The impact of COVID-19 on palliative care workers across the world: A qualitative analysis of responses to open-ended questions.

OBJECTIVE: With over two million deaths and almost 100 million confirmed cases, the COVID-19 pandemic has caused a "tsunami of suffering." Health care workers, including palliative care workers, have been severely impacted. This study explores how the COVID-19 pandemic has impacted palliative care workers around the world and describes the coping strategies they have adopted to face their specific situation. METHOD: We conducted a qualitative analysis of written, unstructured comments provided by respondents to a survey of IAHPC members between May and June 2020. Free text was exported to MAX QDA, and a thematic analysis was performed by reading the comments and developing a coding frame. RESULTS: Seventy-seven palliative care workers from 41 countries submitted at least one written comment, resulting in a data corpus of 10,694 words and a total of 374 coded comments. Eight main themes are emerged from the analysis: palliative care development, workforce impact, work reorganization, palliative care reconceptualization, economic and financial impacts, increased risk, emotional impact, and coping strategies. SIGNIFICANCE OF RESULTS: The pandemic has had a huge impact on palliative care workers including their ability to work and their financial status. It has generated increased workloads and placed them in vulnerable positions that affect their emotional well-being, resulting in distress and burnout. Counseling and support networks provide important resilience-building buffers. Coping strategies such as team and family support are important factors in workers' capacity to adapt and respond. The pandemic is changing the concept and praxis of palliative care. Government officials, academia, providers, and affected populations need to work together to develop, and implement steps to ensure palliative care integration into response preparedness plans so as not to leave anyone behind, including health workers.

Impact of COVID-19 Pandemic on Palliative Care Workers: An International Cross-sectional Study.

OBJECTIVES: The COVID-19 pandemic and the measures taken to mitigate spread have affected countries in different ways. Healthcare workers, in particular, have been impacted by the pandemic and by these measures. This study aims to explore how COVID-19 has impacted on palliative care (PC) workers around the world. MATERIALS AND METHODS: Online survey to members of the International Association for Hospice and PC during the initial months of the COVID-19 pandemic. Convenience sampling was used. Statistical descriptive and contingency analyses and Chi-square tests with P < 0.05 were conducted. RESULTS: Seventy-nine participants (RR = 16%) from 41 countries responded. Over 93% of those who provide direct patient care reported feeling very or somewhat competent in PC provision for patients with COVID-19. Eighty-four felt unsafe or somewhat safe when caring for patients with COVID-19. Level of safety was associated with competence (P ≤ 0.000). Over 80% reported being highly or somewhat affected in their ability to continue working in their PC job, providing care to non-COVID patients and in staff availability in their workplace. About 37% reported that availability and access to essential medicines for PC were highly or somewhat affected, more so in low-income countries (P = 0.003). CONCLUSION: The results from this study highlight the impact of COVID-19 on the provision of PC. It is incumbent on government officials, academia, providers and affected populations, to develop and implement strategies to integrate PC in pandemic response, and preparedness for any similar future events, by providing appropriate and comprehensive education, uninterrupted access to essential medicines and personal protective equipment and ensure access to treatment and care, working together with all levels of society that is invested in care of individuals and populations at large. The long-term effects of the pandemic are still unknown and future research is needed to monitor and report on the appropriateness of measures.

Redefining Palliative Care-A New Consensus-Based Definition.

CONTEXT: The International Association for Hospice and Palliative Care developed a consensus-based definition of palliative care (PC) that focuses on the relief of serious health-related suffering, a concept put forward by the Lancet Commission Global Access to Palliative Care and Pain Relief. OBJECTIVE: The main objective of this article is to present the research behind the new definition. METHODS: The three-phased consensus process involved health care workers from countries in all income levels. In Phase 1, 38 PC experts evaluated the components of the World Health Organization definition and suggested new/revised ones. In Phase 2, 412 International Association for Hospice and Palliative Care members in 88 countries expressed their level of agreement with the suggested components. In Phase 3, using results from Phase 2, the expert panel developed the definition. RESULTS: The consensus-based definition is as follows: Palliative care is the active holistic care of individuals across all ages with serious health-related suffering due to severe illness and especially of those near the end of life. It aims to improve the quality of life of patients, their families and their caregivers. The definition includes a number of bullet points with additional details as well as recommendations for governments to reduce barriers to PC. CONCLUSION: Participants had significantly different perceptions and interpretations of PC. The greatest challenge faced by the core group was trying to find a middle ground between those who think that PC is the relief of all suffering and those who believe that PC describes the care of those with a very limited remaining life span.

Opioid Medications in Expensive Formulations Are Sold at a Lower Price than Immediate-Release Morphine in Countries throughout the World: Third Phase of Opioid Price Watch Cross-Sectional Study.

BACKGROUND: International Association for Hospice and Palliative Care implemented Opioid Price Watch (OPW) to monitor availability, dispensing prices and affordability of opioids. We found that opioids with complex delivery mechanisms [fentanyl transdermal (TD) patches, sustained-release (SR) morphine, and SR oxycodone] had lower dispensing prices than immediate-release (IR) morphine formulations. OBJECTIVE: Identify the extent that SR and TD formulations are dispensed at lower prices than generic IR morphine and the possible reasons to explain this observation. DESIGN: Using OPW data for 30-day treatment Defined Daily Dosages, we identified where SR and TD formulations are dispensed at lower prices than IR morphine. Then we analyzed national lists of essential medicines (EML) in middle- and low-income countries to answer two questions: (1) Do they have opioids included? If yes, (2) Which ones? We then sought information on selection, budget allocation, and procurement for EML. OPW participants confirmed/verified the EML information. RESULTS: Eighteen countries reported higher dispensing prices for IR morphine (oral and/or injectable) than TD or SR formulation. Injectable morphine was highest in seven and lowest in two (range: $74-$742). SR morphine was the least expensive, while TD fentanyl was second. Median dispensing price for IR oral morphine was higher than SR morphine. The EML for 10 countries include opioids in TD and/or SR formulations. CONCLUSIONS: Opioids in expensive formulations are being favored over IR morphine both at the dispensing level and in their inclusion in national EML. Governments must take decisions based on efficacy, safety, and cost-effectiveness of medications.

Palliative care development in South America: a focus on Argentina.

Many Latin American and Caribbean national health systems mainly focus on disease prevention, prenatal assistance, undernourishment, etc. They still do not have the conditions for developing palliative care (PC). In general, quality of life during the dying process is poor, with fragmented assistance, uncontrolled suffering, poor communication between professionals, patients, and families, and a great burden on family caregivers. The development of PC in the region started around 1981, but it is still not available to an acceptable number of patients.

Pain Treatment Continues To Be Inaccessible for Many Patients Around the Globe: Second Phase of Opioid Price Watch, a Cross-Sectional Study To Monitor the Prices of Opioids.

BACKGROUND: Strong opioids are a cornerstone of pain treatment, of which morphine is considered an essential analgesic by the World Health Organization. Access to opioids is limited, due to restrictive laws, limited education, and high prices. This is the second phase of a global project to monitor and report the dispensing price of opioids with the specific aim to expand and increase the information and allow further analysis of the challenges in their availability and affordability. METHOD: Participants were asked to provide the lowest dispensing price of the smallest selling unit and lowest strength of five opioids in 13 formulations from a licensed pharmacy located closest to a public facility that provides diagnosis/treatment for life-threatening conditions. Data were collected from July 2015 to March 2016. Average availability, median (Me), and interquartile range (IQR) price were calculated for four gross national income (GNI) categories: higher income countries (HIC), upper middle income countries (UMIC), low middle income countries (LMIC), and low income countries (LIC). Affordability for one month of treatment with morphine immediate release (IR) tablet was also calculated. RESULTS: Data were submitted by 67 participants from 43 countries. Availability is strongly related to GNI level (Kruskal-Wallis tests p < 0.0001). Mean price for morphine IR tablets for a 30-day treatment within the GNI categories ranged between USD 3.28 and 376; average USD 78.5 (SD = 92, Me = 49.7, IQR = 80.5). Methadone oral liquid and hydromorphone slow release were the lowest priced (Me = 13.1, IQR = 70 and Me = 14.9, IQR = 89.1, respectively). Morphine IR tablet is less affordable in countries in lower income groups: LIC (mean = 54.1 ± 0.873, Me = 54.1); LMIC (mean = 21.1 ± 19.6, Me = 10.6); UMIC (mean = 14.1 ± 14.1, Me = 10.23); and HIC (mean = 3.2 ± 5.2, Me = 1.33). A negative correlation between the number of days and the countries' income category (Rs = -0.7; p < 0.001) was identified. CONCLUSION: Patients in LIC and MIC have less access to opioid medications. This highlights the need to continue efforts at improving access, availability, and affordability.

Consensus-Based Palliative Care Competencies for Undergraduate Nurses and Physicians: A Demonstrative Process with Colombian Universities.

BACKGROUND: A World Health Assembly (WHA) resolution adopted in 2014 strongly encourages member states to integrate palliative care (PC) in undergraduate training for health professionals. OBJECTIVE: The study objective was to describe a consensus-based process workshop to develop PC competences for medical and nursing schools in Colombia and to present a summary of the findings. METHODS: The workshop included 36 participants representing 16 medical and 6 nursing schools from 18 universities in Colombia. Participants were distributed in four thematic groups. Using the International Association for Hospice and Palliative Care (IAHPC) List of Essential Practices (LEP) as guidance, they were asked to discuss and define PC competencies at the undergraduate level. Participants provided feedback and approved each recommendation, and then were asked to complete an evaluation. RESULTS: The resulting competences were separated into six categories: (1) Definition and Principles of PC, (2) Identification and Control of Symptoms, (3) End-of-Life Care, (4) Ethical and Legal Issues, (5) Psychosocial and Spiritual Issues, and (6) Teamwork. A comparative analysis revealed that treatment of several symptoms in the IAHPC LEP (pain, dyspnea, constipation, nausea, vomit, diarrhea, delirium, and insomnia) were included in the competencies. All of the IAHPC LEP related to psychological/emotional/spiritual care was included. The evaluation rate of return was 80%. The assessment was very positive: total score of 4.7/5.0; SD = 0.426), with 89% considering the workshop to be helpful. CONCLUSION: The workshop provided an opportunity for individuals from different disciplines to discuss competencies and achieve consensus. The resulting competencies will be helpful in the development of PC curricula for physicians and nurses throughout schools in Colombia and other countries.

OA59†Developing an innovative model of palliative care in the community in brazil.

BACKGROUND: Despite a National Policy on Pain and Palliative Care (working since 2002) and the Family Health Strategy (primary care), Brazil does not have a strategy to integrate palliative care in primary care. The Atlas of Palliative Care in Latino America (ALCP-2013) did not find any team working with this mode: a primary care teach working. AIM: Propose a model of palliative care in the Public Health Service of Brazil offered through the Primary Care to community. METHOD: The Pilot Project is in the city of Rio Grande, south of Brazil, covering the area 29 with 3000 persons. This area has a team with a family physician, a nurse, a technical nurse and 6 Community Agents of Health (persons of area who work directly with population). The team has 3 aims 1) care: identification of possible patients (using the tracking and opinions of community health workers and the area diagnostics) > evaluation using PIG and SPCIT > care according to needs of these patients 2) awareness and needs assessment of the local/area community with ongoing monthly meetings and community engagement 3) awareness of management institutions in the city. RESULTS: The project started in November of 2014 and the first identification found 51 patients. Evaluation and assessment will begins and this number will be reduced. The first local meeting will happen in January/2015. CONCLUSION: This project seeks to provide a proposal for palliative care offered through primary care in a public health service which does not exist in Brazil.

Cross-sectional pilot study to monitor the availability, dispensed prices, and affordability of opioids around the globe.

CONTEXT: Opioids are essential medicines. The World Health Organization and Health Action International monitor the price of essential medicines. However, their surveys do not include opioids, and there is no information on their affordability. OBJECTIVES: To provide information on access to pain treatment, as measured by the availability and dispensed price of five opioids in 13 formulations, and the affordability of oral immediate-release (IR) morphine. METHODS: The International Association for Hospice and Palliative Care members were distributed by their countries' Gross National Income (GNI) level using the World Bank categories, i.e., high income country (HIC), upper middle income country (UMIC), lower middle income country (LMIC), low income country (LIC), and randomized. A total of 10 participants were selected from each (n=40) domain. Participants were asked to identify a pharmacy located closest to a public facility that provides diagnosis/treatment for life-threatening conditions and report the lowest dispensed price of the smallest selling unit and strength of each formulation. Availability and median (Me) price were calculated for each. Affordability and percentage of international buyer price (IBP) were calculated for morphine oral solid IR. RESULTS: A total of 30 participants from 26 countries (response rate=75%) responded. Significant correlation was found between availability and GNI (range: 65-68% [HIC and LIC]; R=0.781; P<0.0001). Injectable and morphine oral solid sustained release (SR) were the most available (59% and 55%). Methadone (oral) was the least expensive (Me=0.5) followed by fentanyl (transdermal; Me=2.2). The Me price for morphine oral solid IR and ratios between dispensed and IBP were lower in HIC than in LMIC (price=0.03 vs. 0.16; ratio=2.23 vs. 0.03). Affordability for morphine oral solid IR was five days (Me=0.1; range=29-0.25). CONCLUSION: Patients in LMIC and LIC have limited access to opioids, and there are subsidies in place for more expensive medications and formulations in all GNI levels, but not for morphine oral solid IR. Additional research is necessary to identify the reasons behind these findings.

Medical students' palliative care education in a Latin American university: a three-year experience at Austral University in Buenos Aires, Argentina.

BACKGROUND: The School of Medicine of Austral University incorporated palliative care as an elective in undergraduate medicine curriculum during 2010. OBJECTIVE: We analyzed the experience and results after 3 years of teaching palliative care. We compared students who chose palliative care as an elective subject (PC Group) with students who did not (Non-PC Group). We focused on the experience of contact with palliative care patients and self-perceived attitudes. Additionally, the impact produced by palliative care education in knowledge, self-perceived attitudes, and comfort was evaluated. METHODS: All the students tested completed a questionnaire on their attitude when exposed to dying patients. Students in the PC Group completed an additional questionnaire to assess their level of knowledge and their self-perceived comfort when interacting with patients. RESULTS: We tested 146 students. All students in the PC Group and 95.2% in the Non-PC Group considered that specific death issues ought to be part of the curriculum. Some students indicated that they could be present in a mandatory course. Before taking their elective, students in the PC Group confirmed a lack of technical training to understand palliative care patients, as did those students in the Non-PC Group. After taking a palliative care elective students expressed an improvement in self-perceived attitudes toward suffering and there was a significant increase (p<0.0001-0.0045) in knowledge. They also expressed an improvement in comfort levels in evaluation and treatment of pain. More than 95% of the students in the PC Group rated the experience as valuable and perceived the content as not available elsewhere in their training. DISCUSSION/CONCLUSION: Our results show that palliative care education provides opportunities to improve attitudes not specific to this discipline: interprofessional collaboration, holistic care, patient-centered care, self-awareness, and humanism. We conclude that an exposure to palliative care improved student's perception about the complexities of dying patients and their care.

The challenge of international consensus: defining an opioid essential prescription package.

PURPOSE OF REVIEW: To describe a new strategy that aimed to facilitate opioid prescription for better pain management. RECENT FINDINGS: The International Association of Hospice and Palliative Care recently develop a single prescription package (drugs and dosing) with one opioid, one laxative, and one antiemetic for the initiation of opioid treatment in cancer pain and other life-threatening conditions, with the intention to facilitate opioid use, improve patient compliance, and reduce adverse effects. SUMMARY: The opioid essential prescription package was an international project designed to ensure that opioids are better tolerated by reducing the adverse effects of opioids, which could lead to more sustained improvements in pain management.

Palliative care research in Latin America and the Caribbean: from the beginning to the Declaration of Venice and beyond.

BACKGROUND: Research in palliative care has increased significantly in the last decade, while the vast majority of the global disease burden occurs in developing countries. AIMS: To explore the palliative care research activity in Latin America and the Caribbean (LAC) and its visibility in the international palliative care literature, with a special focus on research studies. METHODS: A bibliometric analysis was conducted in MEDLINE(®), Embase(®), PsycINFO(®), and CINAHL(®). Inclusion criteria were: (1) articles published in peer-reviewed scientific journals; (2) main subject was palliative care; (3) research study; (4) the first author or coauthors was based in LAC; and/or (5) the data collected derived from LAC. RESULTS: One hundred six articles from 10 countries were identified in the literature research. The first publication dates from 1989 and was a qualitative study in Brazil. This study shows a modest contribution of publications from LAC. However, the volume of publications within the region is distributed unequally, reflecting the heterogeneity of the region: Brazil published more than half of the articles, while 35 countries have no publications. Most of the studies were quantitative research, predominantly cross-sectional studies. Qualitative studies often used interviews. Health care service was the most researched issue. Seventy percent of studies were carried out in institutions. CONCLUSIONS: Palliative care research should have a place in LAC. The development of a regional research agenda tailored to the needs and features of the region considering the health care structure and local resources available is indispensable.

Strategic pain management: the identification and development of the IAHPC opioid essential prescription package.

The aim of this study was to determine by consensus the components of an opioid essential prescription package (OEPP) to be used when initiating a prescription for the control of moderate to severe chronic pain. Palliative care physicians (n=60) were sampled from the International Association for Hospice and Palliative Care (IAHPC) membership list to represent a range of countries of varying economic levels and diverse geographical regions. Using a Delphi study method, physicians were asked to rank preferences of drug and dosing schedule for first-line opioid, antiemetic, and laxative for the treatment of adults with chronic pain due to cancer and other life-threatening conditions. Overall response rates after two Delphi survey rounds were 95% (n=57) and 82% (n=49), respectively. A consensus (set at ≥75% agreement) was reached to include morphine as first-line opioid at a dose of 5 mg orally every 4 hours. Consensus was reached to include metoclopramide as a first-line antiemetic, but there was no consensus on "regular" or "as needed" administration. No consensus was reached regarding a first-line laxative, but a combination of senna and docusate secured 59% agreement. There was consensus (93% agreement) that laxatives should always be given regularly when opioid treatment is started. Further work is needed to establish a recommended dose of metoclopramide and a type and dose of laxative. The resulting OEPP is international in scope and is designed to ensure that opioids are better tolerated by reducing adverse effects of opioids, which could lead to more sustained improvements in pain management.

International Association for Hospice and Palliative Care (IAHPC) List of Essential Practices in Palliative Care.

The objective of this study was to identify, through a consensus process, the essential practices in primary palliative care. A three-phase study was designed. Phase 1 methods included development of a working group; a literature review; development of a baseline list of practices; and identification of levels of intervention. In Phase 2, physicians, nurses, and nurse aides (n = 425) from 63 countries were asked in three Delphi rounds to rate the baseline practices as essential or nonessential and select the appropriate levels of intervention for each. In Phase 3, representatives of 45 palliative care organizations were asked to select and rank the 10 most important practices resulting from Phase 2. Scores (1-10) were assigned to each, based on the selected level of importance. Results of Phase 1 were a baseline list of 140 practices. Three levels of intervention were identified: Identification/Evaluation; Diagnosis; and Treatment/Solution measures. In Phase 2, the response rates (RR) for the Delphi rounds were 96.5%, 73.6%, and 71.8%, respectively. A consensus point (≥80% agreement) was applied, resulting in 62 practices. In Phase 3, RR was 100%. Forty-nine practices were selected and ranked. "Evaluation, Diagnosis and Treatment of Pain" scored the highest (352 points). The working group (WG) arranged the resulting practices in four categories: Physical care needs, Psychological/Emotional/Spiritual care needs, Care Planning and Coordination, and Communication. The IAHPC List of Essential Practices in Palliative care may help define appropriate primary palliative care and improve the quality of care delivered globally. Further studies are needed to evaluate their uptake and impact.

Opioid inaccessibility and its human consequences: reports from the field.

Strong opioids such as morphine are rarely accessible in low- and middle-income countries, even for patients with the most severe pain. The three cases reported here from three diverse countries provide examples of the terrible and unnecessary suffering that occurs everyday when this essential, inexpensive, and safe medication is not adequately accessible by patients in pain. The reasons for this lack of accessibility are explored, and ways to resolve the problem are proposed.

Palliative care research in Latin America: results of a survey within the scope of the Declaration of Venice.

BACKGROUND: In recent years, there has been an increase in the amount of palliative care research in developing countries. However, it is still very limited in the developing regions of the world, including Latin America. OBJECTIVE: To determine the current status of palliative care research in Latin America. DESIGN: A survey was developed in Spanish and translated to Portuguese. Questions included demographic characteristics and specific research issues. Distribution was done through e-mail and personal hand-outs. MEASUREMENTS: Data were collected and analyzed using descriptive statistics and multivariate analysis. RESULTS: Two hundred sixty-three surveys (17.5% response rate) were received from 17 countries. A small number (10%, n = 263) reported participating in research within the last 5 years. Slightly over half of them received some training and had access to mentorship and guidance from an expert: multivariate analysis showed that training in research (odds ratio [OR] 3.46; 95% confidence interval [CI] 1.71-6.98) and support from an expert (OR 3.03; 95% CI 1.51-6.10) were positive predictor factors, even when adjusted for gender, age, years since graduation, and years working in palliative care. Barriers to conduct research most frequently cited were: lack of funding, insufficient knowledge and expertise, and lack of interest (54%, 21%, and 15%, respectively). CONCLUSIONS: Palliative care research in Latin America is very limited. Regional palliative care teams must adopt and implement systematic research in their practice to improve, guarantee, and sustain quality. Changes in policy, education, and allocation of funds are needed to guarantee the development of research in Latin America.