Special issue article
Jordan palliative care and pain initiative 2011:
building capacity for palliative care programs
in public hospitals
Mohammad Bushnaq1, R.N. Fadi Abusuqair2
1Jordan Palliative Care Society, Jordan, 2Department of Pediatric, School of Medical Sciences Universiti Sains
Malaysia, Kubang Kerian Malaysia
Jordan palliative care initiative was launched in Jordan as WHO demonstration project at 2003 to implement palliative care in Jordan. As a result, palliative care program was established at King Hussein Cancer Center as a model for palliative care in the region. Yet, still only a minority of patients have access to palliative care in Jordan.
The access to opioids is still limited by many factors like fear of opioids among health care workers and policies limiting the duration of opioids prescription. There was a need for a society that would take the initiative to address these challenges and help coordinating the efforts to implement palliative care across Jordan. As a result, the Jordan Palliative Care Society (JPCS) was established in March 2010. The vision of the JPCS is to make palliative care accessible to all patients in needs in Jordan. The JPCS decided to focus on building capacity in eight public hospitals by training health care workers and empowering them to lead the change in their facilities.
In collaboration with WHO office in Jordan and ministry of health, JPCS conducted a 3-day workshop in palliative care and pain management for 24 health care workers from eight public hospitals. The goal of this initiative was to establish palliative care teams as a nucleus for palliative care and pain programs in these hospitals. In this study, we evaluated the outcome of providing intensive workshops (class room and bed side) for 24 health care workers from eight public hospitals.Keywords: Palliative care, Program, Jordan Introduction Palliative care is an approach that improves the qualityof life of patients and their families facing problems
associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial, and spiritual.1,2 Worldwide, millions of patients are in need of palliative
care. Numerous governments, including Australia, Canada, Chile, Costa Rica, Cuba, France, Ireland, Norway, Spain, Uganda, South Africa, and the United Kingdom, have already adopted national palliative care policies.3 World Health Organization (WHO) demonstration project in Jordan has succeeded in improving opioids availability and regulations and in establishing a center of excellence for palliative care at the King Hussein Cancer Center (KHCC).
The importance of palliative care was identified early at the inception of KHCC in 2004 when well trained multidisciplinary palliative care teams were created for adult and pediatrics. After that, a comprehensive adult palliative care program at KHCC was
launched for the first time in Jordan in collaborationwith WHO and the Institute for Palliative Medicine at San Diego Hospice. Through 5 years of experience, the team identified key factors of success including; commitment, positive thinking, team work, and tolerance of challenges.Jordan palliative care initiative and pain initiativeJordan palliative care initiative was launched in Jordan as WHO demonstration project at 2003 to implement palliative care in Jordan through training and education, changing policies related to opioids,
drug availability, and implementation (Fig. 1).4,5 Although before 2003, fewer than 250 patients per year received palliative care, by 2006 there were more Correspondence to: Dr Mohammad Bushnaq, Jordan Palliative Care and Pain Society, Jordan.
E-mail: drbushnaq@yahoo.com
© W.S. Maney & Son Ltd 2012
DOI 10.1179/1743291X12Y.0000000016 Progress in Palliative Care 2012 VOL. 20 NO. 4 203
than 800 patients to benefit palliative care in the country. In 2004, the first palliative care service
began at the recently opened KHCC. The program provides inpatient unit, outpatient clinic, and home care service. In 2005, around 300 patients had been treated in the service and in 2009 this number reached more than 550.4 Increased opioid consumption is a good indicator of
the implementation of palliative care. At KHCC, opioid usage in the outpatient setting alone has doubled from 2.5 kg in 2005 to 5 kg in 2006. This corresponds to a 3.3-fold increase since 2004.
According to International Narcotic Control Group, there was continued morphine consumption
in Jordan. The consumption is 2.069818 mg/capita at 2007, compared to 0.324574 mg/capita at 2003 (Fig. 2).6
Despite the success of palliative care development at KHCC, still only a minority of patients have access to palliative care in Jordan. The access to opioids is still limited by many factors like fear of opioids among health care workers and policies limiting the duration of opioids prescription.
There was a need for a society that would take the initiative to address these challenges and help coordinating the efforts to implement palliative care across Jordan. As a result, the Jordan Palliative Care Society (JPCS) was established in March 2010.
The vision of the JPCS is to make palliative care accessible to all patients in needs in Jordan. The JPCS decided to focus on building capacity in eight public hospitals by training health care workers and empowering them to lead the change in their facilities.
In collaboration with WHO office in Jordan and ministry of health, JPCS conducted a 3-day workshop in palliative care and pain management. The goals of this initiative were to establish palliative care teams as a nucleus for palliative care and pain programs in these hospitals.
Situation analysis Jordan has a population of 6 508 271 people (July 2009 est.) of which 35% are under 15 years of age and 4.8% above 65 years of age. The majority of the population is Sunni Muslim (92%). Christians constitute 6% and the others (Shea Muslim, Druze) constitute
2%. The average number of people per family is six and the average income per household is 4700$ per year.7 According to the National Cancer Registry, cancer is the second leading cause of death in Jordan after heart disease. A total of 4332 new cancer cases were registered among Jordanians in 2007, more than 60%of which are at stage III or IV. The most common cancers are breast, colon, prostate, lung, and leukemia (Fig. 3). There were 1494 non-Jordanian registered cases, accounting for 25.6% of all registered cases (5826 Jordanian and non-Jordanian), 198 reported cases of cancer below the age of 15.8 Jordan’s death rate is approximately 3 per 1000 populations per year, with average more than 16 000 deaths each year. A total of 9600 reported death case Figure 1 Public health strategy for palliative care.
Source:
Stjernswärd et al.5.Figure 2 Jordan Morphine Consumption between 1980 and 2009. Sources: International Narcotics Control Board;World Health
Organization population data. By: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center, 2011.
Bushnaq and Abusuqair Jordan palliative care and pain initiative 2011 Progress in 204 Palliative Care 2012 VOL. 20 NO. 4 (60%) are likely to need pain relief and palliative care, including opioid analgesics before death.4 Cultural specificities
The influence of culture on the meaning and experience of death and dying may be applied to fundamental domains of end-of-life care, such as symptoms management, advance-care planning, and grief and bereavement counseling, for which cultural and religious knowledge, sensitivity, and respect are indispensable.
9 The nurses need to be sensitive to the cultural
differences and develop the skills necessary to clarify and resolve end-of-life care involving patients from different cultures because culture and religion might play important roles in the development of these attitudes.
10 In Jordan, like in most Arab societies, patients cannot be considered independent from their respective families. The family is omnipresent and believes
that it is their right to be fully involved in the patient management. It is thus not acceptable to communicate with the patient alone; the family needs to be involved and its opinion and input have to be respected. Thus, one of the most frequent difficulties we face is the family refusal to tell the truth about one’s health to the patient. ‘Do not tell my father he has cancer’ and ‘Do not tell my wife she will die’ are very frequent requests, the concern of family’s members being to
keep the patient’s spirit up.
Religious and spiritual aspects Muslims are not allowed, by religion, to harm themselves and suffer pain as a redemption exercise; pain killers are thus well accepted by patients and families. Sometimes families are concerned about the addiction issue but it is not difficult to reassure them and calm their worry toward opioids. The ‘chaplain’ in Jordan practices spiritual therapy which consists in putting his/her hands on the patient’s head while reading some chosen verse from the Noble Qura’n, helping the patients find a meaning for their suffering, and helping a dying patient to speak the shahadah (bearing witness that ‘there is no true God but Allah, and Mohammad is verily his servant and his messenger’).
Purposes of the study
The primary objective is to assess the difference in knowledge of the participants after completion of the intensive course workshop (class room and bedside training), to report the outcome of the daily practice of the participants and the implementation of palliative care in their hospitals.
Method
Jordan palliative care society conducts a 3-day class room and bed-side training for palliative care and pain management in collaboration with WHO office in Jordan. The program was designed to cover the essential knowledge and skills needed to provide care for patients with chronic diseases, such as cancer, heart, renal, and nervous disorders. The main domains were holistic approach for relieving suffering, pain management, symptom management, end-of-life
care, communication skills, and wound care.
A geographically dispersed, random sample of 24 members (physicians, nurses, and pharmacist) of eight public hospitals cross Jordan (Prince Hamzah Hospital, Al-Bashir Hospital, Al-Karak Hospital, Royal Medical Services, Jordan University Hospital,
Al-Tafelah Hospital, Al-Zarqa Hospital, and King Abdullah University Hospital, KAUH). A survey was applied before the study to evaluate its situation and availability. We talked to the director of each hospital to guarantee the commitment of the participants as well as the support needed from their administration as an essential part of the success for this initiative.
The workshop took place at Prince Hamza Hospital from May 2–5, 2011. The goal of the workshop was to provide basic knowledge and skills related to palliative care and pain management and to help them change their behavior by interactive sessions, role play, and bed-side teaching. The instructors were two palliative care physicians (Dr Mohammad Bushnaq and Dr Figure 3 Most prevalent cancers affecting Jordanians. Source: National Cancer Registry Report 2007.
Bushnaq and Abusuqair Jordan palliative care and pain initiative 2011 Progress in Palliative Care 2012 VOL. 20 NO. 4 205 (Mustafa Beno) and palliative care nurse (Ghadder Dweik), and the main reference was Education in Palliative and End-of-life Care for Oncology (EPEC-O).
The candidates were asked to undergo pre– and post-test assessment to measure the improvement of knowledge after the workshop. The workshop was followed by two additional meetings over 2 months. The goal was to help the newly developed teams overcome
the challenges they might meet, and to monitor the advancement of implementation of palliative care in their hospitals.
The data were entered to statistical package for the social sciences (SPSS) version 18.0 software. The test was 10 multiple-choice questions related to palliative care and pain management, the correct answer denoted by score 1 and the incorrect one by score
0. An independent two-paired t test was used to compare the total mean score between pre- and posttest. A P value less than 0.05 is considered statistically significant in this study. Results
A total of 24 participants participated in the pre- and post-test exam; the average score prior to the workshop was 4.5 and it increased to 7 after the course.
Because of the limitation in the sample size, a paired t test was conducted to compare the difference between the pre- and post-test. Generally, there was clear progress in the participants scoring on the post-test exam; Fig. 4 shows that there was an increase in the percentage of correct answers for each question. The paired sample
t test showed significant difference between both the exams (Table 1); the pre–test mean score = 4.48 and post-test mean score = 6.68 and P value <0.001. On our follow-up with participants, we tried to assess the outcome of the workshop in terms of their ability to apply what they learned on daily practice and in helping to implement palliative care in their
hospitals.
Starting with Al-Basheer Hospital, the largest government hospital in Jordan, palliative care team was started by a decision from the minister of health. The team includes five physicians, two registered nurses, physiotherapist, and a social worker. The Al-Basheer hospital team started the follow-up of the patients at
the outpatient clinic.
A formal decision to form a team for palliative care and pain management was also given by the managers
Al-Karak Hospital and Prince Hamzah Hospital. Hamzah started to accept referrals in the outpatient
clinic. Narcotics like Morphine and Tramadol were introduced for the first time in Hamzah Hospital.
At KAUH, the team started to develop policies and guidelines for palliative care and pain management,
multiple workshops were conducted to raise the awareness about palliative care among the staff.
The palliative care clinic in King Hussein Medical city adopted the national policy of palliative care
and it provides daily care for approximately 50 outpatients and about 100 inpatients. The decision was
made to expand the team to help more patients. Figure 4 Frequency of correct answers between pre- and post-test exams. Table 1 Exam total score between pre- and post-test
Pre-test Post-test Mean difference (95% CI) Statistics P value 25a 25a −2.2 4.48 (1.39)b 6.68 (1.84)b (−3.24, −1.15) 4.34 (24)c <0.001d aNumber of participants. bMean (SD). ct statistics (df). dPaired t test.
CI, confidence interval.
Bushnaq and Abusuqair Jordan palliative care and pain initiative 2011 Progress in 206 Palliative Care 2012 VOL. 20 NO. 4 The team at Zarka Hospital started to apply palliative care in the Haemodialysis unit. Conclusion. The WHO demonstration project that took place in Jordan was successful to create a model for palliative care at KHCC. Jordan palliative care and pain initiatives were launched to help spreading the culture of palliative care across the country. The 3-day workshop conducted for 24 participants from eight public hospitals, with follow-up before and after the course, was successful in providing knowledge and
skills to the evolving teams, and to change their daily practice.
The long-term objectives of this initiative are to make palliative care available for all citizens who need it. For this, there is a need to conduct additional studies in the future to assess the long-term objectives.
Acknowledgements We would like to thank everybody who contributed to this initiative, namely Dr Hashim Al-Zain, representative in Jordan, Dr Mustafa Beno and Mrs Ghadeer Dweik, RN the two instructors in addition to Dr Mohammad Bushnaq, and to the participants who helped in this study. From KAUH: Buthayna Alshurman, Khalaf Harahshah, Rehab Deeb, and Enas Yosef. From Al-Bashir Hospital: Maram Isaac Ibrahim, Dr Fadi Issa Suleiman, and Nawfal Abdul Alehim. From Al-Zarqaa Hospital: Dr Abdagabr
Massoud, Dr Ammar Shehadeh, Ahlam Sabih, Walid Kilani, and Nagwa Abdel-Dayem. References
1 Sepúlveda C, Marlin A, Yoshida T, Ullrich A. Palliative care: the World Health Organization’s global perspective. Jpainsymman 2002;24:2.
2 WHO Definition of Palliative Care. 2012 http://www.who.int/ cancer/palliative/definition/en/.
3 World Health Organization. In: Pre planning, ed. Cancer
control, knowledge into action – WHO guide for effective programmers,
module
5. WHO; 2007. P.
6. Available from http://
www.who.int/cancer/media/FINAL-PalliativeCareModule.pdf
4 Stjernswärd J, Ferris FD, Khleif SN, et al. Jordan palliative care
initiative: a WHO demonstration project. Jpainsymman 2007;
33(5):628–33.
5 Stjernswärd J, Kathleen MF, Frank DF. The public health strategy
for palliative care. Jpainsymman 2007;33(5):486–93.
6 Drug Control and Assess to Medicines Consortium (DCAM
2008). http://dcamconsortium.net/, http://ppsg-production.
heroku.com.
7 CIA Fact Book. 2011: https://www.cia.gov/library/publications/
the-world-factbook/geos/jo.html.
8 Jordan Cancer Statistics. 2007 http://khcfusa.org/khcfusaorg/
CANCERSTATISTICS/tabid/79/Default.aspx.
9 Ciccarello GP. Stratrgies to improve end of life care in the intensive
care unit. Dimens Crit Care Nurs 2003;22(5):216–22.
10 Barun M, Gordon D, Uziely B. Associations between oncology
nurses’ atittude toward death and caring for dying patients.
Oncol Nurs Forum 2010;37(1):E43–9.
Bushnaq and Abusuqair Jordan palliative care and pain initiative 2011
Progress in Palliative Care 2012 VOL. 20 NO. 4 207
