Study: Minimal standards of palliative care needed

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Furthermore, the number of people who experience serious health-related suffering is much higher, with an additional 35.5-million people requiring pain relief outside of end-of-life care. More than 80% of these cases are in low- and middle-income countries, where access to immediate release morphine, an essential and inexpensive medicine to alleviate pain, as well any other type of palliative care, is severely lacking.

Deplorable pain crisis

These findings form part of The Lancet Commission on Global Access to Palliative Care and Pain Relief, following a three-year project involving 61 co-authors from 25 countries. The authors have developed an essential package of palliative care services – including medicines, equipment and staffing models - to be made available by health systems worldwide, and call for more balanced global policies to facilitate access to opioid analgesics to meet medical need, while limiting non-medical use.

“Inequity in access to essential pain relief for palliative care and pain relief is one of the world’s most striking injustices. The world suffers a deplorable pain crisis: little to no access to morphine for tens of millions of adults and children in poor countries who live and die in horrendous and preventable pain,” says Professor Felicia Knaul, co-chair of the commission from the University of Miami, USA.

“We cannot allow opiophobia to keep inexpensive, essential medicines from low-income patients in agony as they fight diseases such as cancer, HIV or near end of life.

“One of our most emphatic recommendations is that immediate-release, off-patent, morphine that can cost just pennies should be made available in both oral and injectable formulations for any patient with medical need. The disparity and access abyss between the haves and have-nots is a medical, public health and moral injustice that can be effectively addressed by the Commission’s recommendations,” Knaul adds.

Global need for palliative care

In the first analysis of its kind, the authors estimate the global need for palliative care and pain relief by devising a new measure of serious health-related suffering. They analyse the 20 life-threatening and life-limiting health conditions (including HIV, cancers, heart disease, injuries and dementia) and 15 corresponding symptoms (including pain, fatigue, wounds, anxiety and depression) that are most frequently associated with the need for palliative care and pain relief.

In 2015, an estimated 25.5-million people died with serious health-related suffering – equivalent to nearly half of all deaths worldwide. This includes 2.5-million children aged under 15 years (representing more than a third of child deaths). Almost all (98%) of these children live in low and middle-income countries.

In addition, 35.5-million people who did not die also experienced serious health-related suffering, meaning that the total number of people needing palliative care per year was over 61 million, including 5.3 million children. More than 80% of people needing palliative care live in low and middle-income countries.

Failure of health systems

The authors note that almost 80% of deaths requiring palliative care in low income countries are preventable with adequate prevention, treatment and care interventions. They highlight that palliative care cannot be a substitute for improved access to public health interventions and treatments that could have prevented much suffering and premature death in the first place. But, equally, no health system can expect to meet the needs of its people without providing access to basic pain relief and palliative care.

Commenting on the report, Jim Yong Kim, president of the World Bank, says: “Failure of health systems in poor countries is a major reason that patients need palliative care in the first place. More than 90% of these child deaths are from avoidable causes. We can and will change both these dire situations.”

The most common symptoms of suffering were pain, depressed mood, anxiety, fatigue and weakness. The commissioners propose an essential package for palliative care as the minimum standard any health system should make available as a core component of universal health coverage.

Designed to be low-cost and covering medicines, basic equipment and human resources, one of the minimum requirements is the availability of oral or injectable morphine.