|Year : 2019 | Volume
| Issue : 8 | Page : 2563-2567
Primary palliative care competency framework for primary care and family physicians in India-Collaborative work by Indian Association of Palliative Care and Academy of Family Physicians of India
Shrikant Atreya1, Jenifer Jeba2, Nikki Pease3, Ann Thyle4, Scott Murray5, Alan Barnard6, Dan Munday7, Lulu Mathews8, Mhoira Leng9, Gayatri Palat10, Alka Ganesh11, Sulagna Chakraborty12, Sahaya Anbarasi13, Raman Kumar14, Maryann Muckaden15, Elizabeth Grant16
1 Department of Palliative Care and Psycho-oncology, Tata Medical Center, Kolkata, West Bengal, India
2 Department of Medical Oncology, Christian Medical College, Vellore, Tamil Nadu, India
3 Department of Palliative Medicine, Velindre NHS Trust, Cardiff, Wales, UK
4 Emmanuel Hospital Association, New Delhi, India
5 Emeritus Professor of Primary Palliative Care, Primary Palliative Care Research Group, The University of Edinburgh, Edinburgh, Scotland
6 School of Public Health and Family Medicine, University of Cape Town, Cape Town, South Africa
7 National Academy of Medical Sciences, Kathmandu, Nepal
8 Institute of Palliative Medicine, Kozhikode, Kerala, India
9 Makerere University, Kampala, Uganda, Africa
10 MNJ Institute of Oncology and Regional Cancer Center, Hyderabad, Telangana, India
11 Department of Medicine, G Kuppuswamy Memorial Hospital, Coimbatore, Tamil Nadu, India
12 Department of Palliative Medicine, AMRI Dhakuria, Kolkata, West Bengal, India
13 Department of Distance Education, Christian Medical College, Vellore, Tamil Nadu, India
14 Academy of Family Physicians of India, New Delhi, India
15 Department of Palliative Medicine, Tata Memorial Centre, Mumbai, Maharashtra, India
16 Global Health Academy and the Primary Palliative Care Group, The University of Edinburgh, Edinburgh, Scotland
|Date of Submission||08-Jun-2019|
|Date of Decision||19-Jun-2019|
|Date of Acceptance||29-Jul-2019|
|Date of Web Publication||28-Aug-2019|
Dr. Shrikant Atreya
Consultant in Palliative Medicine, Department of Palliative Care and Psychooncology, Tata Medical Center, 14 MAR (E-W), New Town, Rajarhat, Kolkata - 700 160, West Bengal
Source of Support: None, Conflict of Interest: None
The discrepancy in the demand for palliative care and distribution of specialist palliative care services will force patients to be eventually cared for by primary care/family physicians in the community. This will necessitate primary care/family physicians to equip themselves with knowledge and skills of primary palliative care. Indian National Health Policy (2017) recommended the creation of continuing education programs as a method to empower primary care/family physicians. With this intention, a taskforce was convened for incorporating primary palliative care into family/primary care practice. The taskforce comprising of National and International faculties from Palliative Care and Family Medicine published a position paper in 2018 and subsequently brainstormed on the competency framework required for empowering primary care/family physicians. The competencies were covered under the following domains: knowledge, skills and attitude, ethical and legal aspects, communication and team work. The competency framework will be presented to the National Board of Examinations recommending to be incorporated in the DNB curriculum for Family Medicine.
Keywords: Competency framework, family/primary care physicians, palliative care
|How to cite this article:|
Atreya S, Jeba J, Pease N, Thyle A, Murray S, Barnard A, Munday D, Mathews L, Leng M, Palat G, Ganesh A, Chakraborty S, Anbarasi S, Kumar R, Muckaden M, Grant E. Primary palliative care competency framework for primary care and family physicians in India-Collaborative work by Indian Association of Palliative Care and Academy of Family Physicians of India. J Family Med Prim Care 2019;8:2563-7
|How to cite this URL:|
Atreya S, Jeba J, Pease N, Thyle A, Murray S, Barnard A, Munday D, Mathews L, Leng M, Palat G, Ganesh A, Chakraborty S, Anbarasi S, Kumar R, Muckaden M, Grant E. Primary palliative care competency framework for primary care and family physicians in India-Collaborative work by Indian Association of Palliative Care and Academy of Family Physicians of India. J Family Med Prim Care [serial online] 2019 [cited 2019 Nov 13];8:2563-7. Available from: http://www.jfmpc.com/text.asp?2019/8/8/2563/265590
| Introduction|| |
In the last decade, India has seen a dramatic positive move towards better acceptance of palliative care, with many institutions especially oncology centers having palliative care specialists working collaboratively with specialists from other clinical disciplines. Integrating palliative care into the routine care of patients with life limiting conditions improves quality of life, decreases inappropriate use of invasive medical interventions at the end of life, and facilitates a dignified and a peaceful death.,
There is sparcity of palliative care specialists to cater to the growing number of individuals with palliative care needs in a vast country like India. Less than 1% of the 1.3 billion population of India has access to specialist palliative care. The Quality of Death Index commissioned by the Lien Foundation (2015) Singapore measured the quality of palliative care in 80 countries, using 20 quantitative and qualitative indicators across five categories: The Palliative and Healthcare environment, human resources, the affordability of care, the quality of care, and the level of community engagement. India ranked at 67th position out of 80 countries. Palliative care within India is sparsely distributed and concentrated in major cities with the exception of Kerala. Rural and tribal areas have minimal access to palliative care.
India faces an overwhelming need for palliative care, in oncology and other life limiting illness, as it is well established that patients with other life-threatening illness can benefit from palliative care., Nearly all will primarily or eventually be cared by the primary care physicians thus necessitating primary care physicians to equip themselves with the knowledge and skills of primary palliative care. Primary palliative care can be defined as “the clinical management and care coordination including assessment, triage, and referral using a palliative approach for patients with uncomplicated needs associated with a life limiting illness and/or end of life care. Has formal links with a specialist palliative care provider for purposes of referral, consultation, and access to specialist care as necessary.” International research has emphasized the importance of the primary care physician being an indispensable element in the continuum of palliative care provision in the community., Collaborative care between palliative care specialist and primary care/family physician will ensure a seamless transition to community-based care and helps in continuing care in patient's preferred place. However, there are challenges in the provision of primary palliative care. These include inadequate and uneven distribution of primary care physicians, lack of knowledge and skills in palliative care and obstacles in the process of undertaking training in palliative care, negative attitude of primary care physicians towards palliative care, unclear roles, lack of clearly defined responsibilities, and lack of structured communication and collaboration between them and specialist physicians.
The Indian National Health Policy (NHP) 2017 endorsed that palliative care is an essential component of health care and should be provided alongside preventive, promotive, and curative care. International evidence confirms that palliative care competencies can be successfully incorporated in undergraduate, postgraduate, and practising physician curricula. The NHP 2017 also recommends the creation of continuing education programs for primary care physicians in order to upgrade their skills at providing basic palliative care at the community level. Continued medical education and training programs through distance learning methods like webinar and traditional training using contact programs could be accredited by the local medical council as this can potentially motivate family/primary care physicians to undergo training in palliative care.
There are annual national palliative care courses scheduled round the year in India empowering and training physicians, nursing and allied groups across the country. The content of the existing curricula and the methods of training are variable across training programs and are not immediately transferable into the curricula of family physicians.,,,,,,,,
With the intention of establishing consistent training programs appropriate for the primary care setting, a task force comprising National and International Palliative Care Specialists and Family Medicine Physicians was formed in 2017. Members brainstormed to provide recommendations to support the development of palliative care education and service for family/primary care physicians in India.
The present paper is a sequel to the position paper published in 2018 and aims to outline the palliative care competencies required for a primary care/family physician to provide primary palliative care in the community. The competency framework will be presented to the National Board of Examination for it to be incorporated into the primary care/family medicine curriculum. It defines the knowledge, skills, attitudes necessary to provide primary palliative care; including identification of those with palliative care needs, holistic assessment, symptom management, provision of end of life care, support of psychosocial, spiritual needs and communication, ethical and legal aspects.
| Joint Milestones by the IAPC and AFPI|| |
In January 2017, a taskforce was convened to promote the incorporation of primary palliative care into family/primary care practice in order to improved continued palliative care service in the community. The taskforce comprised 15 national and international members with representations from professional disciplines such as palliative medicine, family medicine, Distance education, geriatric medicine, and public health. In January 2017, members of the task force held a panel discussion on, “The role of Family/Primary Care Physician in Community Based Palliative Care” at the 3rd National Conference of the Association of Family Medicine and Primary Care. The presenters introduced the concept of palliative care and emphasized the importance of incorporating primary palliative care into the family/primary care practice. Following the presentation, members of the taskforce met with family medicine faculties with a view to establish the requirements of a community-based palliative care in the country and how best this could be implemented in the community.
Subsequently the task force members met during the 24th International Conference of the Indian Association of Palliative Care (IAPCON), Coimbatore, February 2017 and discussed the way forward for integrating palliative care with family/primary care practice. Following this, in 2018, a Joint position paper by the IAPC and AFPI was published.
The task force drafted the core competencies for primary palliative care. At IAPCON 2019, Kochi, the members presented the competency framework for primary palliative care for family/primary care physicians and this was further vetted in a review meeting in which the various available training curricula in palliative care in India were discussed. The challenges around the feasibility and practicability of training the busy practicing family physicians and incorporation of the curriculum into the postgraduate course of the family physician were addressed. The competency framework will be presented to the National Board of Examinations with a recommendation to be incorporated into the DNB curriculum for family medicine. The members of the task force will work towards developing a module for primary palliative care, taking insights from various national and international training resources for family physicians.
| Goals and Core Competencies|| |
The overarching goal in the incorporation of primary palliative care into the training of primary care/family physicians is to ensure that the primary care/family physicians are able to provide primary palliative care within the community using a standard protocol: effective identification of those with palliative care needs, ability to alleviate suffering and improve quality of life, and offer continued care so a person is able to live and die with dignity in their preferred place. The core competencies and the details of the competencies are enlisted in [Table 1] and [Table 2].
|Table 2: A detailed list of the essential knowledge, skills, and attitudes for delivery of primary palliative care|
Click here to view
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Zimmermann C, Riechelmann R, Krzyzanowska M, Rodin G, Tannock I. Effectiveness of specialized palliative care: A systematic review. JAMA 2008;299:1698-709.
Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA, et al.
Early palliative care for patients with metastatic non small cell lung cancer. N
Engl J Med 2010;363:733-42.
Khanna I, Lal A. Palliative care – An Indian perspective. ARC J Public Health Community Med 2016;1:27-34.
Malpas PJ, Mitchell K. ''Doctors shouldn't underestimate the power that they have'': NZ doctors on the care of the dying patient. Am J Hosp Palliat Care 2017;34:301-7.
Gagyor I, Luthke A, Jansky M, Chenot JF. End of life care in general practice: Results of an observational survey with general practitioners. Schmerz 2013;27:289-95.
De Lima L, Bennett MI, Murray SA, Hudson P, Doyle D, Bruera E, et al
. International Association for Hospice and Palliative Care (IAHPC) list of essential practices in palliative care. J Pain Palliat Care Pharmacother 2012;26:118-22.
Radbruch L, Payne S. White Paper on standards and norms for hospice and palliative care in Europe: Part 1. Eur J Palliat Care 2009;16:278-89.
Quill TE, Abernethy AP. Generalist plus specialist palliative care--creating a more sustainable model. New Engl J Med. 2013;368:11735.
Mitchell GK, Reymond EJ, BP MG. Palliative care: Promoting general practice participation. Med J Aust 2004;180:207-8.
von Gunten CF, Mullan P, Nelesen RA, Soskins M, Savoia M, Buckholz G, et al
. Development and evaluation of a palliative medicine curriculum for third-year medical students. J Palliat Med 2012;15:1198-217.
Schulz C, Möller MF, Seidler D, Schnell MW. Evaluating an evidence-based curriculum in undergraduate palliative care education: Piloting a phase II exploratory trial for a complex intervention. BMC Med Educ 2013;13:1.
Morrison LJ, Thompson BM, Gill AC. A required third-year medical student palliative care curriculum impacts knowledge and attitudes. J Palliat Med 2012;15:784-9.
Radwany SM, Stovsky EJ, Frate DM, Dieter K, Friebert S, Palmisano B, et al
. A 4-year integrated curriculum in palliative care for medical undergraduates. Am J Hosp Palliat Care 2011;28:528-35.
Szmuilowicz E, el-Jawahri A, Chiappetta L, Kamdar M, Block S. Improving residents' end-of-life communication skills with a short retreat: A randomized controlled trial. J Palliat Med 2010;13:439-52.
Fischer SM, Gozansky WS, Kutner JS, Chomiak A, Kramer A. Palliative care education: An intervention to improve medical residents' knowledge and attitudes. J Palliat Med 2003;6:391-9.
Olden AM, Quill T, Bordley D, Ladwig S. Evaluation of a required palliative care rotation for internal medicine residents. J Palliat Med 2009;12:150-4.
Sullivan AM, Lakoma MD, Billings JA, Peters AS, Block SD. Teaching and learning end-of-life care: Evaluation of a faculty development program in palliative care. Acad Med 2005;80:657-68.
Stevens DP, Jones DH, Salerno JA, Ryan BJ. A strategy for improvement in care at the end of life: The VA Faculty Leaders Project. J Palliat Med 1999;2:5-7.
Jeba J, Atreya S, Chakraborty S, Pease N, Thyle A, Ganesh A, et al
. Joint position statement Indian association of palliative care and academy of family physicians of India – The way forward for developing community-based palliative care program throughout India: Policy, education, and service delivery considerations. J Family Med Prim Care 2018;7:291-302.
] [Full text]
[Table 1], [Table 2]