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.

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.

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.

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.

Validación de dos herramientas para la evaluación de cambios en las actitudes de alumnos en situaciones frecuentes en cuidado paliativo / Validation of two instruments to assess attitude changes of students in common situations in palliative care

Objetivo: determinar las propiedade psicométricas de dos escalas utilizadas para evaluar las actitudes en torno a los cuidados paliativos: La Escala de Confort en Cuidados Paliativos (ECCP) de Pereira et al., y la Escala de Tanatofobia (ET) de Merrill et al. Método: Participaron 77 alumnos de 7 cursos virtuales de aspectos psicosociales en cuidados paliativos entre 2010 y 2013. Estos respondieron las escalas de medida antes y después del curso. Se examinó la validez y la fiabilidad de la ECCP y de la ET a través de un análisis de componentes principales, el coeficiente de consistencia interna y el test-retest. Se realizó una comparación de los resultados pre-curso y post-curso para determinar cambios en las actitudes evaluadas. Resultados: El análisis de componentes principales se ajustó satisfactoriamente a los datos y se extrajeron 3 componentes: dos para la ECCP y uno para la ET, explicando el 55,37% de la varianza. El Alfa de Cronbach fue satisfactorio en todos los casos. Las correlaciones test-retest en t1 y t2 no resultaron significativas, esto indica que la relación entre la primera y la segunda medición en las escalas no fue estrecha. Los cursos ocasionaron un cambio significativo en el confort en la atención al paciente (p = 0,004), en el confort en la atención a las familias (p = 0,001), mas no en el grado de tanatofobia (p > 0,05). Conclusiones: Ambas escalas son válidas y confiables. Evalúan de forma satisfactoria las actitudes, y sus cambios relacionados con la práctica de los cuidados paliativos, en lo referente a la atención de aspectos psicosociales

Objective: To determine the psychometric properties of two scales designed to examine attitudes regarding palliative care: Comfort Scale in Palliative Care (CSPC, Pereira et al.) and Tanatophobia Scale (TS, Merrill et al.) Method: Seventy-seven students who completed an online course on psychosocial aspects of palliative care offered by the Latin American Association of Palliative Care participated in the study. They also completed the scales before and after the course. Construct validity and reliability of the CSPC and the TS were assessed using a Principal Components Analysis, internal reliability coefficient and test-retest reliability. Further, comparative statistics between the pre-course and post-course results were obtained in order to determine changes in attitudes. Results: The Principal Components Analysis showed satisfactory fit to the data. 3 components were extracted: two for the CSPC and one for the TS, which explained 55.37% of the variance. Internal consistency coefficients were satisfactory in all cases and Cronbach´s Alphas were satisfactory for all the scales, particularly for the CSPC. Testretest reliability in t1 and t2 was found to be non significant, indicating that measures were not related in time. Regarding pre-course/ post-course comparisons, significant changes in comfort assisting patients (p = 0.004) and comfort assisting families (p = 0.001) following the course were identified, but changes in thanatophobia were non significant (p > 0.05). Conclusions: both scales are valid and reliable. Attitudes regarding the practice of palliative care and how they change, particularly regarding psychosocial issues, can be accurately measured using the examined scales

Encuentro sobre educación de cuidado paliativo en Latinoamérica. Recomendaciones sobre enseñanza en el pregrado y en el primer nivel de atención de salud / Meeting on Palliative Care Education in Latin America Recommendations for teaching undergraduates and primary care health professionals

En muchos países de Latinoamérica el desarrollo del cuidado paliativo es aún incipiente. Una razón fundamental es que la formación de los profesionales de la salud en esta disciplina, aunque intensa y progresivamente mayor, es todavía insuficiente y de calidad variable. Diferentes instituciones y organizaciones relacionadas con la promoción e implementación del cuidado paliativo promovieron un primer encuentro regional sobre aspectos técnicos de la enseñanza de cuidado paliativo en el pregrado y el primer nivel de atención. La reunión se celebró en Buenos Aires, Argentina, en noviembre de 2012 y contó con la participación de 60 profesionales de diversas disciplinas con actividad docente en cuidado paliativo procedentes de 11 diferentes países latinoamericanos. Se identificaron y analizaron temas centrales en la enseñanza básica de cuidado paliativo, se identificaron aspectos que deben ser optimizados y se efectuaron recomendaciones para hacerlo. Todo el grupo estuvo de acuerdo con que el cuidado paliativo debería estar disponible y ser accesible para la mayor cantidad posible de pacientes con enfermedades de riesgo vital en estadios avanzados. También con la evidencia que muestra que más pacientes pueden recibir atención adecuada provista por profesionales del primer nivel de atención de salud, si adquieren los conocimientos, habilidades y actitudes básicas del cuidado paliativo. Este reporte describe el diseño y la organización del encuentro y se presentan los resultados y recomendaciones relacionadas con la docencia en el pregrado y el primer nivel de asistencia

In many Latin American countries Palliative Care development is still in the initial stages. A key reason is that the training of health professionals in this discipline, although intense and gradually increasing, is still insufficient, and with variable quality. The different institutions and organizations involved in the promotion and implementation of Palliative Care sponsored the first regional meeting on technical aspects of Palliative Care teaching to undergraduates and primary care health professionals. The meeting was held in Buenos Aires, Argentina in November 2012, and was attended by 60 professionals from diverse disciplines with teaching activity in Palliative Care from 11 different Latin American countries. Key issues in basic education in Palliative Care were identified and analyzed, challenges were identified, and recommendations were made overcome them. All the participants were in agreement that palliative care should be available and accessible for the majority of the patient population with life threatening conditions. Also, with the evidence that indicates that more patients may be able to receive appropriate care provided by primary care health care professionals, as long as they have the basic palliative care knowledge, skills and attitudes. This report describes the design and organization of the meeting and presents the results and recommendations related to teaching at the undergraduate and the primary care level

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.

Estudio multicéntrico sobre la comodidad y el interés en cuidados paliativos en estudiantes de pregrado en Colombia / Multicenter study on levels of comfort and interest in palliative care among undergraduate students in Colombia

ANTECEDENTES Y OBJETIVO: La educación es considerada uno de los componentes de la estrategia en salud pública para cuidados paliativos (CP) en el modelo planteado por la Organización Mundial de la Salud. Sin embargo, en Colombia solo 3 de 57 facultades de Medicina enseñan CP.como parte de un proyecto con el fin de promocionar la enseñanza de los CP en las facultades de Ciencias de la Salud de Colombia y su integración al currículo de pregrado se realizaron debates con estudiantes de Medicina y/o Enfermería de 3 universidades de Colombia. El objetivo de este trabajo es describir y analizar el nivel de comodidad y el interés de los estudiantes en CP en 3 universidades de Colombia. MÉTODO: Estudio multicéntrico de tipo transversal. La muestra fue constituida por los participantes a los debates de 3 universidades. Se utilizó un cuestionario de preparación percibida respecto a situaciones comunes en CP («cuestionario de comodidad») y un cuestionario de interés. Además se registraron datos sociodemográficos y académicos. RESULTADOS: Doscientos tres estudiantes participaron en los debates (101 de Enfermería, 96 de Medicina). El 25% tuvieron un curso previo en CP. Los estudiantes con cursos previos de CP y los estudiantes de Medicina tuvieron puntuaciones más altas en comodidad. En general, las situaciones de transmisión de malas noticias, manejo del duelo y comunicación de una limitación/adecuación terapéutica fueron reportadas como menos cómodas. Las situaciones clínicas como control de síntomas y manejo de la escala analgésica de la Organización Mundial de la Salud fueron reportadas como más cómodas. El 99% de los estudiantes estuvieron de acuerdo con incorporar el CP en el currículo de pregrado. En una pregunta abierta sobre los temas que consideran importantes, los estudiantes mencionaron: comunicación (especialmente la transmisión de malas noticias), aspectos generales de CP, aspectos éticos y manejo de dolor y otros síntomas. CONCLUSIONES: Estos resultados indican que la formación en CP durante el pregrado mejora el comodidad de los estudiantes en las situaciones habituales de los CP. También señala la necesidad de educación en CP para los futuros médicos. La integración de CP en los programas de Medicina y Enfermería existentes en Colombia es deseada y urgente

BACKGROUND AND OBJECTIVE: Education is considered as a component of the public health strategy Colombia only 3 out of 57 medical schools teach PC. As part of a project to promote the teaching of PC in Colombian medical schools and its integration in the undergraduate curriculum, meetings were held with medical and/or nursing students in 3 universities in Colombia. The aim of this investigation is to describe and analyze the comfort level in common PC situations of students from 3 universities in Colombia, and their interest in this discipline. METHOD: Multicenter cross-sectional study. The sampling was made up of the participants in meetings in 3 universities. Two questionnaires were used: one to evaluate comfort in hypothetical scenarios common to PC, and another to evaluate the interest. Demographic and academic information were also recorded. RESULTS: A total of 203 students participated in the meetings, with 101 nursing students and 96 medical students, of whom 25% had a previous course in PC. Students with previous PC courses and medical students scored higher in comfort than nursing students and students with no previous courses. Topics such as giving bad news, grief management, and communicating therapeutic limitation/adequacy were reported as less comfortable. Clinical issues such as symptom control and implementation of the World Health Organization analgesic ladder were reported as more comfortable. Almost all (99%) of students agreed that it was important to incorporate PC in the undergraduate programs. In an open question regarding topics that students considered more important, were listed: communication (especially breaking bad news), general aspects of PC, ethical issues, and treatment of pain and other symptoms. CONCLUSIONS: These results indicate that training in PC at undergraduate level improves their comfort in common PC situations. It also shows the need to integrate PC into existing programs in Colombia. Inclusion of PC education at the undergraduate level in medicine and nursing schools is desired and urgent