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.

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.

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.

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.

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.

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.

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.

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.

PA28†Assessing physicians' perception of home based palliative care services in the beirut area.

BACKGROUND: The referral process in palliative care is influenced by the structure of the health care system and the understanding of the value of Palliative Care (PC) by healthcare practitioners and patients. Balsam-Lebanese Centre for Palliative Care is a non-governmental organisation that has been providing home-based palliative care services to patients in Greater Beirut since 2010. Lebanon has a highly privatised fee-for-service health care system. In this setting, treating physicians may resist seeking palliative care services for their patients for fear of losing the patient. A lack of awareness regarding the added value of palliative care can also be detrimental to referral rates. We aimed to gain physician acceptance by providing high quality care, consistent communication, and education. AIM: To assess the perceptions of referring physicians towards our home-based palliative care service. METHODS: A sample of primary physicians whose patients have been under the care of Balsam will be interviewed to assess their perceptions of the quality and value of our service to their patients as well as the impact of the service on their practice. 10-15 semi-structured interviews will be conducted transcribed and analysed thematically. RESULTS: Since the initiation of our in 2010, patient load has steadily increased. The pool of referring physicians has also increased from 3 physicians in the first year to 58 physicians to date in 2014. In this study, we will share the findings from our qualitative study with referring physicians. CONCLUSION: Understanding the fears and concerns of referring physicians will guide further interventions and may improve referral rates.

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.

Family medicine in Arab countries.

BACKGROUND AND OBJECTIVES: Information on the practice of family medicine in Arab countries is scant. In this study we aim to describe the current state of the specialty in the region. This includes scope of practice, practice setting, training programs, and the numbers and profiles of their graduates. METHODS: A survey of leaders in family medicine in Arab countries was conducted between October 2008 and June 2009. The survey was administered in person or via e-mail. Snowball sampling was used to obtain at least two respondents from each country. RESULTS: There are 31 family medicine residency programs in Arab countries graduating about 182 residents per year. In most Arab countries, the family physician to population ratio remains low. Most graduates work in clinical practice, and a large proportion of them are employed in government-run clinics. There is significant variability in the scope of practice among practicing physicians. CONCLUSIONS: Family medicine continues to struggle for a clear identity worldwide. In the Arab world, where the specialty is relatively new, steps can be taken to better define our identity as a specialty and increase its desirability as a specialty.

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.