Advancing Palliative Care

in the Public Sector

Dr. Richard Lim Boon Leong,

Leong,
MBBS(Mal)
MBBS(Mal) MRCP(UK)
Consultant Palliative Medicine Physician,
National Advisor on Palliative Medicine,
Ministry of Health Malaysia

Palliative Care in the

Ministry of Health :
When did we start?
 WHO Definition
“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.”

HKL in 1950s – 1970s

History of Palliative care in MOH

Oncology and RT Dept. Sarawak GH

1995

History of Palliative Care in MOH

Queen Elizabeth Hospital, Kota Kinabalu 1995

 1998 MOH Directive
z 1998 – MOH directive for all state hospitals to set up
Palliative care Units (PCUs
(PCUs)) or Palliative Care Teams
(PCTs)
PCTs) by the year 2000

z A palliative care kit was developed to guide hospitals as

to how to develop palliative care units.

z Workshop on improving availability of pain relief drugs

sponsored by WHO and MOH held in 1999.

z 12 Clinical attachment training programmes were held in

Kota Kinabalu from 1999 till 2002.

Alor Setar Kota Bharu

Tanah Merah
Baling
Kuala Krai
Pulau
Pinang Kuala
Terengganu

Bukit
Mertajam

Taiping
Kuantan

Ipoh Jerantut

Manjung
Segamat
Klang

Batu Pahat

Seremban Kota Tinggi

Johor Bharu
Melaka
 QEH Sandakan
Miri

Tawau

Sarawak Network to supply opioid Network of PC Teams in

General Hospital analgesia to interior regions 16 district hospitals

Distribution of PCUs and PCTs in Malaysia in 2002

State PCU PCT BEDS

Perlis - 1 4
Kedah 1 5 19
Penang 1 1 12
Perak 1 5 23
Selangor - 2 2

N Sembilan 1 2 18
Melaka 1 6
Johor 1 8 35
Pahang 1 8
Terengganu 1 4 14
Kelantan - 3 4
Sabah 2 17 47
Sarawak 1 2 8
Total 11 50 200
 ISSUES
z No clearly defined vision or mission statement
on palliative care by MOH

z Lack of career structure and job opportunities

z No set standards of care – no authority on

palliative care

z Lack of clinical leadership and stakeholders to

champion palliative care in the MOH.

History of Palliative Care in MOH

Dec 2002 – PCU selayang developed as first

MOH unit with specialised palliative care.
 History of Palliative Care in MOH

z Dec 2004 – Proposal to develop palliative

medicine as a medical sub-specialty.

z 2005 – Palliative Medicine was recognised

as a medical sub-specialty in MOH

NATIONAL CANCER
MANAGEMENT IN
MALAYSIA
20 - YEAR MASTER PLAN

GOAL 6: PALLIATIVE CARE

 TARGETS

2006-2010 (RMK9)
z Specialized palliative care services in 6 regional
hospitals with palliative medicine and pain specialists

z All medical schools to include palliative care education at

the undergraduate and postgraduate levels

z To integrate palliative care in nurse training programs.

z Develop cancer pain management Clinical Practice

Guideline (CPG)

z To network with other palliative care service providers

within each region
 The Big
Challenge

Improving
Effectiveness,
Efficiency and
Equity
of Palliative Care
Services In Malaysia
 How Can We
Achieve This?

Step 1:

Defining a Vision
 Defining a Vision
z The MOH has made a firm commitment to
the development of palliative medicine as
a service for the country.

Vision
z To achieve universal pain and symptom relief in all
cancer patients.

z To achieve pain and symptom relief in non-

non-cancerous
life threatening conditions.

z To create a unified effort by all healthcare providers to

ensure holistic and comprehensive palliative care
throughout the country providing a support system for
patients wherever they may be.be.

z To promote universal understanding on end-end-of-

of-life
issues maintaining the ethical principles of medicine
while upholding human dignity.
dignity.
 Step 2:

Developing
Specialised Care

Step 2 – Developing Specialised

Care

z Training of specialists in the field of

Palliative Medicine.

z Develop a post-basic palliative care nursing

course for specialised nursing needs.
 Why specialised care?
z Palliative Care is a fulltime medical field that
requires commitment, dedication and
professionalism.

z A career structure is required in order to allow

doctors and nurses who were interested to focus
on palliative care as a full time job.

z Clinical leadership and stakeholders must be

created in order to develop effectively.

Clinical Excellence
z Palliative medicine is a growing field of medicine
worldwide with a growing body of evidence
supporting the skills and knowledge of palliative
care.

z As a specialty it allows these skills and

knowledge to be recognised and acknowledged
by colleagues and peers.

z With such recognition can palliative care receive

the support and resources it requires to
advanced forward and serve the population in
need.
 Specialist Palliative Care
z 3 year fellowship programme post MRCP/MMED

z Structured training:
6 months : basic oncology / radiotherapy
1 year : in-
in-patient palliative medicine (Selayang
(Selayang))
3 months : community palliative medicine (local)
1 year :overseas training (Aust
(Aust / UK / Singapore)
3 months : elective training (geriatrics, rehab, psy)
psy)

Specialised Care

z British Assoc. for Pall Care recommendations:

1 consultant : 160,000 population

z Based on population statistics and standards of

human development in Malaysia as compared to
UK, the current suggested norm for palliative
care specialists is:
1 consultant : 1,000,000 population
 Palliative Medicine Physicians
in Public Sector
z Currently 1 trained consultant, 2 physicians
in training to complete by end of 2009 / early
2010

z 1 physician in HUKM in training to complete in

2009
z 2 physicians in UMMC in training

Step 3:

Organisation and
standardisation
 Step 3: Organisation and
standardisation
z Need to improve and standardise level of care in each
unit.

z Need to coordinate and improve the development of

palliative care in each state.

z Need to coordinate and improve community palliative

care services in each state.

z Need for good link and partnership with NGO and to

develop policies to allow partnership with NGO for
community care

Hospital-based
Palliative Care
Services
 PCU or PCT

z Palliative care unit (PCU) = 4 or more

beds.

z Palliative care team (PCT) = less than 4

beds.

Palliative Care Beds in Malaysia

z British Pall Care 2000 guidelines recommend:
36-54 beds per million population
z Palliative Care Australia 2003 guidelines recommend:
67 beds per million population

z Based on current healthcare resources and

human development standards, the current
suggested beds required is 20 beds per million
population. (532 beds)

z Currently we have 6.8 beds per million

population
 Beds but do they function?
z Majority of beds not providing specialist palliative
care.

z For units without specialist care no standard of care

or guidelines available yet.

z Concept of palliative care still not well understood

even within established units.

z Essential drugs for palliative care still not available

in established units or not easily obtained.

Characteristics of Successful
Units
z Dedicated Clinical leadership

z Supportive Hospital director and Matron

providing resources.

z Independent unit with separate 24 hour staffing

and adequate nurse pt ratio (ideally 1:4).

z Dedicated medical officers working under the

supervision of the specialist in charge.
 New definition of Palliative Care
Unit
z Must be supported by hospital administration and
given continuous support and effort to provide
appropriate resources.

z Must have a dedicated clinical leader (ie specialist or

senior medical officer) who has clear understanding of
palliative medicine and basic principles of specialised
palliative care even though may not be a specialist in
palliative medicine.

z Need not have a dedicated ward or beds but MUST

have admission rights and designation of patients to
be under the care of the palliative care unit as the
primary team.

New definition of Palliative Care

Unit
z Must have dedicated medical officers who work
under the direct supervision of the clinical leader /
specialist in charge.

z Must have dedicated nurses whose job description is

specific to provide palliative care either hospital based or
sometimes community based.

z Must have access to essential drugs for palliative care

and certain equipment such as syringe drivers etc.
 Ideal Organisation structure
HOSPITAL DIRECTOR

Department of Medicine Department of

Matron / Other Dept interested Anaesthesia

PCU ward Palliative Medicine Pain Specialists

sister Unit

Consultant Palliative Medicine

PCU Staff Physician / Other Specialist /
nurses (post clinical Leader
basic + non-
non-
post-
post-pasic)
pasic)

Medical Officers

Community
Palliative Care
Services
 ESSENTIAL Relationship
Hospital Based Palliative Care
• Consultative Service
• In patient Palliative Care Unit

Community Palliative Care

•hospice organisation
• homecare team.

Community Palliative Care

z Majority provided by NGOs and very little
by MOH

z NGOs are a vital resource that helps

provide comprehensive palliative care to
patients.

z MOH must continue to support NGOs

 Supporting NGOs through:
z Medical specialist input

z Networking to supply medications to patients

z Improve referral systems

z Education of volunteers and NGO staff

z Funding

Community Care in MOH

z 44% of population live in rural areas

z At present NGOs exist only in urban

areas.

z Need for homecare services in rural areas

not serviced by NGO groups.
Can we utilise our existing public
health network?

Where are we
going?
 Developments in progress
z On going specialist training and upgrading of
state hospital units.

z Increasing awareness in government medical

schools – HUKM and UMMC developing
palliative care units and training specialists.

z Palliative care undergraduate curriculum in most

major medical schools.

Developments in progress
z Development of Cancer Pain Management
Clinical Practice Guideline.

z Development of Post Basic Palliative Care

Nursing course (Curriculum still in planning)

z Development of Paediatric Palliative Medicine

(Hospital Melaka)

z Incorporating palliative care training in public

health sector geriatric programme.
 Are We
Progressing?

“We are taking too long to

develop”

“You mean it will take 3 years

to train ONE specialist?!”

“We cannot be waiting for the

government while people are
suffering”
START LOW
GO SLOW
BUT DO SO