The teaching hospital for the Northern Province is in Jaffna district, with a district general hospital in each of the other districts. Vavuniya District General Hospital is the second largest hospital in the province, has 20 consultants including pathologist, radiologist, anaesthetist and Oral Maxilla Facial surgeon who serves the whole of the Northern Province. Daily, 800 people attend the hospital outpatient department and in my OMF clinic, 1000 patients attend per month.
My interest in palliative care arose as most of my oral/pharyngeal and other head and neck cancer patients presenting with Stage 3 or 4 disease. Meeting Dr Suharsha Kanathigoda was a turning point in my life and led me to explore the world of palliative care.
Currently, there is not one palliative care specialist in Sri Lanka, many doctors and nurses have misconceptions about opioids, opioid availability is minimal and policies result in restriction of availability of opioids for medical use.
Palliative care initiatives in the Northern Province
The following initiatives have occurred in the Northern Province to date:
- establishing the MDT discussion focussed on palliative care
- establishment of palliative care clinic (Head and Neck (H&N) oncology)
- forming the palliative care data collecting centre and referring centre
- developing H&N oncological hospice, Cheddiculum Base Hospital, Vavuniya, Sri Lanka
- learning and study in the field of palliative care
- teaching doctors, medical students, nurses, nursing officers and allied health workers, through workshops
- starting to do small studies such as audits and research
- founding the regional association of palliative care for the Northern Province
- collaborative work with other institutions, professional bodies and agencies who are in the field of palliative care locally and internationally
- starting to sensitise peoples’ hearts, through an awareness program for non-medical people (corporate sector)
- starting home based palliative care services in Northern Province
- establishing and strengthening the hospital based palliative care services
- promoting palliative care by directing and filming an educational video on palliative care
- launching the web profile for education, awareness and teaching in palliative care.
The role of the Multi-disciplinary Team at the General Hospital in Vavuniya
Both non-oncological and oncological cases are discussed. The team consists of OMF surgeon, oncologist, radiologist, pathologist, pediatrician, psychiatrist, anesthetist, ENT surgeon, physician and general surgeon, as well as other members of the palliative care team. Each case is discussed in detail with the patient and family. Social issues are explored by the palliative care nurses. The patient is assigned home-based, hospital-based or end-of-life care. Home-based palliative care cases are referred to palliative care collecting centre, OMF unit, General Hospital, Vavuniya.
Establishing the Hospital-Based palliative care service at General Hospital, Vavuniya, included implementing a pain assessment and management chart with a ward policy that this is started on every patient admitted.
Education and training
This has been an important focus since our palliative care work commenced. We conducted our first palliative care workshop attended by over 600 participants from backgrounds including medicine, dentistry, allied health, councillors, students, volunteers and community workers. There were many local, national and international participants.
Cancer hospice in base hospital Cheddiculum ,Vavuniya
This will be the first head and neck cancer palliative house in Sri Lanka. The provincial government is directly involved in establishing this centre. The plan is to have a palliative care unit and hospice in Cheddikulum Base Hospital, Vavuniya with the support of the Northern Province Health Ministry, RDHS Vavuniya, PDHS, Shanthi Foundation Sri Lanka Cancer Care Association, Sri Lanka Association of Palliative Care and other charities. The service will be free of charge to patients. It will provide long term care if needed. It will also be an education resource in palliative care practice for the region.
Early research and audit reveals a lack of awareness about the use of opioids, a need for education about the management of patients with oral and pharyngeal cancers and a study of the mode of dying of patients with Head & Neck cancers.
The Vavuniya region has the first ever palliative care nurses in the region, some of whom are working in a voluntary capacity. Home visits by doctors and nurses in the team reveal the high level of poverty and suffering in this community.
One person from this community, Mr M. is a 60 year old Muslim man with oral cancer. I operated on him about one year ago, followed by radiotherapy and chemotherapy treatment. Now he cannot open the mouth at all and able to swallow only liquids, with associated weight loss.
Poverty and pain
Another patient was an elderly woman who lived with her daughter in very poor conditions. The roof of their hut leaked, the toilet was 50m away, there were two plastic chairs, water from the well was unhygienic and had high salt content. Her daughter’s fiancé was asking for a high dowry. She worried about her daughter’s future and not being there to help her.
Forming professional body and the association
To help address the need for palliative care demonstrated by the two cases above, I started the Regional Association of Palliative Care for the Northern Province. It was launched on 13 March 2015. Dr Kanathigoda, Director of the Shanti Foundation, and WHO are international patrons. The National Cancer Control Program and Cancer Care Association, Sri Lanka, are national patrons.
Our association has an MOU with the Shanthi foundation of Australia, the Mental Health Society, Vavuniya and rehabilitation centre in Base Hospital, Cheddiculum. It has close working relationships with the Palliative Care Association of Sri Lanka, as well as its national patrons.
Sensitisation of the public
We made a educational video on palliative care which was released on 18 March, 2015 in Vavuniya. 600 free DVD copies were given to the public. It can be viewed on Youtube or on the official website of the Regional Association of Palliative Care, Northern Province.
We hope to develop our knowledge through visits from and links to international experts, and by conducting collaborative studies with international associations, professional bodies and institutions and palliative care specialists.
Our dream is that Vavuniya hospice and palliative unit will become an international and local centre for palliative care. We aim to expand home based palliative care services to other parts of the country. We will continue to raise public awareness about palliative care and work with charities and NGOs to assist the welfare of our patients and families.
Dr Ranjan Mallawaarachchi is Founder and Coordinating secretary, Regional Association of Palliative Care, Northern Province, and Consultant OMF surgeon, District General Hospital, Vavuniya and Teaching Hospital, Jaffna, Sri Lanka.
This article originally appeared on the website of the Australasian Palliative Link International (APLI). It is reprinted with permission.