Development of palliative care in Lebanon. Obstacles and opportunities.

Palliative care focuses on relieving suffering in patients with serious illness. Patients who receive palliative care have better control of distressing symptoms, are less likely to suffer from depression and have a better quality of life. Although palliative care has become an integral component of health care systems in many developed countries it has yet to be established in most developing countries. In Lebanon, Palliative care was only recently recognized as a specialty and there are not enough palliative care providers to cover the needs of the population. This article describes the opportunities and barriers to the development of palliative care in the Lebanese context.

Interventions to reduce postpartum stress in first-time mothers: a randomized-controlled trial.

BACKGROUND: The postpartum period can be a challenging time particularly for first-time mothers. This study aimed to assess two different interventions designed to reduce stress in the postpartum among first-time mothers. METHODS: Healthy first-time mothers with healthy newborns were recruited from hospitals in Beirut, Lebanon after delivery. The two interventions were a 20-minute film addressing common stressors in the postpartum period and a 24-hour telephone support hotline. Participants were randomized to one of four study arms to receive either the postpartum support film, the hotline service, both interventions, or a music CD (control). Participants were interviewed at eight to twelve weeks postpartum for assessment of levels of stress as measured by the Cohen Perceived Stress Scale (PSS-10). RESULTS: Of the 632 eligible women, 552 (88%) agreed to participate in the study. Of those, 452 (82%) completed the study. Mean PSS-10 scores of mothers who received the film alone (15.76) or the film with the hotline service (15.86) were significantly lower than that of the control group (18.93) (p-value <0.01). Among mothers who received the hotline service alone mean PSS-10 score (16.98) was also significantly lower than that of the control group (p-value <0.05). CONCLUSIONS: Both our postpartum support film and the 24-hour telephone hotline service reduced stress in the postpartum period in first-time mothers. These simple interventions can be easily implemented and could have an important impact on the mental wellbeing of new mothers. TRIAL REGISTRATION: The trial was registered with clinicaltrials.gov (identifier # NCT00857051) on March 5, 2009.

Determinants of exclusive breastfeeding in an urban population of primiparas in Lebanon: a cross-sectional study.

BACKGROUND: The proportion of mothers who exclusively breastfeed their babies up to 6 months remains low. Determinants of breastfeeding practices have been largely documented in high-income countries. Little evidence exists on possible predictors of breastfeeding behaviors in the Middle East. Our aim was to assess the prevalence of breastfeeding in Beirut and determine the factors that impact breastfeeding behavior in this population. METHODS: Data for this longitudinal study is nested within a randomized controlled trial (RCT) assessing the impact of a 24-hour hotline and postpartum support film on postpartum stress. Healthy first-time mothers delivering in the capital Beirut between March and July 2009, were interviewed at 1-3 days and 8-12 weeks post delivery. A multiple logistic regression analysis was used to determine the factors associated with exclusive breastfeeding at 8-12 weeks postpartum. RESULTS: The overall breastfeeding rate at 8-12 weeks postpartum was 67%. The exclusive breastfeeding rate was 27.4%. Factors associated with exclusive breastfeeding included maternal work (OR=3.92; p-value<0.001), planned pregnancy (OR=2.42, p-value=0.010), intention to breastfeed (OR=3.28; p-value=0.043), source of maternal emotional support (OR=1.87, p-value=0.039) and the use the postpartum support video, the hotline service or both (OR=2.55, p-value=0.044; OR=3.87, p-value=0.004 and OR=4.13, p-value=0.003). CONCLUSIONS: The proportion of healthy first-time mothers who exclusively breastfeed in Beirut is extremely low. Factors associated with breastfeeding behavior are diverse. Future research and interventions should target different levels of the maternal-child pair's ecosystem. TRIAL REGISTRATION: ClinicalTrials.gov, NCT00857051.

Setting practice standards for palliative care in Lebanon--recommendations of the Subcommittee on Practice --National Committee for Pain Control and Palliative Care.

Palliative care is in the early stages of development in Lebanon. The National Committee for Pain Control and Palliative Care (NCPCPC) was established under the Ministry of Public Health to work towards the development of palliative care. This paper summarizes the recommendations of the Subcommittee on Practice of the NCPCPC regarding hospital standards and provider competencies in palliative care. The authors propose actions that should be taken to implement these recommendations to help move palliative care forward in the country.

Palliative care need in the Eastern Mediterranean Region and human resource requirements for effective response.

Integration of palliative care into health care systems is considered an ethical responsibility, yet no country in the Eastern Mediterranean Region (EaMReg) has achieved integration. Data on palliative care need and cost are crucial forEaMReg health care planners and implementers in the region. Using data from the Lancet Commission on Palliative Care and Pain Relief, we estimated the number of people in each EaMReg country who needed palliative care in 2015 and their degree of access. In three countries, we estimated the number of days during which an encounter for palliative care was needed at each level of the health care system. This enabled calculation of the number of full-time equivalents (FTEs) of clinical and non-clinical staff members needed at each level to administer the essential package of palliative care recommended by WHO. In 2015, 3.2 million people in the EaMReg needed palliative care, yet most lacked access to it. The most common types of suffering were pain, fatigue, weakness, anxiety or worry, and depressed mood. To provide safe, effective palliative care at all levels of health care systems, between 5.4 and 11.1 FTEs of trained and supervised community health workers per 100,000 population would be needed in addition to 1.0-1.9 FTEs of doctors, 2.2-4.3 FTEs of nurses, and 1.4-2.9 FTEs of social workers. Data from our study enables design of palliative care services to meet the specific needs of each EaMReg country and to calculate the cost or cost savings.

Estimating the Impact of Inpatient Palliative Care Consultations on Health Care Costs in a Low- and Middle-Income Country.

Background: The escalating cost of health care has important implications on national economies and public health. Palliative care (PC) consultations have been shown to reduce health costs while improving the quality of life. Aim: To assess the impact of PC consultations on hospital costs in a low- and middle-income country. Methods: We analyzed billing data of patients who received a PC consultation at our tertiary care hospital over a one-year period. Controls were patients with a serious illness who had at least one admission during the study period. Analysis was conducted for patients discharged alive and those who died during their hospitalization. The primary outcome was cost of hospitalization. Readmission rates, length of stay (LOS), and number of emergency department (ED) visits after discharge were secondary outcomes. Results: Daily hospital costs were 10% lower for patients who received a PC consult (n = 346) compared with controls (n = 698). This difference was more pronounced among patients who died during their hospitalization and when the consult was conducted earlier in the hospital course. LOS (4.92 vs. 4.68, p < 0.0001), readmissions (24.78% vs. 36.41%, p < 0.001), and ED visits after discharge were lower in the PC group compared with the control group (relative risk [RR] = 2.46). Conclusions: We used readily available hospital billing data to demonstrate the cost benefits of inpatient PC consultations. This simple approach can provide powerful data to justify the need for PC services.

Integrating locally-attuned palliative care into health care systems in the Eastern Mediterranean Region.

At the 2014 World Health Assembly (WHA), the ministers of health of all 194 World Health Organization (WHO) Member States affirmed that palliative care, the prevention and alleviation of pain and suffering of any kind associated with serious illness, "is an ethical responsibility of health systems". The Assembly acknowledged "the urgent need to include palliation across the continuum of care, especially at the primary care level," and emphasized that "inadequate integration of palliative care into health and social care systems is a major contributing factor to the lack of equitable access to such care." This WHA Resolution (WHA 67.19) differs from other resolutions regarding specific diseases, interventions, populations, or other aspects of health care. It differs not only because palliative care is essential to the care of adults and children affected by serious illness or humanitarian crisis of any type, but also because the Resolution draws attention to the essence of medicine and nursing, the prevention and relief of human suffering. It does so by amplifying the too-often unheard call of the suffering, the poorest, sickest, and most vulnerable.

The Eastern Mediterranean Regional Palliative Care Expert Network: Designing a roadmap for palliative care development in the region.

Since 2014 WHO has been advocating for the integration of palliative care into health systems. Although there has been some progress in the development of palliative care in the Eastern Mediterranean Region, many countries in the region still have no palliative care activity and none has achieved integration. The WHO Regional Office for the Eastern Mediterranean has been engaged in activities aimed to develop palliative care in the region since 2010. We report on the establishment of the Eastern Mediterranean Regional Palliative Care Expert Network and its mandate, activities, and plans.

Palliative care models and innovations in 4 Eastern Mediterranean Region countries: a case-based study.

Background: There is a global agreement that palliative care should be universally accessible. However, in low- and middle-income countries and conflict zones, most people lack access to it. In the Eastern Mediterranean Region (EMR), no country has achieved integration of palliative care into its health care system, and only 4 countries have better-than-isolated palliative care provision. Aims: To promote and guide palliative care improvement in the EMR, with case studies showing the successes and challenges of palliative care implementation from 4 countries in the Region. Methods: We developed a structured, succinct, case-writing format and invited palliative care leaders in the EMR to use it to describe successes and challenges in palliative care implementation in their countries. Results: Within the EMR, in addition to many challenges and needs, there are examples of successful palliative care policy development, community-based service creation, and paediatric palliative care implementation. Conclusion: The experiences of the regional palliative care leaders documented in succinct, structured case studies, can help guide regional palliative care development in the EMR and other regions.

Implementation of an emergency department computer system: design features that users value.

BACKGROUND: Electronic medical records (EMRs) can potentially improve the efficiency and effectiveness of patient care, especially in the emergency department (ED) setting. Multiple barriers to implementation of EMR have been described. One important barrier is physician resistance. The "ED Dashboard" is an EMR developed in a busy tertiary care hospital ED. Its implementation was exceptionally smooth and successful. STUDY OBJECTIVES: We set out to examine the design features used in the development of the system and assess which of these features played an important role in the successful implementation of the ED Dashboard. METHODS: An anonymous survey of users of the ED Dashboard was conducted in January and February 2009 to evaluate their perceptions of the degree of success of the implementation and the importance of the design features used in that success. Results were analyzed using SPSS software (SPSS Inc., Chicago, IL). RESULTS: Of the 188 end-users approached, 175 (93%) completed the survey. Despite minimal training in the use of the system, 163 (93%) perceived the system as easy or extremely easy to use. Users agreed that the design features employed were important contributors to the system's success. Being alerted when new test results were ready, the use of "most common" lists, and the use of color were features that were considered valuable to users. CONCLUSION: Success of a medical information system in a busy ED is, in part, dependent on careful attention to subtle details of system design.

Recommendations to Improve Palliative Care Provision for Marginalized Populations: Summary of a Roundtable Discussion.

Palliative care is increasingly recognized as fundamental to health and human dignity. However, a growing body of evidence highlights the variations in access to palliative care based on personal characteristics, belonging to a certain group, and socioeconomic background. Discriminatory attitudes and behaviors and lack of legal reform protecting the rights of marginalized populations are still common, particularly across Lebanon and the Middle East and North Africa region. This article presents a summary of a roundtable discussion organized by the Lebanese Medical Association for Sexual Health in collaboration with the Lebanese Center for Palliative Care-Balsam, focusing on improving palliative care provision for the following populations: prisoners; lesbian, gay, bisexual, and transgender people; refugees; migrant domestic workers; and people with substance use disorder. It also offers recommendations based on the key themes identified from the discussion, in the hope that they will guide the development of guidelines and policy to advance equity in palliative care provision for marginalized populations.

Validation of the Arabic version of the Cohen Perceived Stress Scale (PSS-10) among pregnant and postpartum women.

BACKGROUND: This study was conducted to evaluate the validity of the Arabic translation of the Cohen Perceived Stress Scale (PSS-10) in pregnant and postpartum women. METHODS: A sample of 268 women participated. These included 113 women in their third trimester of pregnancy, 97 in the postpartum period and 58 healthy female university students. GHQ-12 and EPDS were also administered to the participants. Internal consistency reliability, assessed using Cronbach's α, was 0.74. RESULTS: PSS-10 significantly correlated with both EPDS and GHQ12 (ρ = 0.58 and ρ = 0.48 respectively), and significantly increased with higher scores on stressful life events. PSS-10 scores were higher among university students who also recorded higher stressful life events scores. CONCLUSION: The Arabic translated version of the PSS-10 showed reasonably adequate psychometric properties.

What do first-time mothers worry about? A study of usage patterns and content of calls made to a postpartum support telephone hotline.

BACKGROUND: Telephone hotlines designed to address common concerns in the early postpartum could be a useful resource for parents. Our aim was to test the feasibility of using a telephone as an intervention in a randomized controlled trial. We also aimed to test to use of algorithms to address parental concerns through a telephone hotline. METHODS: Healthy first-time mothers were recruited from postpartum wards of hospitals throughout Lebanon. Participants were given the number of a 24-hour telephone hotline that they could access for the first four months after delivery. Calls were answered by a midwife using algorithms developed by the study team whenever possible. Callers with medical complaints were referred to their physicians. Call patterns and content were recorded and analyzed. RESULTS: Eighty-four of the 353 women enrolled (24%) used the hotline. Sixty percent of the women who used the service called more than once, and all callers reported they were satisfied with the service. The midwife received an average of three calls per day and most calls occurred during the first four weeks postpartum. Our algorithms were used to answer questions in 62.8% of calls and 18.6% of calls required referral to a physician. Of the questions related to mothers, 66% were about breastfeeding. Sixty percent of questions related to the infant were about routine care and 23% were about excessive crying. CONCLUSIONS: Utilization of a telephone hotline service for postpartum support is highest in the first four weeks postpartum. Most questions are related to breastfeeding, routine newborn care, and management of a fussy infant. It is feasible to test a telephone hotline as an intervention in a randomized controlled trial. Algorithms can be developed to provide standardized answers to the most common questions.

Palliative Care via Telemedicine: A Qualitative Study of Caregiver and Provider Perceptions.

Background: Telemedicine has been proposed as a means to improve access to palliative care. There is limited information about how health care workers feel about providing this kind of care and how families feel about receiving it. Objective: This study assesses provider and caregiver perceptions of the safety and efficacy of the Distance Support Program (DSP) of a home-based palliative care provider in Beirut, Lebanon. Design: Interviews were conducted with 8 physicians and nurses who provided that care through the DSP as well as 49 caregivers of patients who received care between January 2015 and December 2017. Interviews were analyzed thematically. Results: Although they would have preferred having access to home visits, caregivers reported that they valued the information, guidance, and emotional support they received through the DSP and they appreciated having telephone access to providers. Health providers reported the DSP was more efficient than home visits. They felt it was safest when delivered by an experienced provider, they had access to a reliable caregiver, and the patient was assessed at least once. They felt it was important to communicate clear expectations to patients and caregivers when delivering care by telephone. Conclusions: Telemedicine can be a useful tool to provide palliative care services in settings where they would otherwise not be available.

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.

Facility-based audit of maternal mortality in Lebanon: a feasibility study.

OBJECTIVE: To assess the feasibility of establishing a maternal mortality audit in Lebanon. DESIGN: A facility-based reproductive age mortality study (RAMOS). METHODS: Records of reproductive-age female deaths over an eight-year period in three hospitals in Beirut, Lebanon, were reviewed. MAIN OUTCOME MEASURES: Quality of data sources, comprehensiveness of medical charts and accessibility of information. RESULTS: Review of records was feasible. Cross-checking three data sources identified missed cases and coding and data entry errors. The quality and accessibility of data varied between hospitals. The maternal mortality rate was 39/100,000 live births and there were 55 pregnancy-related deaths/100,000 live births. Lack of antenatal care, delay in seeking care and over-intervention on the part of the medical team were among problems identified. CONCLUSIONS: A facility-based approach is a potential tool for conducting a national maternal mortality audit in a developing country like Lebanon. Computerized medical records and mandatory participation of hospitals are prerequisites for success. This would require the government to develop a cohesive national policy on reducing maternal mortality.

Using emergency obstetric drills in maternity units as a performance improvement tool.

BACKGROUND: Obstetric drills are being used increasingly to test, improve, and maintain knowledge and skills related to obstetric emergencies as a means to improve proficiency and efficiency of practitioners. The purpose of this study was to assess the feasibility and usefulness of conducting drills to evaluate the response to obstetric emergencies using a holistic approach that tested the hospital system. METHODS: A prospective trial was conducted at three hospitals (two tertiary referral centers and one small community hospital) in Beirut, Lebanon. Two different emergency obstetric drills at two points in time were conducted between April and May 2006 either in the emergency room or on the labor floor. The drills included medical and paramedical staff, a female actor (simulating a pregnant woman), a research assistant (acting as her companion), and a physician trained in obstetrics (the drill leader). Responses were recorded and critically analyzed. RESULTS: Although overall quality of care was within standards of care, problems were identified related to hospital policies, supplies and equipment, communication, and clinical management. Some technical problems related to administration of the drills were identified. Most drill participants appreciated the exercise and found it beneficial. CONCLUSIONS: Obstetric drills provide a useful tool to identify and address deficiencies in the hospital system. This finding could have implications on improving quality of care provided to obstetric patients.

Respecting patient choices: using the 'Go Wish' cards as a teaching tool.

BACKGROUND: Individuals have different values and priorities that can have an important impact on their medical management. Understanding this concept can help physicians provide medical care that is in line with the goals of their patients. Communicating this message effectively to students is challenging. OBJECTIVE: To report our experience with using Go Wish cards in the medical education setting. DESIGN: A thematic analysis of student reflection papers using grounded theory. SETTING/SUBJECTS: Second-year medical students participated in an activity using the Go Wish cards as part of a course module on palliative care. The activity aimed to encourage students to reflect on their own choices at the end of life and to highlight that different people have different priorities. RESULTS: Forty-two students (42%) mentioned the Go Wish activity in their reflections on the module. They reported that the activity demonstrated the different priorities at the end of life, it illustrated the importance of providing personalised care, it promoted self-discovery, it transformed their view of death and dying, and it increased their appreciation of the importance of palliative care. CONCLUSION: Go Wish cards can be used to help illustrate the variability in priorities of patients. They can be used as an effective to teach medical students about the importance of considering patient preferences when illness progresses.

Palliative Care in the Global Setting: ASCO Resource-Stratified Practice Guideline.

Purpose The purpose of this new resource-stratified guideline is to provide expert guidance to clinicians and policymakers on implementing palliative care of patients with cancer and their caregivers in resource-constrained settings and is intended to complement the Integration of Palliative Care Into Standard Oncology Care: American Society of Clinical Oncology Clinical Practice Guideline Update of 2016. Methods ASCO convened a multidisciplinary, multinational panel of experts in medical oncology, family medicine, radiation oncology, hematology/oncology, palliative and/or hospice care, pain and/or symptom management, patient advocacy, public health, and health economics. Guideline development involved a systematic literature review, a modified ADAPTE process, and a formal consensus-based process with the Expert Panel and additional experts (consensus ratings group). Results The systematic review included 48 full-text publications regarding palliative care in resource-constrained settings, along with cost-effectiveness analyses; the evidence for many clinical questions was limited. These provided indirect evidence to inform the formal consensus process, which resulted in agreement of ≥ 75% (by consensus ratings group including Expert Panel). Recommendations The recommendations help define the models of care, staffing requirements, and roles and training needs of team members in a variety of resource settings for palliative care. Recommendations also outline the standards for provision of psychosocial support, spiritual care, and opioid analgesics, which can be particularly challenging and often overlooked in resource-constrained settings. Additional information is available at www.asco.org/resource-stratified-guidelines . It is the view of ASCO that health care providers and health care system decision makers should be guided by the recommendations for the highest stratum of resources available. The guideline is intended to complement but not replace local guidelines.

Risk factors for the development of striae gravidarum.

OBJECTIVE: The purpose of this study was to identify risk factors associated with striae gravidarum (SG). STUDY DESIGN: A cross-sectional study of 112 primiparous women delivering at a private teaching hospital was conducted. Participants were assessed during the immediate postpartum period for evidence of SG. Presence and severity of SG were compared to characteristics of women using t tests and Chi-square tests. RESULTS: Sixty percent of the study participants had developed SG. Women who developed SG were significantly younger (26.5 +/- 4.5 vs 30.5 +/- 4.6; P < .001) and had gained significantly more weight during pregnancy (15.6 +/- 3.9 vs 38.4 kg +/- 2.7; P < .001). Birthweight (BW), gestational age at delivery, and family history of SG were associated with moderate/severe SG. CONCLUSION: Maternal age and weight gain during pregnancy are associated with SG. BW, family history of SG, and gestational age at delivery are associated with moderate/severe SG.