Palliative Care in Nepal

Nepalese Association of Palliative Care (NAPCare)

NAPCare was officially registered as an association in December, 2009. INCTR PAX in collaboration with other health workers involved in palliative care initiatives in Nepal promoted the formation of NAPCare and has continued to play a vital role in its establishment and continued development and activities. The objectives of NAPCare are to provide support, education and networking opportunities to its members. NAPCare aims to support patients and family members, and to inform and educate the community about palliative care and will help to develop a national palliative care policy. Several training programs have been undertaken by NAPCare members. In February 2010, a six week palliative care training program was offered to nurses. The association is also planning to develop national gUidelines regarding practical problems that include cancer pain.

INCTR PAX Faculty Visits

Several visits to Nepal are made by the PAX team each year. In early April 2010, Dr Fraser Black, Dr Gayatri Palat, and Mr Doug Ennals visited several of the palliative care sites in Nepal, including BPKMCH in Bharatpur, where, in addition to presentations and ward rounds, they discussed the expansion of the palliative care team, and its facilities, the addition of a psychosocial element, training (some of which will take place in Hyderabad, India) and collaboration with NAPcare and NNCTR. The twinning program with Victoria Hospice was also discussed. In a meeting with Dr. Bishnu Paudel, a recent graduate of the Pain and Policy Study Group Fellowship program in Madison, a review of current opioid use and availability in Nepal was undertaken. Plans to expand the program at Bhaktapur Cancer Center, including training, facilities and the establishment of a referral process were also discussed. A visit to Kanti Children's Hospital was made to review opioid availability and usage, to discuss opportunities for trainees at Kanti in order to establish a palliative care team at Kanti.

Nanaimo Bhaktapur Hospice Palliative Care Twinning Project

A palliative care team from Nanaimo, Canada, led by Dr. Robin Love who serves as a consultant to INCTR's PAX program, made their 4th site visit to Bhaktapur Cancer Center (BCC), Nepal from mid October to mid November in 2010. This visit was made as part of the Partners in Compassion Project - also known as the Nanaimo Bhaktapur Hospice Palliative Care Twinning Project. The primary focus of the trip was to assist in teaching a palliative care course hosted by BCe's Palliative Care Program.

The major purpose of the visit was to conduct a two week course in palliative care. It was attended by 47 participants, including seven physicians and many nurses from the Kathmandu region. The comprehensive course including a variety of topics: challenges in palliative care, ethics, pain and symptom management, Nepali and Canadian nurses. Photo Credits: Richard Tran Venetia Mah palliation in cancer and non¬malignant diseases, psychosocial aspects of care, development of a palliative care service including home care, care of the caregiver, and the roles of surgery, chemotherapy and radiotherapy in palliative care. Practical workshops and bedside clinical teaching were an important part of the course.

Separate workshops related to patient handling, transferring and positioning were held - not only during the course given at BCC, but also at 4 other hospices and cancer care programs. This is both to ensure that patients are as comfortable as possible, but also for teaching the staff safe patient handling to reduce the risk of injury to nurses and family members. It was very well received, and the team made the workshop fun and entertaining as well as useful. It is a goal to develop an online module for teaching these skills.

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A comfortable patient in the palliative care unit at Bhaktapur Cancer Hospital - Photo Credits: Richard Tran Venetia Mah, Partners in Compassion

Another new initiative is a research project that consists of a qualitative study designed to explore the impact of the Partners in Compassion project. It consists of a series of structured interviews with some of the partners including Nepali physicians, nurses, patients and families, and some partners in Canada, including physicians, nurses, administrators and nursing students. The main objectives of
the project are to explore how this partnership has shaped end-of-life care in the host community, to determine whether the goals and vision of this project are being achieved, to document the experiences and outcomes of the friendship built between Nanaimo and Bhaktapur, and to identify the potential needs and barriers that still exist to the dying and their families in accessing quality and compassionate comfort care at BCC. The information obtained will be utilized as a learning tool for improvement and refinement of current and future hospice twinning projects and to develop a tool to increase awareness in the medical and general community of the concept of twinning and its utility in meeting global needs, in particular the development of palliative care internationally. It will be used to encourage and raise interest in other hospices for future implementation of hospice twinning partnerships and palliative care initiatives. The information will be presented as a documentary film.

The visiting team spent time working alongside medical and nursing colleagues in the palliative care unit at BCC in order to continue mentoring and teaching at the bedside and to continue to provide support for their work. It is envisioned that ongoing dialogue and education can continue through a shared Facebook page.

Discussions about the development of a palliative home care nursing service that will be part of the BCC program have been held and will continue. The team was encouraged by the progress made in the further development of the Palliative Care program at BCC. The Medical Director, Dr. Sudip Shrestha, remains very supportive and committed to improvement, and Dr. Chadani Vaidya has been designated as the palliative physician for the unit. Laxmi Shrestha is the Matron of the Hospital and Nursing Leader of the PCU. Her leadership and commitment remain key features of the program. The PCU staff remains very dedicated to their work and they are more comfortable with the use of morphine and other medications and techniques for symptom management. Their role in developing and hosting the two week course helped to increase their sense of identity and responsibility as a "center of excellence" for palliative care in the Kathmandu Valley.

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