The urgent need to train doctors, nurses in palliative care: the Kerala story

Cancer and other patients who are under active treatment in tertiary hospitals in Kerala, continue to be denied palliative care and suffer needless physical pain, apart from mental trauma, anxiety and other depressive disorders, due to missing elements in the State’s palliative care programme.

Though the Kerala government has announced its plan to coordinate the functioning of all palliative care facilities in Kerala and bring together all entities on a single platform, there are many vitally important elements in the State Palliative Care Policy (2019) that still remain at the conceptual stage.

While Kerala has one of the strongest palliative care programmes in the country, these missing elements, combined with a shortage of trained doctors and a paucity of funds mean that many patients with serious, agonising illnesses are unable to access palliative care, point out experts

“Palliative care has been flourishing in the primary care sector, but remains elusive at the tertiary level. One of the main revisions we sought when the State’s Palliative Care Policy of 2008 was revised in 2019 was that disease treatment and palliative care should go hand in hand. Thus the revised policy suggested starting palliative care divisions in all medical college hospitals, which could be developed into full-fledged departments in the next five years. However, it has come as a disappointment to me that we still have not even started discussing this,” says M.R. Rajagopal, founder chairman, Pallium India, an NGO that works for pain relief and palliative care.

Since 2019, palliative care has been included in the curriculum of medical students but they do not get an opportunity to familiarise themselves with the concept or see it practised.

Lack of doctors with requisite training

“Shortage of funds at the government level is a serious handicap, but there are at least a few doctors and nurses trained in palliative medicine in many departments in medical colleges. If they can at least make a beginning — a full-time palliative care nurse and a doctor who can spare half a day a week — the service can be slowly expanded,” Dr. Rajagopal says.

A host of agencies and personnel, including community volunteers, ASHA workers and palliative care nurses are involved in delivering palliative care at the primary care level . But doctors with training in palliative care are not available in the majority of primary and community health centres.

Taluk hospital are designated the first referral units for bed-bound and home-bound patients, who might need hospitalisation for the management of acute pain episodes. However, for the majority with serious illnesses, it is just not possible to reach taluk hospitals.

A palliative care nurse in a primary health centre (PHC), who finds patients with advanced cancer in agonising pain, has no way of getting oral morphine to these patients because of the shortage of doctors trained in palliative care at the PHC level.

“Even when doctors who are interested in palliative medicine send out a request for attending a training course, their application is often rejected citing staff shortage as the reason. Just one G.O. [government order] asking that these doctors be deputed for training in the nearest training centre (government or NGO) would make a world of difference,” a PHC doctor says.

Government targets not achieved

One of the objectives in the 2019 policy was enhancing the capability of the health system to meet the requirements. As part of capacity building, in the first year, at least 150 doctors and nurses each from the government were to successfully complete the Foundation Course in Palliative Care. (10-day ‘hands-on’ training in palliative care with three days/20 hours of interactive theory sessions). Also, at least 50 more doctors and nurses were to complete a six-week certificate course in palliative medicine and palliative nursing.

In 2024, even this target has not yet been achieved, experts pointed out.

There is also a lack of coordination between government and NGO palliative care centres. But ensuring minimum standards of practice for every agency, mandatory requirements for facilities at each level, and quality control are vital for networking so that patients can be seamlessly transferred from one facility to another as may be required. The revised palliative care policy had sought the accreditation of NGOs at the primary, secondary and tertiary levels, for which guidelines are yet to be framed.

Kerala, a front-runner, but has miles to go

Even though Kerala dispenses at least 15 times more morphine than any other States, when compared to the manner in which palliative care is managed in Western Europe or the U.K., not even a fraction of the requirement of morphine is served here, says Dr. Rajagopal.

A 2017 study, on the oral morphine use in South India by Mr. Rajagopal and others determined the oral morphine consumption in Kerala to be 1.32 mg/capita and found that it had increased over the study period (2012 to 2015) by 27%, from 1.23 mg/capita to 1.56 mg/capita

In 2015, 31% of morphine providers (51 of 167) were government institutions; they delivered 48% of total morphine in Kerala.

The study also pointed out wide variation between districts in morphine use and confirmed that while oral morphine use seemed to increase over time, the supply remained substantially lower than the estimated need.

“The situation has not changed dramatically from 2017. Morphine stocks are available in taluk hospitals but access remains poor because of logistic issues as well as shortage of trained doctors. Because for oral morphine to be dispensed, the pain assessment should be done and the dosage prescribed by a doctor,” Dr. Rajagopal points out. Also, for a patient with chronic illness who might suffer several episodes of pain, a once-a-month visit by a palliative care-trained nurse will not cut it.

As per government figures, currently, there are 1,142 primary and 231 secondary home care units at the government level, in addition to the over 500 home nursing care units operated by NGOs and over 50,000 trained volunteers, catering to nearly 2.5 lakh patients across the State. Secondary services are being provided through 102 hospitals.

But unless the government makes palliative care training for doctors a priority and facilitates the training of more doctors in the provision of pain relief, Kerala’s lofty aim of becoming a total palliative care State is likely to remain unfulfilled.