Assessing Palliative Care Services for Cancer Patients in Tobago

Taurean Cowan
Tiffany Patterson
Mandisa Jack
Vernisha Joseph
Kimberlee Henry- Dookna
College of Science Technology and Applied Arts of Trinidad and Tobago
Lecturer: Ynolde Sitahall

INTRODUCTION
Cancers figure among the leading causes of morbidity and mortality worldwide, with
approximately 14 million new cases and 8.2 million cancer related deaths in 2012 . (WHO
2015)
Cancer rates have been steadily rising worldwide with the number of new cases expected to
rise by about 70% over the next 2 decades. This places a significant burden on the health
systems of countries of the world. This burden is felt more so in developing countries. With
the increased cancer rates and the commensurate cancer related deaths the need for care til
death is more evident. As such palliative care is a growing specialty area .
Palliative care reinforces the idea of patient centered care even more so because its focus is
on the patient- the person as well as his or her family. This according to Jonston 1999 is
because All life-threatening illnesses be they cancer, neurological, cardiac or respiratory
disease have implications for physical, social, psychological and spiritual health, for both
the individual and their family. They must be made to feel comfortable and well cared for
until death.
Nurses are usually the front runners of this type of care and as such the role of palliative
nursing is therefore to assess needs in each of these areas and to plan, implement and evaluate
appropriate interventions. It aims to improve the quality of life and to enable a dignified death.
Johnston 1999

Background

This study comes as a result of conversations about and observations of the care given to persons
with terminal illnesses specifically cancer. It is often found that in the hospital setting that nurses
are task oriented rather than patient oriented. The reality is with staff shortages and multiple
patients to provide care for the nurses are often left with no other choice than to ensure that only
basic needs are met. For patients facing the reality that they are dying or may die soon ensuring
basic needs may not be enough. This is where palliative care comes in.
Noteworthy is that visibility of this kind of care or service appears limited. Comments made
during initial informal conversations were that you go hospital to dead or stay home an dead.
This prompts several questions

What happens during that period before death? Do these persons just wait to die?

Are there palliative care services available

How effective is the care given if they exist.

Are there other available options such as care facilities?

Who makes the choice of where a person dies? How do they choose?

If there are services what policies govern the provision of care?

These questions admittedly are asked based in part on the assumption that some form of
palliative care exists for cancer patients. This is assumed especially because Trinidad and Tobago
is among the countries in Latin American and Caribbean region noted to have the highest
mortality rates of cancer. Additionally palliative care is expected to be adopted when prevention

and treatment strategies are unsuccessful as it represents the only mode of action that can be
taken as per the WHO cancer strategy.
There are many unknowns about palliative care in Tobago. The limited visibility of palliative
care services begs the question of what is available. Additionally the extent of need is not known
specifically for Tobago. Generally for the region research is lacking in several aspects of
palliative care. The development of palliative care services and facilities appears to be slow
regionally and specifically for Tobago. Trinidad has to date 3 palliative care facilities but Tobago
is not known to have any. While the Government of Trinidad and Tobago has a National
Oncology Programme there is no clearly stated policy on palliative (at least not known to
researchers). There exist certain nongovernmental organisations whose purpose is geared
towards palliative care such as the Palliative Care Society of Trinidad and Tobago but the extent
of its involvement in Tobago is not known. This study will seek to discover the unknowns and
look at effectiveness of care which is assumed to exist.

Objectives
To assess the palliative care services for cancer patients in Tobago
This is broken down into a series of questions:

What is palliative care?

To what extent is palliative care needed?

What services, policies and systems are in place?

How effective are these?

What factors contribute to or pose challenges?

How does the service measure against what is best practice?

Literature Review
The selected literature was obtained using a the databases EBSCOHOST and Gale along with
the use of Google scholar. Key words used were PALIATIVE CARE, HOSPICE CARE
LATIN AMERICA AND CARIBBEAN, CARIBBEAN, BEST PRACTICE, MODELS
OF Palliative care, Theories of palliative care.
In 2011 Dr. Karen Cox-Seignoret in her paper entitled Palliative Care which was published in the
Caribbean Medical journal she noted that palliative care was under recognised in Trinidad and
Tobago but there was much taking place quietly behind the scenes. She noted that Community
based palliative care teams were formed in some regions and pilot projects commenced.
Sadly, many of these initiatives were not sustained. The good news, though, is that all was not
lost. The seed was sown. A few of these projects have continued and there have since been
heartening developments in other areas. She further stated So local palliative care infrastructure,
although thankfully burgeoning is patchy at best. Individual regions are doing their own thing,
with the two hospices providing in-patient support, but community outreach teams are sadly
lacking. Unfortunately not much has changed since then with evidence of this is found in the
study by Lynch et al 2013

Mapping Levels of Palliative Care Development: A Global Update

Trinidad and Tobago was classified as a country with isolated palliative care provision
According to Lynch et al 2013 this classification means that the development of palliative care
activism is patchy in scope and not well supported: source of funding is heavily donor dependent
; limited availability of morphine and a small number of hospice-palliative care services that are
often home based in nature and limited in relation to the size of the population.

Palliative Care Research in Latin America and the Caribbean: From the Beginning to the
Declaration of Venice and Beyond
The study was a response to a request made in the Declaration of Venice by the International
Association for Hospice and Palliative Care (IAHPC) and the European Association for
Palliative Care (EAPC) to contribute to the development of a global research strategy in
developing countries.
Its purpose was to explore the palliative care research activity in Latin America and the
Caribbean and its visibility in the international palliative care literature, with a special focus on
research studies. The research into palliative care has been scarce more so for Trinidad and
Tobago. Trinidad and Tobago had no known studies of palliative care found in any official
databases but as the researchers pointed out There are a unknown number of research studies that
are presented during academic activities and/or published in local newspapers or gray literature,
that are not indexed in the principal databases that could not be included in this study. This
makes them unavailable not just for this study, but for others researchers as well. According to
Patrana et al( 2012) Palliative care research is critical to develop and implement practices as well

as to monitor the quality, efficacy, and efficiency of the delivery of palliative care and to identify
the needs of specific populations.
These study illustrates that there is a need for research to be done into this area especially with
our rising cancer mortality rates. Not enough is known about what systems policies or services
exist. Although statistics of cancer mortality may demonstrate need there is no real
measurement of need especially for Tobago since research appears lacking into the area much
more needs to be known to have a greater idea of what must be done to assist those persons
with cancer or who may become newly diagnosed.
Additionally noted in the studies encountered thus far is a need for education and governmental
commitment. According to Webster et al (2007) three specific barriers to palliative care
implementation that are generally accepted as the major impediments: lack of government
commitment, opioid availability and limited education. The data on developing countries
suggests that even in those countries where palliative care services exist, the coverage of many of
the programs is limited and palliative care is not on the health agenda of their governments as a
public health problem. This limits the ability of palliative care services to impact on the
populations that most need them.

Kolcaba Comfort theory

This theory is focused on comfort as a means of assessment of improved health. It encompasses
the basic needs of ease, relief and transcendence in the context of physical, sociocultural,
psycho- spiritual, and environmental for holistic care to be carried out.

Orem Theory of Self care

Orem focused on the theory of self-care, self-care deficit and theory of nursing systems. Theory
of self- care states the performance or practice of activities that individuals initiate and perform
on their own behalf to maintain life, health and well-being but is determined by conditions. This
hold three self-care requisites (universal, development and health deviation).
Roper-Logan-Tierney Model of Living.
This models focus is on 12 factors of activity of daily living to show the level of independence
which have been grouped into 5 categories. These categories include biological, psychological,
socio-cultural, environmental, and politico-economic. This living model incorporates the
activities of daily living to show that if these requirements are met, health or health response
would be improved or in this case stabilise. In palliative care these activities of daily living play
a pivotal role in caring for these patients.
An overview of hospice and palliative care nursing models and theories
The authors of this paper Dobrina et al (2014) looked at the hospice and palliative care literature
research geared toward the development of a theoretical framework for palliative care which
were published during the period of 2002 to 2012. Three hospice and palliative care nursing
model and theories were analyzed in the article. These are Shared theory, Unitary caring model
and Transition model. This paper highlighted the core concepts of hospice and palliative care
nursing which may be grouped into three main categories: the patient, the nurse, and the nurse
patient relationship. This paper is of particular importance because the development of theories
and models and the examination of these, may improve the competences and practice of
palliative care nurses thus improving the quality of care for patients.
Humanistic Nursing Theory: application to hospice and palliative care

This theory developed by Wu et al (2012) emphasizes the lived experience of nurses as a source
of knowledge (Oconnor 1993, Kleiman 2001, McCamant 2006) while acknowledging that the
viewpoint of nurses and patients are equally important. Nursing in this theory is According to
Paterson and Zderad (1976), a purposeful call and response, in which the nurse response to call
by caring for a person who has health- related unmet needs Nurses play a very key role in
hospice and palliative care, as they advocate for patients and families and provide direct care on
an continuous basis ( Krisman Scott & McCorkle 2002). The nurse patient relationship is
characterized by interactions designed to promote wellbeing and growth.
The Humanistic nursing theory is relevant because incorporates a number of concepts and
perspectives which are applicable to palliative care. For example seeing the patient as an
individual and thus providing individualised care.

Methodology
The study utilised a mixed method approach using a combination of qualitative and quantitative
approaches. It was done in two phases The first phase employed the use of a questionnaire that
assessed public knowledge of palliative care services and also to ascertain views and attitudes
towards death and dying.
The second phase will took the form of a series of semi structured interviews with persons who
have been and are directly involved in oncology care either providing or receiving care. The
interviews took approximately 45 minutes.
Sampling

The samples for the questionnaire were selected by random sampling. Participants were provided
with a brief outline of the purpose of the study and terms used to reduce any confusion or
misunderstandings of the terminology used. The questionnaire was done anonymously with a
statement of participation as giving consent included to ensure that there was no breach of ethics.
For the semi-structured interviews the samples would be convenient sampling involving the
oncology unit and other staff members of the Tobago Regional Health Authority. Informed
consent was obtained for those participants to be interviewed, with the signing of the form
prepared see appendix Necessary letters seeking participation were sent to relevant departments
accompanied by consent forms which were signed by the participant and co signed by an
investigator.

Data Analysis
The data was analysed using qualitative research data analysis methods. The methods used were
that of narrative and discourse analysis, ethnography, with possible usage of the constant
comparative method of Strauss and Glasser.
The inclusion of ethnographic method is relevant to this study because it looks at cultural ideas
especially towards death and dying. Additionally this method helps to identify the differences
between cultures specifically those within which palliative care practice was developed and the
culture of Trinidad and Tobago. This aids in analysis of factors which may or may not contribute
to development implementation and access to and of services. The works of Dobrina et al 2014
Wu et al (2012) were used in the analysis of the data.

This data was also considered using the nursing theories of Kolcaba, Roper Orem and Roy since
these look at patients and their care from the perspectives of comfort, functioning care of self and
overall well being.
Findings
The survey

30 questionaires were prepared and 26 of those were filled and returned. Of those 8
were male 17 were female and 1 undetermined.
For the age categories
8 participants (5 males, 3 females) were in the 18-25 year group
7 participants (all female) were in the 26-32 year group
3 participants (all female) were in the 33-39 year group
8 participants (1 undetermined, 3 male, 4 female) were in the 40 and over
year group
All except 1 participant does not reside solely in Tobago .Of the remaining 11 have lived
outside of Tobago (9 female, 2 male) and 14 (1 undetermined, 6 male, 7 female) have

never lived outside Tobago

All participants demonstrated an understanding of what cancer is identifying the
following areas
Cell the refuse to die
Out of control growth of cell
A bad cell
Invasive disease
Left untreated can result in death
No cure
Abnormal cell refuses to die
A killer [ at ] stage 4
A tumour that grows off the body gets you sick leads to death once not
treated
A disease that has no boundary age or status
Incurable sickness can be called terminal kills a lot of people
Makes you weak

Destructive cells that cause degeneration of the organ or body

Malignant cell that changes to ones metabolic state
Destroys cells from growing normally
Abnormal growth in the body
Life threathening
Painful condition that affects various parts
Causes loss of a part or death
Traumatic stage of Life
Destroys cells in the body / Eats out your inside
It needs to be cured
In response to questions on thoughts of dying the participants gave answers that mostly
reflected that dying is inevitably and that it was an uncomfortable thought expressing
that it is difficult to accept does not like the idea of it or redirecting by saying they
prefer to focus on life . a small percentage express acceptance and made reference to a

religious aspect.
Just over half of the participants knew what palliative care was. 21 were unaware of

any service of this kind being offered in Tobago

Most believed that palliative care is important with 1 being undecided in this regard
however all participants view palliative care as important for a patient who is suffering

from cancer.
19 of the participants have had family members who have died as a result of cancer
When asked about preferred place to die based on the options hospital, car facility or
home. The responses and reasoning were as follows:
o 1 participant stated none of the above
o 1 participant stated it does not matter
o 3 participants chose hospital. Reasons are as follows
-

Professionals to deal with situation

Lessen burden on family

Emotional pain of family

Reminders that they died there

Difficulty for family to come to terms with

Medication to ease away smoothly

o 3 participants chose Care Facility. Reasons are as follows

-

Home is heart wrenching

Hospital tends to be too careless

Family can live home after

Better constant care

No loneliness

Access to drugs

o 18 participants chose Home. Reasons are as follows

-

Presence of loved ones

Familiarity and comfort

Familial support

Service in hospital and health facilities poor

Peaceful

Tradition

Interviews

The definition of palliative care revealed certain themes and or concepts. These are as
follows
Comfort
Symptom management
Alleviate suffering
Reassuring relatives
End stage of life
Terminal illnesses
Caring for patients and relatives.

These sentiments were expressed in the following statements.

The main focus is to keep patients and the families comfortable at end of life, manage their
symptoms and keep them comfortable at end of life. Cause all we go out there to do is comfort
care, we no longer treating for cure in palliative care, palliative care is all about keeping the
clients comfortable and their relatives reassured as to what is happening.
palliative care means symptom management basically, it making the patient comfortable at
any part of the illness continuum

basically giving care to persons who have terminal illnesses. It starts from time of diagnosis
until bereavement. Someone comes into us and is diagnosed with cancer palliative care starts
until even time of death.
Further the nurses described how they provided care which aligned with their definitions of
palliative care. The nursing process used here though different in some aspects reflected
nursings focus on patient response to disease process and in this case dying.

At present the palliative care service is guided by the International Association of

Hospice and Palliative Care and adapted information based on models used in the United
Kingdom. These serve to guide how each case is managed while the care team is in the
process of developing their own official policies in conjunction with the quality assurance

department of the Tobago Regional Health Authority.

To truly examine effectiveness ethically a grieving period of 6 months must be given and
then an official assessment can be done. (Frank 2015). However each person interviewed
believed that the care provided was effective. They identified the following as a measure
of effectiveness
Extending life
Easing pain
making patients comfortable
family acceptance

This was expressed with the adage that results were seen inspite of the barriers and
challenges that existed.

Identified as barriers were

Availability of transport or transport devices
Time
Staffing
Building and storage
Unable to be with clients at certain points
Patient perceptions
Cultural beliefs
Availability of drugs ( pain medication)

Palliative care in Tobago has unofficially been practiced since 2009 soon after the
Oncology Unit was established. This developed with the recognition that some patients
could no longer access treatment because of immobility and these patients needed more
than basic treatment. The speciality of palliative care is a relatively new area of
development especially in Trinidad and Tobago. Previously there was only one Nurse,
Nurse Karen Frank, in Trinidad and Tobago trained in Palliative care. There are now 5
persons in Trinidad and Tobago. Nurse Frank is the only Nurse with this speciality in

Tobago.
The model of palliative care used is that of community palliative care. It is still in the
developmental stages as its policies and procedures are still being formulated.

The number of patients receiving treatment at the oncology unit has more than doubled
since 2010. A number of these new cases are often diagnosed at the later stages in the
development of cancer. This translates into limited treatment options and reduced
likelihood of a curative effect. There has been an average yearly increase of
approximately 52 persons receiving care at the oncology Unit. At present of the 505
persons recorded for 2015 , 17 are receiving palliative care.

Discussion
Palliative care officially started on September 23, 2014. In fact some may go so far as to argue
that what was practiced was not palliative care before the official date. According to one
participant
Prior to that [September 23, 2014] there was no palliative care in Trinidad and Tobago , what
would happen is , myself and another doctor used to go out and see patients at home but it was
never called palliative care , because palliative care is a new speciality and it, the society ,
palliative care society was launched in 2011 on the 4th of April. Prior to that we couldnt hear
the word palliative care, we didnt know what it meant.
The model of palliative care used in Tobago is that of community palliative care. This model
according to the International Association of Hospice and Palliative Care (2015), seeks to
provide care for terminally ill patients in their own homes or the home of relatives, or care homes
for the frail or aged. These patients are not in a hospital or in-patient palliative care unit.

This mode of care fits into the current health care frame work, as recommended by the World
Health Organisation, which focuses on primary care and has a number of community based
services provided. This selected mode continues with the work already started by the unit, in
communities in 2009 and aligns itself with the beliefs of members of the community.
69%of the participants in response to the question of preferred place to die chose home stating
comfort and familiarity, being with family and tradition as reasons for this choice. Tradition
specifically indicates the way in which culture shapes and influence beliefs and choices. The
majority of these persons acknowledged the inevitability and many found the thought
uncomfortable. The linkage between choice and un-comfortableness can be explained in the
theory that persons who are usually from collectivistic cultures tend to focus on connections
and thus seek out others in times of distress. This explanation is a part of the Terror Management
Theory. According to this theory
the anxiety caused by mortality [ or in this case facing questions of mortality] is a major
motivator behind many human behaviors and cognitions, including self-esteem, ethno/religiocentrism, and even love. The terror refered to in terror management theory is that which is
brought on by the awareness of the inevitable death of the self.
The service provided by the team appears to incorporate a number of nursing theories namely
that of Kolcaba, Orem and Roper.
Kolcaba Comfort Theory
The palliative care team at oncology can be seen as using this model to aid in the provision of
care. The palliative team aids in treating the symptoms of the disorder, this can be placed under
basic needs of ease and relief in the context of the physical. The team encourages and

incorporates relatives and/ or caretakers in the care plan for a patient. This care plan also focuses
on the cultural traditions, beliefs and environmental factors that will improve the comfort levels
of the patient. As cultural beliefs play a vital role within the island the palliative care team seeks
to make the patient as comfortable as possible within the context of each individuals life. This
often results in providing the tools needed for care to the home because of the prefernce to die at
home with their family, which also creates a sense of comfort for them.
Orem Self-Care Theory
The major provision of care is provided by the family or care taker. This is due to palliative care
being provided at home and not in a facility. The universal requisites (activities of daily living)
are all done by the care taker and/or family in conjunction with the care team.
Self- care deficit theory is considered here because there is a need for the nurse to aid in
enhancing self-care abilities for survival, wellbeing and better quality of life. This aid takes the
form of acting and doing for another, guiding and directing (procedures and provision of care for
patient and relative), teaching, providing physical and physiological support and by making
regular home visits with counselling to patients and relatives and/ or care takers.
In the past the wholly compensatory role was filled solely by relative and/or care taker. Now
their role is partially and supportive in nature with the development and support of palliative
care team.
Roper-Logan-Tierney Model of Living.
One of palliative cares major role is to provide comfort while recognising that the individual is
in the dying phase of life. Each category aids in boosting not only the patient but also the

relatives to provide the care. This model also reflects incorporates culture which is of importance
since dying at home is described as tradition for a number of persons. Roper believed that every
patient acitivities of daily living should be assessed using the 5 categories because the patient
remains the same its the nurse that provides the care changes. However within the palliative
team once a nurse start a case with a patient that nurse continues with that patient until the very
end to promote a good healthy therapeutic relationship to facilitate openness and maintain a
stable relationship.
Through the narrative of their own personal experiences members of the palliative care team
revealed that providing this type of care can have an emotional effect on the nurse. This is one of
the primary factors that deter other nurses from pursuing this speciality.
nurses, think that they cant deal with dying patients so we have nobody interested in going
to do palliative care so that is one for the biggest barrier the lack of trained nurses
This may in the future lead to shortages where staffing is concerned because the demand for
palliative care is likely to increase as cancer and other terminal illness rates rise. Note worthy is
that often patients who are referred for palliative care perceive this as abandonment. One of the
participants stated that patients think
that from the time you are placed onto palliative care, well we give up on you, we putting you
to die but that is not it. You are being placed on palliative care because there is no longer
curative treatment for you.
This is where the nurse-patient relationship as outlined in the work of Dobrina et al (2014) comes
in. Outling the situation including the nurses role for the patient helps them to accept its realities

and recognise that the nurse has their best interest at heart and infact take on more of a
supportive role as quoted by Dobrina et al (2014) the
Therapeutic relationshiphospice and palliative care nurses are in a unique position to create
powerful, healing relationships with patients and families (Murray, 2007; Reed, 2010; Desbiens
et al, 2012). Moreover, by means of compassionate caring, nurses can assist patients and
families to achieve optimal comfort and function, while through education and support they can
help to empower the patient and bring about their autonomy.
What was also mentioned is the fact that although the current approach is adequate at the
moment it lacks all the members of the multidisciplinary team that is deemed necessary based
on the models of care used internationally which was recommended by the World Health
Organisation. These missing members are a nutritionist, psychologist and Chaplin.
Additionally the nurses have outlined the limitations that they have in providing care. The major
limitation is that of time. The oncology unit and palliative care team as part of the unit are only
officially allowed to operate between the hours of 8 am and 4pm on weekdays and 8 am to 12 pm
on Saturdays. As such working outside of these times leaves the members of the palliative care
team unprotected by the Tobago Regional Health Authority. Patients receiving palliative care
often require support and the presence of their nurses especially as they go through the dying
phase of life. This is supported by Rushton et al 2009 who states that nurses presence constitutes
a powerful intervention in the quality of end of life care.
Drug availability was another area that was a concern for the nurses. Although morphine is
readily available the current cross section of pain medications available is limited. Morphine
remains the only and strongest pain relief medication available. This to date has not been
problematic but as stated by one of the interviewees

 we dont have other narcotics , that u can say if the patient is reacting [negatively] to
morphine that we can use, if u reacting to morphine thats it we have nothing else for you.

The Oncology unit only came about due to the lobbying of patients. Before its establishment
Oncology existed as a satellite clinic. There was a delayed response to growing need. It appears
that this pattern has repeated itself where palliative care is concerned. The primary factor that
contributed to this slow response is the fact that statistics for cancer and the need for such
services were either not effectively done or reported. Additionally research into areas such as
these or any subject regarding health appears to be lacking. In fact there is no official published
study done into palliative care and only a handful exists where cancer is concerned. One of the
reasons identified is the fact that the Tobago Regional Health Authority does not have an ethics
committee which can approve proposals for research and grant permissions into its various
facilities. To be able to illicit a favourable response such as the implementation of recommended
services evidence must be given. The interaction of these stated factors and other possible ones
cause a significant delay.
Although the studys primary focus was on Palliative care in interviews a number of interviews
primary healthcare and the perception that its screening and prevention strategies appear to be
failing was discussed.
This failure is evidenced by the continually growing rates of cancer as well as other illnesses
and also that cancers are often discovered in the third or fourth stage of development. The
common thread is the need for a change in current strategies. The usual model which bares
resemblance to Bowles jug and mug principle of education. This principle states that teachers

are the jugs filled with knowledge and they pour knowledge into the empty mugs of their
students. Replace teachers with nurses and students with patients and one can see what appears
to be the way in which primary prevention is done to some extent rather than empowering and
guiding clients. Further it appears that the health system has not addressed effectively culture and
its effects on health. Culture here includes gender culture that exists. For example many
acknowledge the perception that healthcare services seem geared towards womens health yet
this appears to not have been addressed. It must be acknowledged as well that each individual
bears responsibility for his or her own health.
The information gathered on what exists in Tobago further corroborates previous findings of
studies done on Palliative care availability and practice. These are that palliative care is still in
development and is done on a more community based level. Additionally it shows that the
barriers mentioned in the study by Webster et al (2007), of lack of government commitment,
opioid availability and limited education were also present. However in terms of opioid
availability it is the limited cross section of available drugs not lack of overall availability that is
a potential barrier to care
Limitations
The sample used for the questionnaire was small and this was due to the limited time available
for thorough analysis of these. The participants were predominantly female and this may also
affect the data gathered.
The study was designed to include patients who have received this type of care or are receiving
care to assess effectiveness of the service provided. However permissions were not obtained for
these interviews and the required permissions would take some time for approval. Time also

factored into the use of the members of the health care team both past and present. By limiting
the interviews to the healthcare team the response to the question of effectiveness may skew the
data and can be seen as laden with bias.

Conclusion
Despite the limitations such a small sample size, limited time and the inability to gather views
from the perspective of those receiving care, the research was able to uncover several pieces of
unknown and vital information about palliative care in the context of Tobago.
The main focus of the palliative team was shown to be the provision of community based care, in
which the treatment of symptoms of the illnesses and provision of comfort. The team faces
limitations such as an incomplete multidisciplinary team and limited drug cross section.
The team providing palliative care services for cancer patients in Tobago, was shown to function
in spite of major barriers and with no written polices thus far.
As to the question of effectiveness, from the nurses stand point, the care provided is efficient. It
was also noted that as time changes and the need for palliative care increases the team would
need more trained personnel to meet demands.
The team needs to have its policies and procedures clearly outlined to facilitate optimum care
under the recommended guidelines. Additionally avenues necessary for nurses to further their
education in palliative care must be provided and encouragement of training in this area must be
done.

Recommendations
The following recommendations provided are based on the responses that were obtained from
the participants during the semi-structured interviews.

The palliative care team should have written policies done for optimum care under proper

guide lines.
More speciality trained nurses for palliative care are needed along with making the

necessary avenues to further their studies within the realm of palliative care.
The team need to have the all recommended team members to provide care such as the

psychologist and nutritionist.

The palliative care team needs to have their own unit that is connected to the oncology

unit and not functioning out of oncology.

The lack of drug availability in terms of cross section of drugs must be addressed.

Feasibility of other drugs for the reduction of pain must be done.

The hours that the unit operates under needs to be extended to facilitate 24hr care to the

patients
Transportations is needed for the unit to ensure 24hr care to the patients.
The palliative care unit needs to be broaden to facilitate all end of life care and not just
oncology

Glossary

Care - The provision of what is necessary for the health, welfare, maintenance and protection of
someone by meaning there needs.
Cancer - A generic term for a large group of diseases that can affect any part of the body. It is
also the rapid creation of abnormal cells that grow be-yond their usual boundaries, and which can
then invade ad-joining parts of the body and spread to other organs. This process is referred to as
metastasis. Metastases are the major cause of death from cancer. (WHO)
Client/ Patient. - These terms will be used interchangeably but refers to the individual accessing
or receiving any form of care or service from a medically trained professional. It also refers to
the person receiving care and his or her relatives
Comfort - A state of physical ease and freedom from pain or constraint or the easing or
alleviation of a person's feelings of grief or distress.
Effective- producing a decided, decisive, or desired effect
Palliative - Relieving pain without dealing with the cause of the condition.
Palliative care - According to the World Health Organization (WHO) Palliative care is an
approach that improves the quality of life of patients and their families facing the problem
associated with life-threatening illness, through the prevention and relief of suffering by means

of early identification and impeccable assessment and treatment of pain and other problems,
physical, psychosocial and spiritual. Palliative care:

provides relief from pain and other distressing symptoms;

affirms life and regards dying as a normal process;

intends neither to hasten or postpone death;

integrates the psychological and spiritual aspects of patient care;

offers a support system to help patients live as actively as possible until death;

offers a support system to help the family cope during the patients illness and in their
own bereavement;

uses a team approach to address the needs of patients and their families, including
bereavement counselling, if indicated;

will enhance quality of life, and may also positively influence the course of illness;

is applicable early in the course of illness, in conjunction with other therapies that are
intended to prolong life, such as chemotherapy or radiation therapy, and includes those
investigations needed to better understand and manage distressing clinical complications.

Terminal Illness - A disease that cannot be cured or adequately treated and that is reasonably
expected to result in the death of the patient within a short period of time. This term is more
commonly used for progressive diseases such as cancer or advanced heart disease.

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