Palliative Care Services Operational Policy
Palliative Care Services Operational Policy1
MEDICAL DEVELOPMENT DIVISIONMINISTRY OF HEALTH MALAYSIA2Palliative Care Services Operational Policy
Palliative Care Services Operational Policy3
PALLIATIVE CARE SERVICESOPERATIONAL POLICY4Palliative Care Services Operational Policy
Palliative Care Services Operational Policy5
This policy was developed by the Medical Services Unit, Medical Services DevelopmentSection of the Medical Development Division, Ministry of Health Malaysia and theDrafting Committee for the Palliative Care Services Operational Policy.Published in November 2010A catalogue record of this document is available from the library and Resource Unit ofthe Institute of Medical Research, Ministry of Health;MOH/P/PAK/203.10 (BP)National Library of MalaysiaCataloguing-in-Publication DataISBN 978-983-44999-7-6All rights reserved. No part of this publication may be reproduced or distributed inany form or by any means or stored in an database or retrieval system without priorwritten permission from the Director of the Medical Development Division, Ministryof Health Malaysia.6Palliative Care Services Operational Policy
AcknowledgementsThe Medical Development Division would like to thank Dr. Richard Lim, NationalAdvisor for Palliative Medicine Services and the Drafting Committee for the PalliativeCare Services Operational Policy for making the development of this policy possible.The Medical Development Division is also grateful to members of the Review Panelfor reviewing the policy and providing constructive comments on the draft policy.Palliative Care Services Operational Policy7
CONTENTSFOREWORDDirector General Of Health Malaysia10Deputy Director General Of Health (Medical)12National Advisor For Palliative Medicine Services14ARTICLES1 Introduction192 Objectives Of Service213 Scope Of Service224 Components Of Service245 Organisation256 General Statement277 Palliative Care Services297.1 Inpatient Palliative Care Unit297.2 Consultative Palliative Care Service327.3 Outpatient Clinic337.4 Community Palliative Care Service347.5 Daycare Services358 Training And Education379 Whole Hospital Policy40APPENDICESAppendix 1 WHO Definition Of Palliative Care45WHO Definition Of Palliative Care For Children46Definition Of Palliative Medicine46Appendix 2 Principles Of Palliative Care Management47Appendix 3 MOH Vision And Mission Statement For Palliative Care49Appendix 4 Integrated Model Of Palliative Care50Appendix 5 Components Of Palliative Care Services And Their51RelationshipsAppendix 6 Ideal Organisational Structure For Palliative Care Service InHospitals With Resident Palliative Medicine PhysicianAppendix 7 Organisational Structure Of Palliative Care Service In Hospitals852With No Resident Palliative Medicine PhysicianPalliative Care Services Operational Policy53
Appendix 8 Organisational Structure Of Palliative Care Service In54Non-Specialist HospitalsAppendix 9 Recommendations For Ideal Staffing Of Palliative Care Services55Appendix 10 Recommended Essential Drugs For Palliative Care Services57Appendix 11 List Of Essential Equipment In A Palliative Care Unit61REFERENCES63DRAFTING COMMITTEE66REVIEW PANEL68Palliative Care Services Operational Policy9
10Palliative Care Services Operational Policy
DIRECTOR GENERAL OF HEALTH MALAYSIALife expectancy in Malaysia is increasing due to better healthcare. Thishowever has also resulted in an increase in the number of Malaysianssuffering from chronic incurable illnesses such as cancer, organ failure andneurodegenerative disorders. Comprehensive healthcare developmentshould therefore not only encompass progress in the treatment of chronicillnesses but also in the palliation of the sufferings caused by such conditions.As our nation develops and the standard of living improves, our society willalso become more aware of the need to ensure a good quality of life despitehaving illnesses and the provision of end-of-life care in conditions where cureis not possible and deterioration inevitable.Healthcare professionals see increasing numbers of patients with advancedlife-limiting illnesses and should be prepared to offer all reasonable optionsavailable to them. Patients should have opportunities to receive highquality palliative care throughout their entire illness trajectory. In addition totraditional treatment goals, relieving patients’ suffering and optimizing theirquality of life should remain high priorities for all health care professionals.Palliative care services have been developing in the Ministry of Healthhospitals since the mid-1990s. The goals of palliative care, namely to improvethe quality of life of patients and families facing problems associated withlife-threatening illnesses is very much in keeping with the Ministry of Health’smission emphasizing caring and respect for human dignity. The sub-specialtyof Palliative Medicine should therefore be encouraged to grow further andmore specialised palliative care units should be developed in order to meetthe needs of our society.I would like to congratulate the Medical Programme, in particular the MedicalDevelopment Division and Dr. Richard Lim for their efforts in developingthis operational policy. It is only appropriate that palliative care services bePalliative Care Services Operational Policy11
developed based on a well documented operational policy similar to otherclinical disciplines, more so because it is a relatively new clinical disciplinewithin the Ministry of Health.Tan Sri Dato Seri Dr. Hj. Mohd. Ismail Merican12Palliative Care Services Operational Policy
DEPUTY DIRECTOR GENERAL OF HEALTH (MEDICAL)It is said that the duties of a doctor is ‘to cure sometimes, to relieve oftenand to comfort always’. Hence, it is the responsibility of every healthcareprofessional to provide palliative care whenever necessary. Internationalbodies including the World Health Organisation have emphasized thatpalliative care is an essential part of healthcare particularly for those withlife limiting illness and it has even been argued that palliative care should berecognized as a human right. The relief of suffering in the dying particularlythe relief of pain should always be recognized as a humanitarian need.In Malaysia, dedicated palliative care units have been developing in theMinistry of Health hospitals since the mid-1990s and in 2005, the field ofPalliative Medicine was recognized as a medical sub-specialty by the Ministryof Health. These developments have been necessary in order to improve theeffectiveness, efficiency and equity of palliative care services throughout thecountry. At present the number of palliative care services and consultantpalliative medicine physicians are still not adequate, but efforts are beingmade to address this.Although palliative medicine is a relatively new field within the Ministry ofHealth, it is hoped that this operational policy will serve as a guide for thosewho are pioneering and working towards developing palliative care services.This policy will also serve to enlighten other clinicians and healthcare managerson the roles and functions of a palliative care service including the scope ofservice, types of service components, essential drugs and equipment requiredas well as staffing and the organizational structure of the services.I would like to congratulate the Medical Development Division for initiatingand coordinating the development of this policy. I would also like to commendthe drafting committee led by Dr. Richard Lim for their commitment indeveloping this policy. I sincerely hope that in years to come, palliative carewill be a service accessible to all patients who require it, be it in a communityPalliative Care Services Operational Policy13
setting or a hospital, and that quality of life and dignity be the common goalof all healthcare providers managing patients with incurable life-threateningillnesses.Datuk Dr. Noor Hisham Abdullah14Palliative Care Services Operational Policy
NATIONAL ADVISOR FOR PALLIATIVE MEDICINE SERVICESIt is a great honour and delight to produce this operational policy forpalliative care services in the Ministry of Health. Over the past 10 years, theunderstanding of palliative care has gradually increased not only amongsthealthcare professionals but also among the lay public. At present, most statehospitals have some form of palliative care service; some with dedicated inpatient units and some without. A few services have fulltime specialists andmedical officers but many others are still lacking in organisation and dedicationto a fulltime service. This operational policy highlights the ideals and goalsthat the Ministry of Health aspires to achieve for palliative care services.Palliative care is a service provision that all healthcare services should makeavailable and this is emphasized by the local as well as international hospitalaccreditation organisations such as the MSQH and JCI (Joint CommissionInternational). Standards on pain management, end-of-life care and patientdignity are always emphasised as patient and family rights. This not onlyemphasizes the fact that Palliative Care is an important area to develop if wewant our healthcare services to be of good standard but also emphasizes thefact that palliative care is a service that must be fulfilled as a basic human needto comfort and relieve those who suffer from their illnesses. Hence we shouldnot look at development of palliative care services solely from the perspectiveof fulfilling a hospital accreditation standard, but really to improve care forpatients and their families.The scope of palliative care in developed nations is rapidly evolving toinclude not only incurable cancer patients but also many chronic lifethreatening medical conditions as well such as end-stage organ failure andneurodegenerative diseases. The scope for further development is thereforevast and the needs are endless as people who are living longer with chronicillnesses are more likely to face a protracted and lingering death. As we are allat risk of this, we should therefore ensure that good palliative care servicesexist in our country in order to meet with these challenges as healthcarePalliative Care Services Operational Policy15
advances. As the sanctity of life will always be a major principle to our goalsas healthcare providers, so to should comfort, relief of suffering and dignity atthe end-of-life be remembered as being equally important.With the development of Palliative Medicine as a subspecialty, it is hoped thatthese aspirations will become a reality in the near future as more dedicatedspecialists endeavour to pursue fellowship training in Palliative Medicine inorder to provide the clinical leadership for its further development.I would like to express my heartfelt thanks to our Director General of HealthTan Sri Dato’ Seri Dr. Mohd. Ismail Merican, Deputy Director General of Health(Medical) Datuk Dr. Noor Hisham Abdullah, Dato’ Dr. Azmi bin Shapie and theMedical Development Division for their continued guidance and unendingsupport towards the development of Palliative Care in Malaysia.Dr. Richard Lim Boon Leong16Palliative Care Services Operational Policy
Palliative Care Services Operational Policy17
18Palliative Care Services Operational Policy
Palliative Care Services Operational Policy19
1.INTRODUCTION1.1Palliative medicine is a new service which was formally introducedin the Ministry of Health (MOH) in 1995.1.2In 1997 a directive by the Ministry of Health ordered all MOH statehospitals to develop palliative care units by the year 2000.1.3In 2005, Palliative Medicine was officially recognized as a medicalsubspecialty and gazetted internal medicine physicians were eligibleto train in a three- year fellowship programme. It has however alsobeen suggested that other routes of entry for palliative medicinetraining should also be considered in the future.1.4Palliative Care is clearly defined by the World Health Organizationas an approach that improves the quality of life of patients andtheir families facing problems associated with life-threateningillness. The complete definition is stated in Appendix 1.1.5The Ministry of Health regards palliative care as an importantcomponent of care which should be made available in all Ministry ofHealth Hospitals and also at the level of community health careservices.1.6At present the strategic plan for palliative care in the Ministry ofHealth is to eventually develop specialized units in all state hospitalsin the country especially in hospitals where there are increasingspecialist services dealing with more complex and technical diseaseprocesses involving patients with life threatening conditions andsignificant disease related morbidity. Until then, resident palliativemedicine subspecialty services shall be developed in identifiedhospitals on a regional basis.20Palliative Care Services Operational Policy
1.7Although Palliative Medicine is now established as a medical subspecialty in the Ministry of Health, the availability of Palliative Careservices is not solely dependent upon the availability of trainedPalliative Medicine Specialists. Basic palliative care (ie. pain andsymptom management , counselling, good nursing care and dischargeplanning) should still be available to all patients who requireit wherever they may be and it is the responsibility of every healthcare professional dealing with patients with life threateningconditions to ensure that comprehensive care is provided notonly during the active management of a life threatening conditionbut also during discharge and the dying phase. (refer to Principles ofPalliative Care Management; Appendix 2)1.8This policy covers key areas of palliative care service provision suchas organization, human resource, asset requirements, drugrequirements, training, work processes, ethics and clinicalgovernance.1.9 It is intended to guide health care providers, hospital managers andpolicy makers on the requirements, operation and development ofpalliative care services in Ministry of Health hospitals.1.10The document outlines optimal achievable standards in accordancewith best practices and guidelines. In hospitals where thesestandards are not fully met, necessary steps need to be taken tomeet these standards.1.11 The document shall be reviewed and updated every 5 years or whenthe need arises.Palliative Care Services Operational Policy21
2. OBJECTIVES OF SERVICE2.1To provide comfort and relief of distressing physical symptomsrelated to advanced and incurable progressive life threateningconditions.2.2 To provide support to patients and family members facingpsychosocial and spiritual issues related to incurable progressive lifethreatening conditions.2.3To prevent and minimize suffering by early identification, impeccableassessment and prompt intervention of physical, psychosocial andspiritual problems related to incurable progressive life threateningconditions.2.4 To promote understanding and respect towards patients at the endof life and to prevent unnecessary and futile interventions in orderto allow a peaceful and dignified death.2.5 To promote education in the field of palliative medicine and palliativecare for both healthcare and non-healthcare professionals.22Palliative Care Services Operational Policy
3.SCOPE OF SERVICE3.1In the present era of modern palliative medicine, the scope of servicecovers both cancer and non-cancer patients with progressive lifethreatening illness including:3.1.1 Medical management of chronic cancer pain and otherdistressing physical symptoms related to advanced cancer.3.1.2Medical management of pain and other distressing physicalsymptoms related to progressive life-threatening noncancerous illnesses. Key areas where palliative medicine innon-cancerous conditions is rapidly developing includes:a) End stage cardiac disease with refractory symptoms.b) End stage renal disease where dialysis support is notfeasible or being withdrawn.c) Progressive neurodegenerative disorders (eg. MotorNeurone Disease, Multiple Sclerosis).d) Severe chronic airway limitation with deterioratingrespiratory function and poor candidate for ventilatorysupport.e) Life threatening paediatric conditions (to be managedby paediatric palliative medicine physician) including lifethreatening congenital disorders.f) HIV / AIDS not responding to anti-retroviral therapyor rapidly deteriorating due to overwhelming diseaserelated complications (infections or malignancy).Palliative Care Services Operational Policy23
g) Frailty in the elderly with multiple progressivecomorbidities (consider collaboration with geriatricianwhere available).3.1.3 Provision of psychosocial and spiritual supportive care topatients and families facing life-threatening illness.3.1.4 Provision of terminal care for patients at the end of life.3.1.5 Provision of respite care for patients and families.3.1.6 Provision of a holistic management plan to optimize quality oflife throughout the course of patients’ illness and to apply amultidisciplinary approach to care.3.1.7 Provision of consultative advice and assistance to othermedical colleagues regarding palliative management ofpatients with life threatening situations under their care.3.2 The service should collaborate with oncology services when requiredfor the treatment of cancer pain and other distressing physicalsymptoms.3.3 The service should collaborate with chronic pain specialists formanagement of difficult pain.3.4 The service should coordinate and provide community palliative caresupport where possible.3.5 The service should play a role in the teaching and promotion ofpalliative care.24Palliative Care Services Operational Policy
4. COMPONENTS OF SERVICE4.1 In-patient palliative care service.4.2 Out-patient palliative care service.4.3 Consultative palliative care service in general wards.4.4 Consultative palliative care service in other hospitals withoutpalliative care units.4.5 Community palliative care service.4.6 Day palliative care service.Palliative Care Services Operational Policy25
5.ORGANISATION5.1 The Palliative Care Unit should ideally be headed by a trainedPalliative Medicine Physician credentialed by the Ministry of Health.5.2 When the unit is headed by a palliative medicine physician, theunit may administratively be under the Department of Medicine (oras an independent unit under the Medical Directorate).5.3The palliative care service can also be developed underany specialised unit/department provided there is a trained,dedicated and committed full time specialist/clinician incharge. The palliative care unit shall then come under thedepartment concerned and the clinician in charge shall beresponsible for the day to day running of the unit i.e. conduct wardrounds and review cases.5.4As the palliative care service is evolving in Malaysia, it may bedeveloped in any hospital/department which has the commitmenttowards palliative care and has a trained specialist/clinicianwho is willing to take charge for the provision of such a service. Incertain circumstances, it may be acceptable to delegate theresponsibility of the specialist-in-charge of the palliative care unit toa senior medical officer with special interest and training in palliativemedicine.5.5 In non-specialist hospitals, the palliative care service will be underthe responsibility of the hospital director.5.6 The head of the palliative care unit or palliative care service shouldbe responsible for the following:5.6.1 Clinical management of patients and supervision of medicalofficers.265.6.2 Procurement of equipment and consumables.Palliative Care Services Operational Policy
5.6.3 Development of clinical care pathways and protocols tocater to local needs. However policies/guidelines should bedeveloped at the national level and disseminated throughoutthe Ministry of Health hospitals.5.6.4 Continuing medical education programme.5.7 All state hosp
Palliative Care Services Operational Policy 15 NATIONAL ADVISOR FOR PALLIATIVE MEDICINE SERVICES It is a great honour and delight to produce this operational policy for palliative care services in the Ministry of Health. Over the past 10 years, the understanding of palliative
DEPARTMENT DIVISION NAME Family Medicine Palliative Medicine Algu,Kavita Palliative Medicine Arvanitis,Jennifer Palliative Medicine Berman,Hershl (Hal) Palliative Medicine Buchman,Stephen (Sandy) Palliative Medicine Cellarius,Victor Palliative Medicine Goldman,Russell Palliative Medicine Hashemi,Narges Palliative Medicine Howe,Marnie
palliative care plan 2012-2016 Inpatient palliative care There are 300 specialist palliative care beds located in NSW public hospitals, affiliated hospitals and other facilities in the NSW health system. Care is also routinely provided in non-designated palliative care beds. In 2008-09, there were 19,800 palliative care
1 Palliative Care Quality End of Life Care Resource Book Palliative Care Needs Round Checklist (Based on the ACU and Calvary Palliative Care Needs Rounds Checklist) Palliative Care Needs Round Checklist Triggers to discuss resident at needs rounds One or more of: 1. You would not be surprised if the resident died in the next six months 2.
L N E C Pediatric Palliative Care Issues of Justice in Palliative Care Provision of quality palliative care Inequity in care delivery 56% of child deaths in hospital (US) Obstacles to access Lack of knowledge regarding pediatric palliative care Responsibility to provid
Mar 11, 2015 · FOR QUALITY PALLIATIVE CARE To build a national consensus around the definition, philosophy and principles of palliative care To promote consistent and high quality care Clinical practice guidelines for quality palliative care released 2004, revised 2009 Established the eight domains of palliative care
polices, pain policies, integrated palliative care services or hospices. Palliative care, public health and human rights . Three disciplines (palliative care, public health, and human rights) are now interacting with a growing resonance. The maturing of palliative care as a clinical specialty a
Review of Adult Palliative Care Services in New Zealand 5 2 Key aspects of current palliative care services Settings of services In New Zealand, primary and specialist palliative care services are delivered in hospitals, aged residential care, private homes and hospic
Abrasive Jet Machining INTRODUCTION Abrasive water jet machine tools are suddenly being a hit in the market since they are quick to program and could make money on short runs. They are quick to set up, and offer quick turn-around on the machine. They complement existing tools used for either primary or secondary operations and could make parts quickly out of virtually out of any material. One .
