Designing and delivering training in palliative care, Karachi, Pakistan

Middle aged white woman with short white hair smiling with green trees behind her.
Dr Gill Horne 
GPNN Champion & Programme Director Care Services, Rowcroft Hospice.

I discovered that their staff had little or no prior palliative care training. Through video calls with one of their medical team to help prepare the training, I asked them to give me examples of the types of patients, diseases, and scenarios their staff were facing, being keen to design the training around their learning needs. Cases included for example a man in his 50s, who had severe epilepsy following an RTA, with left-sided paralysis, aphasia, complications of bedrest and his family not able to take him home; an elderly woman with oropharyngeal cancer, who had an emergency tracheostomy and no prior discussion about future plans and a patient with dementia, frailty and multiple chest infections. There was also a general concern about struggling to recruit and retain nurses in a mission hospital where conditions of work and pay were different to surrounding private and state-run hospitals.

I designed a 12-hour programme over three days. Together we agreed this would include the core tenets of palliative care: principles of palliative care; communication skills; recognising dying, pain, and symptom management – recognising they had little or no opioids available; spiritual care; grief, loss, and bereavement; self-care and compassion. We were told most of them had a good understanding of English, but once in country I was grateful that a retired Urdu speaking GP colleague, part of the team, was able to offer translation.

The workshops were designed for doctors, nurses, and technicians. We used interactive methods – something that is uncommon in Pakistan, where didactic delivery is the norm. We were thankful for Wi-Fi and access to a computer and screen, but warned of power failures – so we were prepared. All other resources were packed into my suitcase: paper, crayons, blue tack, poems, flip chart pens and other tools.

Some of the many challenges for staff in Karachi and in Pakistan is a lack of government provided reliable supplies of opioids. They had some oral mild-moderate opioids such as Tramadol available, and benzodiazepines such as Midazolam, and yet none of these were used subcutaneously at the end of life. In terms of communication skills training, as per my prior experience in other LMIC’s and Pakistan, its more common that the man of the family is informed of bad news and is the key decision-maker, rather than the patient. Relational autonomy is more important in their culture, nevertheless trainees welcomed learning about how to communicate news to the patient and family together and we discussed the merits of both types of autonomy.

Whilst in country, we were also able to offer some leadership and management advice in relation to supporting the head of nursing and we were invited to advise on their wish to develop a palliative care service.

Following positive feedback about the learning, including staff wanting to make their own plans about future care, and reports from one of their nurse trainers about gaining knowledge in interactive training methods, there were further impacts. These included for example, following the training in palliative care emergencies in the morning, that very afternoon a patient was diagnosed in the emergency department with Superior Vena Cava obstruction, the doctor suggested that having just been taught about this they were more easily able to recognise it. Reports since my return are that they have admitted several patients whom they recognised were dying and admitted them for palliative care. Excitingly, they are putting together a business proposal to creating a small palliative care unit within the hospital.

Gill is a Global Palliative Nursing Network (GPNN) Champion – if you are a nurse do think about joining the network.

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