nurses are able to work closely with patients and families to
make appropriate referrals to other disciplines and health-care services. In some settings,
where the number of doctors is small, nurses may lead the multidisciplinary team and be
responsible for the provision of all aspects of palliative care. In such settings, nurses need
specialist training that is appropriate to the cultural and economic circumstances in which
they work. Nurses in many settings play a role in providing public and volunteer education
about palliative care.

27
PALLIATIVE CARE

SOCIAL WORKERS AND PSYCHOLOGISTS

The role of the social worker or psychologist is to help the family and patient deal with the
personal and social problems of illness and disability, as well as to provide support during
the progression of the disease and the bereavement process if the patient is at the end of
life. The social worker’s assessment helps define the patient’s and family’s needs from a
psychosocial perspective, and helps anticipate problems within the family that may result from
dysfunction and financial difficulties, particularly as the family begin planning for the future.
Social work and psychology are both instrumental services. They may offer such interventions
as referral to needed community services, emotional support (including individual counselling
of patients and family members) and bereavement counselling.

SPIRITUAL COUNSELLORS
The spiritual counsellor should be a skilled and non-judgemental listener, able to handle
questions related to the meaning of life. Such questions invariably arise for patients and their
families. The role of the spiritual counsellor is often one of listening, to facilitate recollection
of the past and growing readiness for what lies ahead. The spiritual counsellor also often
serves as a confidant and source of support for those with a religious tradition, organizing
religious rituals and sacraments that are meaningful to them. Spiritual counsellors need to
be trained in end-of-life care.

VOLUNTEERS
The role of the volunteer within the palliative care team will vary according to the setting.
In some low- or middle-resource settings, volunteers may provide most of the care for
the patients. Volunteers are included in hospice and palliative care teams with the aim of
assisting health-care professionals to provide the optimal quality of life for patients and
families. Volunteers come from all sectors of the community, and often provide a link between
health-care institutions and patients. Incorporating volunteers in a palliative care team
brings in a dimension of community support and community expertise. With the appropriate
training and support, volunteers can provide direct service to patients and families, help
with administrative tasks, or even work as counsellors. They can also take on several other
roles, such as raising awareness, providing health education, generating funds, helping with
rehabilitation, or even delivering some types of medical care.

PHARMACISTS
Drug therapies are a major component of symptom management in palliative care, so the
pharmacist plays an important role. The pharmacist ensures that patients and families have
access to the essential drugs for palliative care. The pharmacist’s expertise is also needed
to support the health-care team by providing information on drug doses, drug interactions,
appropriate formulations, routes of administration, and alternative approaches.

28
 Planning step 3

Morphine and other suitable medicines are necessary for palliative care. In many low- and
middle-income countries, access to medicines is limited not only by the general lack of
pharmacists to dispense medications, but also by the relatively high cost of medicines which
makes them unaffordable for many cancer patients. For these reasons, pharmacists, even
those with fairly basic skills and limited training are vital to palliative care service delivery.
They can constitute analgesic medicines from the starting materials, like morphine powder,
which is very cheap. Furthermore they can play a role in the management of an adequate
distribution system for home care patients.

TRADITIONAL HEALERS
The role of traditional medicine and traditional healers is well recognized. Worldwide, about
two thirds of cancer patients resort to some form of complementary or alternative therapy
(Ott, 2002). In most settings, traditional healers do not usually become members of the
palliative care teams. Nevertheless, there should be scope for an open discourse between
health-care providers and traditional healers with a view to coordinate their efforts to address
the needs of patients and their families, in a sensitive and respectful way, taking into account
the diverse cultures of communities and individuals.

CREATE PALLIATIVE CARE TEAMS

Figure 3 illustrates the distribution of professionals and community caregivers in palliative
care teams at the different levels of care in a low- or middle-income country. This model
assumes that the following conditions apply:
p At tertiary level, all physicians and nurses dealing with cancer patients will get basic
training in managing pain and other symptoms, and in providing psychosocial support.
In complex cases, they will refer patients to a specialized team composed of a physician
specialized in palliative care, a nurse, a part-time social worker (or psychologist) and a
pharmacist. This team will also act as a national reference and training group.

p At secondary level, all physicians and nurses dealing with cancer patients will get basic
training in managing pain and other symptoms, and in providing psychosocial support.
In complex cases, they will refer patients to a specialized team composed of a physician
and/or nurse specialized in palliative care, a part-time social worker and a pharmacist.
This team will also act as a district reference and training group.

p At primary level, all nurses dealing with cancer patients will get basic training in
managing pain and other symptoms, and in providing psychosocial support. In complex
cases, they will refer patients to a specialized team at the secondary or tertiary level.
The specialist nurses in the primary-level teams will be trained to train and supervise
community leaders, family caregivers and traditional healers.

29
PALLIATIVE CARE

Figure 3. Network of palliative care teams across the levels of

health-care

Tertiary care level

(national or regional hospital)
Specialist palliative care team: physician, nurse, part-time
social worker and pharmacist. All physicians and nurses
dealing with cancer patients provide basic palliative care,
supervised by the specialist team.

Secondary care level

(district hospital)
Specialist palliative care team: physician, nurse who supervises
primary health-care clinics, part-time social worker and pharmacist.

Primary care level

Nurses trained in basic palliative care who are supervised
by the district level and who train and supervise community volunteers and family caregivers.

Community level
Community leaders, traditional healers and family caregivers,
who are trained to provide basic home-based care, and who are supervised by primary care level nurses.

Across the levels of care, services can be provided through inpatient care, outpatient care
and home-based care.

INPATIENT CARE
In low-income countries, where a stand-alone unit for inpatients would be relatively cost-
intensive, a specialized palliative care team is an effective way of providing palliative care
services to inpatients in a variety of health-care settings. A specialized team may be more
sustainable than a free-standing unit.

A palliative care team is typically composed of a physician trained in palliative medicine, at

least one clinical nurse and a part-time social worker, all supported by adequate administrative
staff. Such a team has no dedicated beds of its own but advises on every aspect of palliative
care. This approach makes it possible to provide palliative care consultations to a large
number of patients, in a hospital or nursing home. It is an ideal way of providing specialist
care while at the same time training the large numbers of physicians and nurses with whom
the team interacts.

30
 Planning step 3

OUTPATIENT CARE
In some developing countries, the day-care unit or outpatient unit performs the important role
of offering low-cost care to people who are not too sick to attend. It also offers an opportunity
to review a patient’s need for periodic procedures (such as draining pleural effusions or
ascites), and to train the patient’s family in how to provide care. Often, day-care services
may focus on providing respite for relatives by ensuring that patients get medications and
food, and have their physical, psychological and spiritual needs met.

HOME-BASED CARE
In high-income countries, home-based care services are usually more resource-intensive
than in low- and middle-income countries. They often operate from a specialist palliative
care unit or hospice, and sometimes provide round-the-clock coverage.

In low- and middle-income countries, where patients usually prefer to die at home, home-
based care is generally more acceptable and affordable than hospital care. For example, with
the support of local nongovernmental organizations, the Ministry of Health of Uganda has
included pain relief and palliative care in a home-care package, based on a needs assessment
of patients and their caregivers. Services include essential drugs for the relief of pain and
other symptoms, as well as the provision of food for the patient, and support for the patient’s
family (Logie and Harding, 2005).

A variety of models of home-based palliative care are currently being implemented in low-
resource countries. A popular approach in low-resource settings, where the number of people
needing care is high and the number of nurses and doctors available to provide that care is
low, is to provide care through community caregivers or volunteers who are supervised by a
nurse trained in palliative care. The Neighbourhood Network in Palliative Care in Kerala, India,
and the Hospice and Palliative Care Association of South Africa, for example, have developed
community-based, home-based care along these lines.

Ideally, any model of home care will have strong links to an inpatient facility for patients
requiring more intensive palliative care for symptom control or for terminal care.

Examples of models for organizing palliative care

services can be found at i
http://www.who.int/cancer/modules/en/index.html www

31
PALLIATIVE CARE

EDUCATE CAREGIVERS
In order for a palliative care programme to be successful, education and training in palliative
care need to be tailored to meet the objectives and priorities identified in the plan. An
effective education programme will ensure that appropriately trained programme managers
and health-care practitioners exist across all levels of care. Because the complexity, scope
and coverage of care differ at different levels of services, health-care providers working at
different levels need different types of training.

For example, if the palliative care plan calls for home-based care services in a target area,
the educational efforts should concentrate on raising awareness in the target community, and
training health-care workers, community leaders and family caregivers in basic home-based
care. The health-care workers at the community level should be trained and supervised by
professionals from the district level.

For a palliative care programme to be effective, education needs to be synchronized with the
introduction of the new services, which will include making oral morphine and other essential
medications available. Health workers trained in palliative care often get discouraged because
they lack the necessary resources to carry out their work. A viable option is to organize
in-service training in the target area for the palliative care teams, with the support of the
local authorities. With this type of training, health-care providers remain connected to their
working environment and contribute to organizing and implementing the needed palliative
care services as the team jointly progresses in its learning activities.

When initiating a palliative care programme in a low- or middle-income country, education and
training should be provided for all health workers in the target area. The following steps will
ensure that priority services for the majority of patients are in place in a relatively short time:
p First, provide basic training (20–40 hours) for the health-care providers working at the
primary and community levels.
p Second, provide intermediate-level training (60–80 hours) for the physicians and nurses
working at the secondary and tertiary levels, who are dealing with cancer patients.
p Third, provide proficiency (specialized) training (3–6 months) to the specialized teams
or palliative care units at the secondary and tertiary levels.
p Finally, provide undergraduate training in medical and nursing schools.

Palliative care services require skills in the following areas:

p communication
p decision-making
p management of complications of treatment and the disease
p management of pain and symptoms
p psychosocial care for the patient and family
p spiritual understanding and approaches
p care of the dying
p bereavement care.

32
 Planning step 3

For each of these sets of skills, innumerable educational modules have been developed for
the wide range of health-care professionals who are involved in palliative care. For example,
such educational materials exist for community health-care workers and volunteers, and for
nurses, physicians, medical students, pharmacists, health managers and policy-makers.

Links to e-learning courses and publications on palliative

care education for health professionals and caregivers can i
be found at www
http://www.who.int/cancer/modules/en/index.html

Palliative care training materials developed by WHO

(Integrated Management of Adolescent and Adult Illness
and Integrated Management of Childhood Illness) are i
available to download from www
http://www.who.int/hiv/capacity/modules/en/index.html

EDUCATE FAMILY AND

VOLUNTEER CAREGIVERS INDIA
The empowerment of family members and
volunteers to be effective palliative caregivers Example of a nongovernmental
may be the most realistic approach for meaningful initiative to train volunteers in
coverage, especially in rural areas. Family
members and volunteers can also sensitize
community-based palliative care
relevant local and national governmental The Neighbourhood Network in Palliative Care (NNPC) in Kerala, India,
is a successful programme that involves volunteers at various levels.
organizations to the need for palliative care. Under the programme, people who can spare at least 2 hours per week
In order to provide appropriate home care, the to care for the sick in their area are enrolled in structured training
training of families and volunteers needs to (16 hours of interactive theory plus 4 days of clinical practice under
supervision, with an evaluation at the end). On successful completion
focus on personal care, personal services, social of this ‘‘entry point’’ training, the volunteers are encouraged to form
companionship, and applied medical care. themselves into groups of 10–15 people per community. Each group
then works to identify the problems of the chronically ill in their area
and to organize appropriate interventions. These NNPC groups are
supported by trained doctors and nurses. The NNPC groups work closely
with existing palliative care facilities in their area or, if necessary, create
such facilities themselves. Volunteers from these groups make regular
home visits to follow up the patients seen by the palliative care team.
Volunteers also identify patients in need of care, and address a variety
of non-medical concerns, including financial problems, organizing
programmes to create awareness in the community and raising funds
for palliative care activities.
Source: Kumar S (2007) Kerala, India: a regional community-based palliative
care model. Journal of Pain and Symptom Management, 33:623–627.

33
 PALLIATIVE CARE

ARGENTINA EDUCATE PATIENTS

Example of a nongovernmental initiative Patients have a right to know what
choices they have at the end of life,
to deliver home-based palliative care and to know how to demand better
Since 1985, LALCEC San Nicolas – the Palliative Care Programme of the Medical management of pain and control of
Federation of Buenos Aires (FEMEBA) Foundation – has been delivering palliative other symptoms. They need to be aware
care in San Nicolas, Argentina, with a team of two anaesthesiologists, one that they do not have to suffer, and that
psychologist, one social worker and five to seven trained volunteers. All the team
members work on a voluntary basis. Most of the patients are from low-income appropriate treatment of pain and other
groups, and care is free; medications and administrative expenses are funded physical and emotional symptoms can
by charities. The volunteers, under the supervision of the team physicians,
assess patients at home and collect data on the evolution of treatment. They
dramatically improve their quality of
also educate the family about analgesic use and treatment issues. Treatments life. Patients and families need to know
are delivered according to WHO guidelines. Patients are provided with what services can allow patients to be
opioid analgesics for oral use, prepared by the team or at a public pharmacy
(6 mg/ml morphine or 10 mg/ml methadone in aqueous solution).
cared for at home instead of in hospital,
Sources: Wenk R et al. (1991). Argentina´s WHO Cancer Pain Relief Program: a patient
enabling them to make choices about
care model. Journal of Pain and Symptom Management, 6:40–43. Additional information quality of life and, when dying, place
provided by Roberto Wenk, Medical Federation of Buenos Aires Foundation, Argentina.
of death.

EDUCATE THE GENERAL PUBLIC AND

POLICY-MAKERS
In order to increase the likelihood of reaching people who need palliative care with the
required services, it is important for the general public to understand what palliative care is,
who should be referred for services, what those services are, and how patients and families
may benefit from palliative care programmes. The general public can play a role in palliative
care, for example, by volunteering to help teams of health professionals. Before volunteering,
however, people need to know how they can help.

It is particularly important for policy-makers to understand that palliative care is part of the
continuum of care of cancer and other diseases, that it can be integrated into the existing
health-care system at a relatively low cost, and that it requires opioids to be available across
all levels of care.

The media need to be involved in disseminating reliable information of educational value,

while avoiding sensationalism. This can be achieved by putting journalists in touch with
patients with advanced illness who wish to talk about the importance of pain relief to their
quality of life. Safeguards should be put in place to ensure that the media respects the dignity
and rights of patients and their families. The media should also be informed of the needs of
patients and their families for support and care.

For the International Association for Hospice and

Palliative Care list of essential drugs, see i
http://www.hospicecare.com/resources/emedicine.htm www

34
 Planning step 3

UGANDA, INDIA, ROMANIA

ENSURE THE AVAILABILITY Examples of improvement of
OF ESSENTIAL DRUGS FOR opioid availability
THE MANAGEMENT OF PAIN
AND OTHER SYMPTOMS UGANDA
Uganda is the first African country to prioritize palliative
A national palliative care plan must include policy care in its National Health Plan (2001–2005). It has made oral
measures to provide the wide range of drugs required morphine freely available to those districts that have specialist
palliative care nurses or clinical officers, and has promoted
to manage the common symptoms of cancer, including morphine use down to the village level. Because doctors are
scarce in rural areas, Uganda has passed laws that allow
pain, nausea, vomiting, delirium, agitation, insomnia, nurses to prescribe morphine. There are no limits to the number
fatigue, depression and anxiety. These drugs should of days or doses which doctors or trained nurses and clinical
officers can prescribe within the hospice setting, although the
be included in an essential medicines list to ensure doses available are weak. Doses of 5 mg/ml are available to
that decisions regarding resources are based on the community nurses outside the hospice setting. The programme
is in its early stages but it is a working model of morphine
medical needs of the majority of the population. access achieved through policy, legislative and clinical efforts.
Source: Jagwe JGM (2002). The introduction of palliative care in Uganda.
The preparation of an essential drugs list and a Journal of Palliative Medicine, 5:160–163.
palliative care protocol should be done by a INDIA
multidisciplinary team. These documents should be Pain relief and the availability of morphine were designated
priorities in the National Cancer Control Programme in India in
mandatory, and should apply nationally to the selection 1992. The Ministry of Health convened national workshops to
of palliative care medicines in all private and public ascertain why morphine use was not being implemented. The
assessment of opioid availability revealed that stringent state
institutions. WHO provides a model list of essential laws and the multiplicity of licences were significant barriers.
Gradually, the situation has changed. By 2002, a total of 7 out
medicines (WHO, 2007), including palliative care of 28 states or territories had adopted a model rule to make
drugs, as a guide for countries to develop their own morphine available for palliative care.
essential drugs list. Also, the International Association This rule has, however, been implemented successfully only in
for Hospice and Palliative Care has recently published Kerala. In Kerala, the state government simplified the licensing
process and stipulated that for morphine to be available from
a list of 34 drugs that experts consider essential a health centre there must be at least one physician at the
for palliative care (http://www.hospicecare.com/ health centre with at least one month of practical experience
in palliative care. As well, the national drugs controller
resources/emedicine.htm). exempted palliative care programmes from needing a drug
licence, thereby eliminating the need for a pharmacist. Kerala
established an integrated palliative care network consisting of
Various governments have adopted palliative care about 50 small programmes, thus creating a system to facilitate
the distribution of morphine for palliative care.
drug lists. National drug policies should also address
the handling of medications. Guidelines produced by Sources: Joranson DE, Rajagopal MR, Gilson AM (2002). Improving
access to opiod analgesics for palliative care in India. Journal of Pain and
the Ministry of Health of Uganda provide an example Symptom Management, 24:152–159 and Rajagopal MR, Venkateswaran C
(2003). Palliative care in India: successes and limitations. Journal of Pain
that can be used as a model (Ministry of Health of and Palliative Care Pharmacotherapy, 17:121–128.
Uganda, 2001).
ROMANIA
The reform of drug control policy for palliative care in Romania
Fear of the misuse of opioids sometimes obstructs the reflects a government-sponsored effort to undertake a
fundamental, guideline-based, comprehensive assessment
medical use of these drugs. Law-makers and even health of drug control policy, with the aim of addressing regulatory
professionals are often insensitive to this problem. barriers and improving access to opioids for pain relief and
palliative care. The ultimate goal of the Romanian Ministry
of Health Commission in revising the national opioid control
The medical need for opioid analgesics is clear, and policy was to improve patient access to opioids for pain relief.
The Romanian process serves as a positive example of how
guidance is available to help governments develop a outdated and restrictive national anti-narcotic laws can be
reformed into legislation that embodies the principle of balance:
national policy for palliative care drugs, specifically retaining essential control over the security and distribution of
opioids (WHO, 1996; WHO, 2002b). controlled substances, while allowing physicians to practise
modern medicine and provide palliative care for their patients.
Source: Mosoiu D et al. (2006). Reforming drug control policy for
palliative care in Romania. Lancet, 367:2110–2117.
PALLIATIVE CARE

DEVELOP PALLIATIVE CARE STANDARDS

Palliative care standards should be developed with the wide participation of stakeholders,
to ensure that palliative care services meet minimum service requirements. Their aim is to
improve the care provided to all patients with life-threatening illnesses, including vulnerable
patients such as children and people with low incomes.

Standards should be based on current evidence of palliative care practice. They should set
out core functions that are optimal, achievable and measurable. The implementation of
standards should be monitored regularly.

Standards should be developed for palliative care because they:

p provide a common understanding of the work to be done and indicate a level of quality
for service provision;
p help to ensure that the quality of service being provided is maintained as operational
coverage is extended;
p help the process of continuous improvement of service quality by determining those
areas of service provision where problems that require remedial attention exist;
p serve to inform patients and their families of what quality of care they can expect and
should demand as service users;
p enable staff to know what they are expected to provide;
p serve as a resource for palliative care training.

Examples of standards of palliative care in various

countries are available at i
http://www.hospicecare.com/standards/ www

36
EVALUATE AND MONITOR THE PALLIATIVE CARE PLAN
AND ACTIVITIES
Both the development and the implementation of a palliative care plan need to be monitored and evaluated
periodically in order to ensure that the objectives of the plan are achieved. Evaluation requires careful design
and planning. This should start early in the process of programming the implementation of activities. A
basic information system needs to be put in place early on so that the necessary data for monitoring and
evaluation are collected on a regular basis.

The performance of palliative care activities can be evaluated using the quality improvement framework
described above (see page 12). Guidance is available on monitoring and evaluating cancer control programmes,
including palliative care, using the quality improvement and the system model frameworks (WHO, 2002a).

No matter which framework is used, the evaluation plan needs to define clearly:
p who will evaluate the implementation of palliative care activities;
p what will be evaluated;
p what will be the core indicators (measures) and their respective standards (values set by stakeholders);
p how will the evaluation be designed and carried out to ensure credibility;
p how will the results of the evaluation be used to improve the performance of palliative care activities.

Table 6 gives examples of structure, process and outcome indicators, and related standards, for use in
evaluating palliative care activities.

37
PALLIATIVE CARE

Table 6. Examples of structure, process and outcome indicators,

and their associated standards, for use in evaluating the fully
established activities of a cancer palliative care programme
Core indicators Standards
STRUCTURE
• Policies and regulations include palliative care as a key component of national cancer control Official documents, laws,
regulations, guidelines and
• Funding and service delivery models established to support the provision of cancer palliative care in all manuals published, updated
settings where patients receive care and available

• Opioid prescribing laws and regulations for pain relief

• List of essential medications for palliative care

• Network of health-caregivers across the different levels of care Accreditation of palliative care
services delivery at all levels
of care

• Network of community leaders and caregivers trained and motivated to provide good quality palliative Accreditation of community
care services, including home-based care based-care initiatives

• Communities that own and support palliative care services Mapping of communities

• Educational courses that provide: Undergraduate and

- core knowledge and skills to practising health-care professionals across all levels of care postgraduate courses
- expert knowledge and skills to a few selected health-care professionals to lead palliative care available, including in-service
services at the secondary and tertiary levels training for health-caregivers
- undergraduate palliative care education for health-care professionals (physicians, nurses, across all levels of care
pharmacists, social workers)

PROCESS
• Number of advanced cancer patients receiving palliative care according to established standards

• Number and type of trained health-care professionals at the different levels of care qualified to provide
palliative care according to established standards

• Proportion of advanced cancer patients who get early palliative care according to established standards >80%

• Proportion of advanced cancer patients who get palliative care according to established standards >80%

• Proportion of advanced cancer patients receiving home-based care provided by trained caregivers >80%

• Proportion of advanced cancer patients receiving home-based care who need to be referred for <20%
specialized palliative care services at the secondary and tertiary levels

• Proportion of family caregivers who get psychosocial support through the course of the disease, and >80%
through bereavement care, according to established standards

OUTCOME
• Proportion of advanced cancer patients who get timely relief from pain and other physical, psychosocial >80%
and spiritual problems

• Proportion of caregivers of advanced cancer patients who get timely relief from psychosocial and >80%
spiritual problems

38
 Conclusion

CONCLUSION
Palliative care is a key component of an overall cancer control plan and
programme. It responds to the needs of advanced cancer patients and their
families. Palliative care services should be linked to cancer prevention, early
detection and treatment strategies in order to respond to all the cancer priority
needs in a community and make the best use of scarce resources.

A cancer palliative care programme should also be part of a broader palliative

care strategy that addresses all patients with chronic life-threatening
conditions.

Evidence-based standards of palliative care services, focusing on improving

clinical and organizational knowledge and practice are needed in all settings.
Simple and low-cost public health models of palliative care can be implemented
to reach the majority of the target population, particularly in low-resource
settings, where the majority of cases are diagnosed in late stages. These
models consider the integration of palliative care services in the existing
health system at all levels of care, but with special emphasis on community-
and home-based care. They involve the public and the private sector, and are
adapted to the specific cultural, social and economic settings.

Cancer Control
Knowledge into Action
WHO Guide for Effective Programmes

This module on palliative care is intended to evolve

in response to national needs and experience. WHO
welcomes input from countries wishing to share their
Palliative Care
successes in palliative care. WHO also welcomes
requests from countries for information relevant to their specific needs.
Evidence on the barriers to cancer palliative care in country contexts – and
the lessons learned in overcoming them – would be especially welcome
(contact at http://www.who.int/cancer).

39
PALLIATIVE CARE

REFERENCES
• Joranson D (1993). Availability of opioids for cancer pain: • WHO (1996). Cancer pain relief with a guide to opioid
recent trends, assessment of system barriers, new World availability, 2nd ed. Geneva, World Health Organization.
Health Organization guidelines, and the risk of diversion.
Journal of Pain and Symptom Management, 8:353–360. • WHO (2002a). National cancer control programmes: policies
and managerial guidelines, 2nd ed. Geneva, World Health
• Logie DE, Harding R (2005). An evaluation of a morphine public Organization.
health programme for cancer and AIDS pain relief in Sub-
Saharan Africa. BioMed Central Public Health, 5:82–89. • WHO (2002b). Achieving balance in national opioids control
policy: guidelines for assessment. Geneva, World Health
• Ministry of Health of Uganda (2001). Guidelines for handling Organization.
Class A drugs. Kampala, Ministry of Health of Uganda.
• WHO (2004). A community health approach to palliative care
• Ott MJ (2002). Complementary and alternative therapies in for cancer and HIV/AIDS patients in sub-Saharan Africa.
cancer symptom management. Cancer Practice, 10:162–166. Geneva, World Health Organization.

• Sepúlveda C et al. (2003). Quality of life at the end of life in • WHO (2007). WHO model list of essential medicines,15th ed.
Africa. British Medical Journal, 327:209–213. Geneva, World Health Organization.

40
 Acknowledgements

ACKNOWLEDGEMENTS
EXTERNAL EXPERT REVIEWERS Antonio Pascual, St Paul’s Hospital, Baffour Awuah, Komfo Anokye Teaching
WHO thanks the following external Autonomous University of Barcelona, Hospital, Ghana
experts for reviewing draft versions of Spain Volker Beck, Deutsche Krebsgesellschaft
the module. Expert reviewers do not M.R. Rajagopal, Pallium India, India e.V, Germany
necessarily endorse the full contents of Mike Richards, St Thomas’ Hospital, Yasmin Bhurgri, Karachi Cancer Registry
the final version. England and Aga Khan University Karachi,
Carla Ripamonti, Cancer Institute, Italy Pakistan
Ann Berger, Pain and Palliative Care, Javier Rocafort Gil, Regional Palliative Vladimir N. Bogatyrev, Russian Oncological
Clinical Centre, National Institutes of Care Programme, Regional Government Research Centre, Russian Federation
Health, USA of Extremadura, Spain Heather Bryant, Alberta Cancer Board,
Yasmin Bhurgri, Karachi Cancer Registry Jan Stjernsward, WHO Collaborating Division of Population Health and
and Aga Khan University Karachi, Centre for Palliative Care, England Information, Canada
Pakistan Bee Wee, Sir Michael Sobell House and Robert Burton, WHO China Country Office,
Sara Bistre, Mexican Association for the Oxford University, England China
Study and Treatment of Pain, Mexico Roberto Wenk, Argentine Programme of Eduardo L. Cazap, Latin-American and
Gian Domenico Borasio, Munich University Palliative Medicine, Medical Federation Caribbean Society of Medical Oncology,
Hospital, Germany of Buenos Aires Foundation, Argentina Argentina
Eduardo Bruera, University of Texas and Young Ho Yun, National Cancer Center, Mark Clanton, National Cancer Institute,
Anderson Cancer Center, USA Republic of Korea USA
Barry D. Bultz, Tom Baker Cancer Centre Margaret Fitch, International Society of
and University of Calgary, Canada Nurses in Cancer Care, Canada, and
Cheryl Cavanagh, Department of Health, THE FOLLOWING WHO STAFF Toronto Sunnybrook Regional Cancer
England ALSO REVIEWED DRAFT Centre, Canada
David Currow, Flinders University, Australia Kathleen Foley, Memorial Sloan-Kettering
VERSIONS OF THE MODULE
Liliana de Lima, International Association Cancer Center, USA
of Hospice and Palliative Care, USA WHO regional and country offices Leslie S. Given, Centers for Disease
Lea Derio, Ministry of Health, Chile Cherian Varghese, WHO India Country Control and Prevention, USA
Msemo Diwani, Ocean Road Cancer Office Nabiha Gueddana, Ministry of Public
Institute, United Republic of Tanzania Health, Tunisia
Julia Downing, African Palliative Care WHO headquarters Anton G.J.M. Hanselaar, Dutch Cancer
Association, Uganda Akiki Bitalabeho Society, the Netherlands
Margaret Fitch, International Society of Marie-Charlotte Bouësseau Christoffer Johansen, Danish Institute of
Nurses in Cancer Care, Canada, and Sandy Gove Cancer Epidemiology, Danish Cancer
Toronto Sunnybrook Regional Cancer Suzanne Hill Society, Denmark
Centre, Canada Andreas Reis Ian Magrath, International Network
Liz Gyther, St Luke’s Hospice, South Africa Cecilia Sepúlveda for Cancer Treatment and Research,
Sue Hawkett, Department of Health, Willem Sholten Belgium
England Anthony Miller, University of Toronto,
Dae Seog Heo, Seoul National University of Canada
Medicine, Republic of Korea WHO CANCER TECHNICAL M. Krishnan Nair, Regional Cancer Centre,
Emilio Herrera Molina, Social and Health GROUP India
Care Affairs and Public Health, Regional The members of the WHO Cancer Twalib A. Ngoma, Ocean Road Cancer
Government of Extremadura, Spain Technical Group and participants in Institute, United Republic of Tanzania
Neeta Kumar, Cancer Control Consultant, the first and second Cancer Technical D. M. Parkin, Clinical Trials Service Unit
Geneva, Switzerland Group Meetings (Geneva 7–9 June and and Epidemiological Studies Unit,
Suresh Kumar, Institute of Palliative Vancouver 27–28 October 2005) provided England
Medicine, Medical College Calicut, India valuable technical guidance on the Julietta Patnick, NHS Cancer Screening
Anne Merriman, Hospice Africa Uganda, framework, development, and content Programmes, England
Uganda of the overall publication Cancer control: Paola Pisani, International Agency for
Gayatri Palat, International Network of knowledge into action. Research on Cancer, France
Cancer Treatment and Research, India

41
PALLIATIVE CARE

You-Lin Qiao, Cancer Institute, Chinese Other participants Jo Kennelly, National Cancer Institute of
Academy of Medical Sciences and Barry D. Bultz, Tom Baker Cancer Centre Canada, Canada
Peking Union Medical College, China and University of Calgary, Canada Luiz Figueiredo Mathias, National Cancer
Eduardo Rosenblatt, International Atomic Jon F. Kerner, National Cancer Institute, Institute, Brazil
Energy Agency, Austria USA Les Mery, Public Health Agency of Canada,
Michael Rosenthal, International Atomic Luiz Antônio Santini Rodrigues da Silva, Canada
Energy Agency, Austria National Cancer Institute, Brazil Kavita Sarwal, Canadian Strategy for
Anne Lise Ryel, Norwegian Cancer Society, Cancer Control, Canada
Norway Nina Solberg, Norwegian Cancer Society,
Observers
Inés Salas, University of Santiago, Chile Norway
Benjamin Anderson, Breast Health Center,
Hélène Sancho-Garnier, Centre Val Cynthia Vinson, National Cancer Institute,
University of Washington School of
d’Aurelle-Paul Lamarque, France USA
Medicine, USA
Hai-Rim Shin, National Cancer Center,
Maria Stella de Sabata, International Union
Republic of Korea
Against Cancer, Switzerland
José Gomes Temporão, Ministry of Health,
Joe Harford, National Cancer Institute, USA
Brazil

42
The World Health Organization estimates that 7.6 million people died of cancer in
2005 and 84 million people will die in the next 10 years if action is not taken. Cancer Control
More than 70% of all cancer deaths occur in low and middle income countries,
where resources available for prevention, diagnosis and treatment of cancer are Knowledge into Action
limited or nonexistent.
WHO Guide for Effective Programmes
Yet cancer is to a large extent avoidable. Over 40% of all cancers can be prevented.
Some of the most common cancers are curable if detected early and treated. Even with
late cancer, the suffering of patients can be relieved with good palliative care.

Cancer control: knowledge into action: WHO guide for effective

programmes is a series of six modules offering guidance
on all important aspects of effective cancer
control planning and implementation.

Worldwide, millions of cancer patients could be relieved from pain and unnecessary suffering if they had
timely access to good palliative care.

This module explains how to develop an effective palliative care programme within the context of a
national cancer control programme. It is based on the Planning module, which provides a comprehensive
understanding of the overall cancer control planning process.

Although this Palliative care module focuses on cancer and does not specifically address other diseases,
it recognizes the need for developing palliative care with a public health approach that targets all age
groups suffering from diseases or conditions in need of palliative care. These conditions include HIV/AIDS,
congestive heart failure, cerebrovascular disease, neurodegenerative disorders, chronic respiratory
diseases and diseases of older people, among others.

The principles guiding the development of palliative care within a cancer control programme are very
similar to those needed in providing palliative care for people with other chronic diseases.

ISBN 92 4 154734 5

Palliative Care