An evaluation of palliative care in rural Tanzania where availability of oral morphine is intermittent or absent

Includes bibliographical details.In Tanzania, palliative care is relatively new, and faces the common challenges of access to services, crucial medications, and education. Since 2004, an initiative within the health system of the Evangelical Lutheran Church in Tanzania (ELCT) began to promote and develop palliative care, using as a model the Selian Hospice and Palliative Care Programme. The hospitals which are the sites for team development and service delivery are widely scattered throughout rural Tanzania. Access to oral morphine was only a dream, as it is for much of the rural population of the world. In 2007, a program called CHAT (Continuum of care for people living with HIV/AIDS in Tanzania), funded by the U.S. government, allowed the up-scaling of these palliative care programs, resulting in 13 strong and mature teams by 2011, though still lacking oral morphine. Part of the monitoring and quality assurance of the program has been use of a tool developed by APCA: the APCA African Palliative Outcome Scale (POS). Hundreds of people living with cancer and HIV were subjected to the questions of the tool, which was always sent on to the core supervising team for assessment and feedback. Tramadol was the strongest analgesic available to the teams throughout the study time. 145 APCA African POS results on cancer patients were assessed, looking at differences in pain scores (0 to 5 scale) over time as well as assessing the other domains of care (psychological, spiritual, social, and family). 11 Palliative care nurses were also interviewed, asked to reflect on specific cases from their experience with both good and bad pain control. 5 of the nurses came from Selian, with access to oral morphine, while 6 of them came from the CHAT hospitals. Significant improvement in pain scores over 4 weeks was noted (3.83 to 2.31, p < 0.0001). All other domains assessed in the POS also improved significantly. Nurse interviews revealed an emphasis on the holistic approach and a strong preference for having access to oral morphine. In this rural Tanzanian environment, effective palliative care services – including pain control - were delivered even in the absence of oral morphine. Such services can become a strong advocacy at the government level for achieving breakthroughs in palliative care, including access to oral morphine

Where there is no morphine: The challenge and hope of palliative care delivery in Tanzania

Background: In Tanzania, a country of 42 million, access to oral morphine is rare.Aim: To demonstrate the effectiveness of palliative care teams in reducing patients’ pain and in increasing other positive life qualities in the absence of morphine; and to document the psychological burden experienced by their clinical providers, trained in morphine delivery, as they observed their patients suffering and in extreme pain. Setting: One hundred and forty-five cancer patients were included from 13 rural hospitals spread across Tanzania.Method: A mixed method study beginning with a retrospective quantitative analysis of cancer patients who were administered the APCA African POS tool four times. Bivariate analyses of the scores at time one and four were compared across the domains. The qualitative arm included an analysis of interviews with six nurses, each with more than five years’ palliative care experience and no access to strong opioids.Results: Patients and their family caregivers identified statistically significant (p \u3c 0.001) improvements in all of the domains. Thematic analysis of nurse interviews described the patient and family benefits from palliative care but also their great distress when ‘bad cases’ arose who would likely benefit only from oral morphine.Conclusion: People living with chronic cancer-related pain who receive palliative care experience profound physical, spiritual and emotional benefits even without oral morphine. These results demonstrate the need for continued advocacy to increase the availability of oral morphine in these settings in addition to palliative care services

Where there is no morphine: The challenge and hope of palliative care delivery in Tanzania

Background: In Tanzania, a country of 42 million, access to oral morphine is rare. Aim: To demonstrate the effectiveness of palliative care teams in reducing patients’ pain and in increasing other positive life qualities in the absence of morphine; and to document the psychological burden experienced by their clinical providers, trained in morphine delivery, as they observed their patients suffering and in extreme pain. Setting: One hundred and forty-fie cancer patients were included from 13 rural hospitals spread across Tanzania. Method: A mixed method study beginning with a retrospective quantitative analysis of cancer patients who were administered the APCA African POS tool four times. Bivariate analyses of the scores at time one and four were compared across the domains. The qualitative arm included an analysis of interviews with six nurses, each with more than fie years’ palliative care experience and no access to strong opioids. Results: Patients and their family caregivers identifid statistically signifiant (p < 0.001) improvements in all of the domains. Thematic analysis of nurse interviews described the patient and family benefis from palliative care but also their great distress when ‘bad cases’ arose who would likely benefi only from oral morphine. Conclusion: People living with chronic cancer-related pain who receive palliative care experience profound physical, spiritual and emotional benefis even without oral morphine. These results demonstrate the need for continued advocacy to increase the availability of oral morphine in these settings in addition to palliative care services