Palliative Care Policy for Kerala

Sl. No: CONTENTS PAGE NUMBER

1. PRE-AMBLE 02
2. AIMS AND OBJECTIVES 06
3. DEVELOPMENT OF SERVICES 09
4. CAPACITY BUILDING 13
5. AVAILABILITY OF MEDICINES AND OTHER EQUIPMENTS 15
6. ROLE OF OTHER SYSTEMS OF MEDICINE 16
7. RESEARCH 16
8. BUDGET ALLOCATION 16
9. PALLIATIVE CARE POLICY & OTHER HEALTH PROGRAMMES 17
10. EVALUATION AND MONITORING 17

APPENDICES
I. ACTION PLAN 18
II. W.H.O. RECOMMENDATIONS ON PALLIATIVE CARE 23
III. MEDICINES TO BE ADDED TO THE ESSENTIAL DRUGS LIST 25
IV. GUIDELINES FOR R.M.I. TRAINING 27
(FOR TRAINEES, TRAINING CENTRES AND TRAINERS)
V. CAPACITY BUILDING IN GOVT SECTOR 28
VI. STRUCTURE OF MONITORING COMMITTEES 31
VII PROPOSED BUDGETARY SOURCES 33

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PALLIATIVE CARE POLICY FOR KERALA,
 Palliative Care Policy for Kerala

1. PRE-AMBLE

1.1. The suffering in incurable and debilitating diseases:

a. Life with an incurable and debilitating disease is often associated with a lot of
suffering. Pain, many other symptoms like breathlessness, nausea and
vomiting, paralysis of limbs, fungating ulcers etc can make life unbearable not
only for that person, but also for the family. Such suffering exists in incurable
cancer, HIV/AIDS, many neurological, pulmonary, cardiovascular, peripheral
vascular and end-stage renal diseases, incapacitating mental illnesses and in
problems of old age.
b. In addition to physical problems, they usually suffer from social, emotional,
financial and spiritual issues caused by the illness. Many have clinical states of
anxiety or depression. On the social domain, when wage-earners get the
disease, in the absence of any social security system, families often get
financially ruined. Cost of treatment adds to the problem. It may lead to their
children dropping out of school; families losing their homes, and often going
into debt.
1.2. The relevance of palliative care:
a. Modern Principles of palliative care can take care of the suffering in patients
with incurable diseases, considerably diminishing the anguish for the patient
and the family. Palliative care is aimed at improving quality of life, by
employing what is called “active total care”, treating pain and other
symptoms, at the same time offering social, emotional and spiritual support.
b. The World Health Organization in 2002 defined palliative care as “an
approach that improves the quality of life of patients and their families facing
the problems associated with life-threatening illness, through the prevention
and relief of suffering by means of early identification and impeccable

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PALLIATIVE CARE POLICY FOR KERALA,
 assessment and treatment of pain and other problems, physical, psychosocial
and spiritual.
Palliative care:
• Provides relief from pain and other distressing symptoms
• Affirms life and regards dying as a normal process
• Intends neither to hasten or postpone death
• Integrates the psychological and spiritual aspects of patient care
• Offers a support system to help patients live as actively as possible
until death
• Offers a support system to help the family cope during the patient’s
illness and in their own bereavement
• Uses a team approach to address the needs of patients and their
families, including bereavement counselling, if indicated
• Will enhance quality of life, and may also positively influence the
course of illness
• Is applicable early in the course of illness, in conjunction with other
therapies that are intended to prolong life, such as chemotherapy or
radiation therapy, and includes those investigations needed to better
understand and manage distressing clinical complications.
c. In a study done in Malappuram District of Kerala (it was found that around
40% of those people who are dying would have benefited from applying the
principles of palliative care in their management. In Kerala, with a population
of 32 million and a crude death rate of 6.3 (Reference: Census 2001) around
80,000 dying patients and their families would be benefited each year. To this
if we add the number of people living for years with chronic conditions the
total number will be much more.
d. To ensure that palliative care is available and accessible to the majority of the
needy, a major thrust should be on a primary health care approach. World
Health Organisation observes that “The fundamental responsibility of health
profession to ease the suffering of patients can not be fulfilled unless palliative
care has priority status with in public health and disease control programme; it
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PALLIATIVE CARE POLICY FOR KERALA,
 is not an optional extra. In countries with limited resources, it is not logical to
provide extremely expensive therapies that may benefit only a few patients,
while the majority of patients presenting with advance disease and urgently in
need of symptom control must suffer with out relief” (National Cancer Control
Programmes, Policies and Managerial Guidelines. WHO, Geneva 2002)
e. Even when the disease is amenable to curative treatment, especially if the
treatment is a long-drawn out process like in cancer, all principles of palliative
care need to be applied from the time of diagnosis. This is commonly called
supportive care and needs to be incorporated into the disease-specific
treatment program.
f. Palliative care is a well-established branch of health care in most developed
countries. The state, under Article 21 of the constitution of India, is duty-
bound to ensure the fundamental right to live with dignity. This policy is
aimed at ensuring that palliative care services are established and integrated
into routine health care in the state.
1.3. Present palliative care scene in Kerala
a. At present there are around 100 palliative care units in Kerala. Majority of
them are:
• organised and supported by Community Based Organisations (CBO) and
the rest are based in government and private hospitals.
• supported by local communities
• self-sustainable in terms of manpower, money and other amenities.
• dependent on trained volunteers for organising the services and
psychosocial support
• supported by Local Self Governments Institutions (LSGI) and are
• able to provide home visits, outpatient service and free drugs for the poor.
In some districts however, palliative care services are rudimentary.
b. Currently palliative care training programmes for professionals are run by
Institute of Palliative Medicine, Kozhikode and Regional Cancer Centre,
Thiruvananthapuram. Calicut Medical College has been offering regular
placement in palliative care for house officers as part of training.
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PALLIATIVE CARE POLICY FOR KERALA,
c. There are around 4000 trained volunteers in palliative care in Kerala at the
moment. About 25 doctors, 15 staff nurses and 50 trained nurses are working
full time in palliative care in the state. I addition to this there are many health
care professionals who contribute part of their time for palliative care.

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PALLIATIVE CARE POLICY FOR KERALA,
2. AIMS AND OBJECTIVES

2.1. Aim: To provide palliative care to as many of the needy in Kerala as possible.
2.2. Objectives
2.2.1 Short-term objectives for the first two years
2.2.a.1. To train at least 300 volunteers in palliative care in each district to
facilitate the development and involvement of CBOs with emphasis on
districts where there are no palliative care facilities.
2.2.a.2. To conduct sensitisation programmes in pain relief and palliative care
for 25% of all doctors, nurses and other health / social welfare workers in
the state
2.2.a.3. At least 150 doctors and 150 nurses in the state to successfully
complete Foundation Course in Palliative Care. (Ten days ‘hands on’
training in Palliative Care with three days/20 hours of interactive theory
sessions)
2.2.a.4. At least 50 more doctors and 50 more nurses in the state to
successfully complete six weeks training in palliative care (Basic
Certificate Course in Palliative Care). In addition to this availability of
essential drugs including oral morphine and protected time for trained
professionals and provision for inpatient beds where appropriate to be
ensured in government hospitals having doctors and nurses successfully
completed six weeks courses.
2.2.a.5. To develop more than 100 new community based palliative care
programmes with home care services in the state with active participation
of CBOs, LSGIs and local government and other health care institutions.
2.2.a.6. To develop common bodies/platforms in at least 25% of the LSGIs to
coordinate the activities of CBOs, LSGIs and local health care programmes
in the field of palliative care.
2.2.a.7. To establish a palliative care service, with availability of essential
drugs including oral morphine and with at least one trained doctor and

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PALLIATIVE CARE POLICY FOR KERALA,
 trained nurse, in all government medical college hospitals in the state and
in district hospitals in districts without Medical College.
2.2.a.8. To integrate the provision for palliative care into the house visit and
field level activities of the field workers (Junior Health Inspector and
Junior Public Health Nurse) and their supervisors.
2.2.a.9. To make essential medicines for palliative care available to patients
covered by palliative care services through palliative care units / Primary
Health Centres/other government hospitals.
2.2.a.10. To develop at least four more training centres in the state for
advanced training in palliative medicine and nursing.
2.2.a.11. To develop and incorporate palliative care modules in medical,
dental, nursing, pharmacy and paramedical courses.
2.2.a.12. To introduce palliative care in to the training programmes for elected
members to LSGIs and concerned officials.

b. Long term objectives (five - ten years)

2.2.b.1. To ensure the presence of at least 1000 active volunteers trained in
palliative care in each district at any time.
2.2.b.2. To make community based palliative care programmes with home
care services available to most of the needy in the state with active
participation of CBOs, LSGIs and local health care programmes
2.2.b.3. To develop common bodies/platforms in most of the LSGIs to
coordinate the activities in the field of palliative care of CBOs, LSGIs and
local health care programmes.
2.2.b.4. To ensure the presence of the minimum necessary trained
professionals in palliative care in each district. This will mean all the
doctors, nurses and other health / social welfare workers sensitised;
Minimum of 75 doctors and 75 nurses to complete Foundation course;
Minimum of 25 doctors and 25 nurses to complete Six week course in
Palliative Care. There should be a mechanism to utilise the services of
trained professionals in the delivery of services.
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PALLIATIVE CARE POLICY FOR KERALA,
2.2.b.5. To empower the LSGIs in the state to develop programmes for
training volunteers in palliative care and facilitating the development and
involvement of CBOs.
2.2.b.6. To develop a system of monitoring the palliative care service in the
state to facilitate quality assurance. A guideline for quality control to be
developed at state level with a monitoring / implementing mechanism at
the district level.
2.2.b.7. To develop a system to document and compile data on the palliative
care related activities and patient population at district and state level.
2.2.b.8. To continue training and facilitation to empower community to share
the care and support of people needing palliative care by organising
human and financial resources available locally
2.2.b.9. To develop post graduate courses in palliative care in Medical and
Nursing Colleges in the state
2.2.b.10. To establish Palliative care as part of basic health care available at the
community level

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PALLIATIVE CARE POLICY FOR KERALA,
3. DEVELOPMENT OF SERVICES
3.1. Guiding principles:
a. Home-based care should be the cornerstone of palliative care in the state.
The role of family in the care of chronically ill patients should be recognised.
They should be socially supported and empowered to cope with the situation.
The patient and the family should be the focal points of the palliative care
programmes.
b. Palliative care should be part of general health care system of the
Government machinery.
c. The three tier governance system in Kerala in which health care institutions
up to the district level are transferred to the LSGIs, gives good opportunity for
the LSGIs to facilitate the development of pain and palliative care services
through the existing network of institutions in co-ordination with CBOs and
community in general.
d. Field level health workers and their supervisors should be able to
incorporate the principles of palliative care into their routine activity at the
household level. For this purpose the existing manpower and institutions in
health need to be oriented and equipped adequately.
e. The Government machinery will make use of the experience that CBOs /
NGOs have acquired in training and delivery of palliative care in the state and
will work with them.

3.2. Involvement by different sectors

a. Government Sector: There should be adequate facilities in govt. hospitals and
other health institutions for providing palliative care services at the
institutional level and field level. They are expected to work closely with the
CBOs and NGOs under the overall coordination of the LSGIs.
3.2.a.1. Field level and Sub Centre level activity: Male and Female Multi
purpose health workers, who are expected to provide the components of
comprehensive primary health care services at the household level
through the sub centers and at the PHCs, can be provided with the
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PALLIATIVE CARE POLICY FOR KERALA,
 necessary orientation cum skill development training to play a major role
along with the CBO volunteers and family members in providing home
based care. CBOs and LSGIs should be encouraged to participate in
palliative care delivery at this level.
3.2.a.2. Primary Health Centres and Community Health Centres: The PHCs
and CHCs in the rural areas should be empowered to provide the
necessary institutional level palliative care. Through the necessary
training programmes and by filling the critical gaps in availability of
drugs and other components of service provision, these institutions are to
be equipped for the above purpose. The medical officer of the PHC/CHC
will have a crucial role along with the CBOs and the LSGIs in developing
a common platform for the co ordination.
3.2.a.3. Taluk Head Quarters hospitals: Where ever the existing palliative
care services are located at far away centres, efforts should be made to
provide full fledged palliative care services in Taluk hospitals. Efforts
should also be made for the integration of the pain and palliative care
concepts and skills into the existing specialty services of the Govt.
Hospitals
3.2.a.4. District Hospitals & Medical Colleges: Each district must have a
tertiary level pain and palliative care service with a trained doctor and
staff nurse, housed either in a Medical College Hospital or a District
Hospital. They should have specialist and inpatient palliative care
services and ideally, facilities for training too.
3.2.a.5. Creation of training centres: More training centres need to be
developed in the state. In addition to training centres which may evolve
in the NGO/CBO sector, efforts should be made to start more training
centres in government sector.

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PALLIATIVE CARE POLICY FOR KERALA,
b. Community Based Organisations (CBOs) Issues associated with patients
needing palliative care are as much social as emotional or physical. The society
can pool its resources through CBOs to address many of these issues. As
shown by experience in some Northern districts of Kerala, there is tremendous
improvement is palliative coverage where CBOs are active. So participation of
CBOs in palliative care should be encouraged.
3.2.b.1. Proposed minimum criteria for involving community based
organisations in palliative care.
a) They should be local organisations having clearly stated interest in
the care of patients with needing palliative care in their area.
b) The organisation should take the lead role in providing home care
services to the bedridden patients.
c) Should not charge patients or family for their services.
d) The persons involved in the care of patients needing palliative care –
volunteers, nurses, doctors and other health care workers – should
have basic training in palliative care.
3.2.b.2. Responsibilities of CBOs
a) Identify patients needing palliative care in the area with the help of
Local Self Governments (LSGI).
b) Assess the needs of each patient and provide care accordingly.
c) Provide home care service for needy patients.
d) Empower the patients and their families; provide social support and
rehabilitation where ever necessary.
e) Conduct awareness programmes in palliative care for the community
and provide training for volunteers and health care workers.
f) Work together with Local Self Governments and the Government /
Non Government Health Institutions in the area for improving the
care received by the patients.
3.2.b.3. Identification of CBOs: With the help of palliative care programmes
in the neighbourhood, the LSGIs can identify and support CBOs.

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PALLIATIVE CARE POLICY FOR KERALA,
 3.2.b.4. Support for CBOs
a) Local Self Governments can take initiative to form a common platform
for CBOs, Governmental and Non Governmental Health Institutions for
organising support to the patients and family.
b) Local Self Governments should take steps to provide medicines and
other accessories to the poor patients with chronic diseases identified by
the CBOs, with the help of Government health care system.

c. Private Sector: Private sector plays a major role in the health care scenario in
Kerala. Many private hospitals in Kerala are providing palliative care to needy
patients free of cost. Palliative care initiatives by private hospitals should also
conform to the quality control and training criteria set by the palliative care
policy.

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PALLIATIVE CARE POLICY FOR KERALA,
4. CAPACITY BUILDING:
In Kerala at any time there may be a minimum of one lakh people needing
palliative care. So each Panchayat will be having approximately 100 patients at any
given time. To give adequate care to these patients there should be at least one
doctor and two nurses trained in palliative care in every Panchayath to work along
with CBOs and other health care institutions. Also there should be enough trained
volunteers for effectively organising and running the programme at local level.
a. Capacity building in government sector Considering the higher prevalence
of the Non Communicable Diseases including cancers in Kerala, the significant
number of people with HIV/AIDS and due to the increase in the percentage of
the elderly population and the associated conditions requiring the palliative
care services, it is essential that the health staff including the doctors are
equipped with adequate technical and humanitarian skills for dealing the pain
and palliative care services in a systematic manner.
4.1.a.1. Palliative care sessions will be built into existing educational
programs (some of them are given in appendix V)
4.1.a.2. Deputation of staff will be given for the following training programs:
4.1.a.2.1. One to two day sensitisation programs in palliative care arranged
for the purpose in collaboration with existing training programs in
the field.
4.1.a.2.2. 10 day foundation course on pain relief for doctors and nurses.
This course will authorise the doctors to man Recognised Medical
Institutions (RMIs) which can store and dispense oral morphine and
can provide basic pain relief to the needy.
4.1.a.2.3. Six weeks’ certificate course for doctors and nurses in approved
centres.
4.1.a.2.4. Other training programs yet to be developed for other categories
of staff including pharmacists, public health nurses, health inspectors
etc.

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PALLIATIVE CARE POLICY FOR KERALA,
b. Capacity building at CBO/ NGO level: There are many NGOs and CBOs
actively involved in palliative care training programmes for doctors, nurses
and volunteers. Along with supporting these initiatives these training
programmes should be validated and guidelines given. The experience the
NGOs and CBOs have in training can be used to formulate and initiate
palliative care training programmes in government sector. There should be
efforts from governments, CBOs and NGOs to recruit and train more
volunteers at local level.

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PALLIATIVE CARE POLICY FOR KERALA,
5. AVAILABILITY OF MEDICINES AND OTHER EQUIPMENTS
5.1. A palliative care programme cannot exist unless it is based on a rational drug
policy. Persons with incurable and other chronic illnesses need medicines for
prolonged periods, which they may not be able to afford. In many areas CBOs and
NGOs are now providing medicines and other equipments, which is not enough to
cover the enormous needs in the state.
5.2. Medicines commonly needed for palliative care should be included in the essential
drug list of the government hospitals. (Appendix II: List of medicines to be added
to the present ‘Essential Drug List’) Also LSGIs should have provisions to
purchase and distribute medicines and other equipments based on the need in
their area with the help of health care institutions and CBOs.
5.3. There should be clear and adequate guidelines for procuring, storing and
dispensing medicines needing special licenses like morphine. (Appendix III:
Guidelines on training)

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PALLIATIVE CARE POLICY FOR KERALA,
6. ROLE OF OTHER SYSTEMS OF MEDICINE
6.1. Currently palliative care services are developing more as part of Modern Medicine.
The possibility of having similar programmes in other recognised Systems of
Medicine should be explored.

7. RESEARCH
7.1. There should be provisions for locally relevant audit and research at various levels
for improving the programmes and for sharing the experiences.

8. BUDGET ALLOCATION
8.1. There should be separate provision for budget allocation for palliative care
services under
a. Directorate of Health Service
b. Directorate of Medical Education
c. Local Self Government Institutions
d. National Health Programmes
e. Employees State Insurance Scheme

8.2. There should be provisions for deputation of government doctors and nurses to
palliative care services for supporting clinical work and training programmes.

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PALLIATIVE CARE POLICY FOR KERALA,
9. PALLIATIVE CARE POLICY AND OTHER HEALTH PROGRAMMES
9.1. Palliative care can be a component of many health programmes like National
Cancer Control Programmes, National AIDS control Programme, National Non-
communicable Disease Control Programme, National Rural Health Mission etc.
The state palliative care policy is also in line with these related health care
programmes.

10. EVALUATION AND MONITORING

10.1. It is necessary to evaluate the progress of the program at the end of one year,
so as to analyse the strengths and weaknesses of the system and to formulate
strategy for the long term policy. An advisory panel of palliative care workers will
be formed comprising of representatives of the concerned government
departments along with palliative care workers. The annual review will be
followed by revision of short term strategy for the second year as well as
formulation of long term strategy.

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PALLIATIVE CARE POLICY FOR KERALA,
 Palliative Care Policy for Kerala
APPENDIX I

ACTION PLAN FOR TWO YEARS

Ref. Objective Action Responsibility Outcome measure

No:
(See
Policy)
2.2.1.1 To train at least 300 volunteers in Identification and Existing palliative care Number of volunteers
palliative care in each district to training of volunteers groups, Networks and trained
facilitate the development and Facilitation of formation training centres Number of districts covered
involvement of CBOs with of CBOs Local Self Government
emphasis on districts where Institutions (LSGIs )
there are no palliative care
facilities.
2.2.1.2. To conduct sensitisation Formulate and conduct Training centres, Number of government
programmes in pain relief and sensitisation programmes palliative care training programmes in
palliative care for 25% of all for doctors, nurses and organisations (Formulation which palliative care
doctors, nurses and other health other health / social welfare and training) incorporated
/ social welfare workers in the workers. Director of Health Total number of
state Inclusion of palliative Services (Facilitation) sensitisation programmes
care sessions in conducted
Government health training Number of doctors, nurses
programmes and health / social welfare
Inclusion of palliative workers sensitised
care sessions in Cancer
control and HIV/AIDS
training programmes
2.2.1.3. At least 150 doctors and 150 Formulate training Existing Training centres Training module for
nurses in the state to successfully programmes (Institute of Palliative Foundation Course
complete Foundation Course in Announcement of the Medicine, Kozhikode and Number of doctors and
Pain management. (Ten days programme Regional Cancer Centre, nurses trained
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PALLIATIVE CARE POLICY FOR KERALA,
 ‘hands on’ training in with three Self selection by the Trivandrum)
days/20 hours of interactive candidates Newly identified training
theory sessions) centres
Director of Health
Services (Authorise DMOs
for deputing interested
doctors and nurses for
training)
2.2.1.4 At least 50 more doctors and 50 Formulate training Existing Training centres Training module for 6
more nurses in the state to programmes (Institute of Palliative Weeks Course
successfully complete six weeks Announcement of the Medicine, Kozhikode) Number of doctors and
training in palliative care (Basic programme Newly identified training nurses trained
Certificate Course in Palliative Self selection by the centres Number of Government
Care). In addition to this candidates Director of Health hospitals having palliative
availability of essential drugs Ensure availability of Services (Authorise DMOs care services with essential
including oral morphine and essential medicines for deputing interested drugs including oral
protected time for palliative care doctors and nurses for morphine
and provision for inpatient beds training and provision of
where appropriate to be ensured medicines)
in government hospitals having
doctors and nurses successfully
completed six weeks courses.
2.2.1.5. To develop more than 100 new Identify CBO/volunteers Existing palliative care Number of palliative care
community based palliative care Training of volunteers units and networks, State programmes established
programmes with home care Facilitation of and District palliative care Number of patients covered
services in the state with active establishment of palliative Associations and training Number of projects from
participation of CBOs, LSGIs and care services with Home centres. LSGIs
local government and other Care programmes LSGIs (Formulation and
health care institutions. LSGI support through implementation of projects)
projects Dept. of Local
Administration
(Modification of rules if
necessary and evolving
guide lines for projects)
19
PALLIATIVE CARE POLICY FOR KERALA,
2.2.1.6. To develop common Identify interested LSGIs Dept. of Local Number of LSGIs in which
bodies/platforms in at least 25% Identify CBOs Administration common bodies formed
of the LSGIs to coordinate the Instruction to local (Facilitation) Number of CBOs and
activities of CBOs, LSGIs and government health care Dept of H&FW health programmes involved
local health care programmes in programmes / institutions (Instruction to concerned Frequency of meetings by
the field of palliative care. Local workshops by local health care the common body
LSGIs programmes)
Existing palliative care
units and networks, State
and District palliative care
Associations and training
centres.(Help in identifying
CBO)
2.2.1.7. To establish a palliative care Identification of trained Director of Medical Number of medical college
service, with availability of and interested doctors Education with regular palliative care
essential drugs including oral To provide protected time Principals of Government services
morphine and with at least one for the trained health Medical Colleges Number of trained
trained doctor and trained nurse, professionals Existing Training Centres professionals in these units
in all government medical Purchase of medicines (Facilitation) Availability of essential
college hospitals in the state. medicines for palliative care
in medical colleges
2.2.1.8 To establish palliative care Identification of trained Director of Health Number of district hospitals
service, with availability of and interested doctors Services with regular palliative care
essential drugs including oral To provide protected time District Medical Officers services
morphine and with at least one for the trained health Existing Training Centres Number of trained
trained doctor and trained nurse, professionals (Facilitation) professionals in these units
in all district hospitals in Purchase of medicines Local palliative care units Availability of essential
districts without a govt. medical medicines for palliative care
college in district hospitals
2.2.1.9. To integrate the provision of the Training JHI, JPHN and Dept of H&FW Number of Local Health
home care services for bedridden supervisors (Instruction to concerned Programmes involved in
and chronically ill patients into Interaction between local local health care home care services.
the house visit and field level health programmes, CBOs programmes) Number of trained JHI,
activities of the field workers and LSGIs Existing Training JPHN and supervisors
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PALLIATIVE CARE POLICY FOR KERALA,
 (Junior Health Inspector and Centres, palliative care involved in home care
Junior Public Health Nurse) and units and networks services in these units
their supervisors. (Facilitation)
Common bodies /
platforms as in 2.2.1.6.,
(Facilitation)
2.2.1.10 To make essential medicines for Inclusion of medicine Discussion group for Essential drugs list for
palliative care available to needed for palliative care to palliative care policy palliative care
patients covered by palliative ‘Essential Drugs List’ (preparation of essential Number health institutions
care services through palliative To make provision for drugs list for palliative with regular supply of
care units /Primary Health annual indent for relevant care) medicine for palliative care
Centres/other government health institutions Dept of H& FW Development of guidelines
hospitals. Evolve guidelines for (purchasing and for purchase and
purchase and uninterrupted distribution of medicines) uninterrupted distribution of
distribution of medicines by Dept. of Local medicines by LSGI to the
LSGI to the patients Administration patients identified by CBOs /
identified by CBOs / (Modification of rules if palliative care units
palliative care units necessary and evolving
guide lines for purchase
and supply of medicines
through projects)
2.2.1.11 To develop at least four more Formulate criteria for Advisory Panel to Drugs Criteria for training centres
. training centres in the state for training centres controller on RMIS Number of new training
advanced training in palliative Identification / self (Formulating and centres
medicine and nursing. selection from palliative Identification) Number of trainers
care centres satisfying the Local CBO/NGO/LSGIs
criteria for training centres (Infrastructure building)
Provision for additional Local CBO/ existing
infra structure and other training centres/ Dept of
facilities including staff H& FW
Provision of trainers
2.2.1.12 To develop and incorporate Workshop for preparing Indian Association of Modules developed for each
palliative care modules in the modules Palliative Care – Kerala course
medical, dental, nursing, Introducing modules in (Workshops) Number of Undergraduate
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PALLIATIVE CARE POLICY FOR KERALA,
 pharmacy and paramedical Government teaching National level palliative course in which palliative care
courses. institution in Kerala care programmes is introduced.
Taking up the issue with (Facilitation)
Medical, Dental, Nursing DME, DDE, State
and Paramedical Councils Nursing and Paramedical
councils (introduction of
modules)
Dept. of H&FW (Taking
up the issue with National
Councils)
2.2.1.13 To introduce palliative care in to To develop module for Kerala Institute of Local Modules developed for
the training programmes for training Administration (KILA) training
elected members to LSGIs and Incorporate the module in Existing palliative care Number of elected members
concerned officials. to training programmes training centres and officials trained
2.2.1.14 To modify current regulations To restructure current Drugs controller with New standard operating
regarding recognition of procedures bringing in help of advisory panel procedures
Recognised Medical Institutions updated standard operating
and for improving availability of procedures
opioids for medical use
2.2.1.15 To review results and Compiling data Existing State and Action plan for future
formulate/modify action plans Comparing with targets District level organisations
after two years, in accordance Identifying deficiencies in palliative care
with long-term objectives. Suggestions for Department of H&FW
improvement Department of Local
Administration
Advisory panel to Drugs
Controller

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PALLIATIVE CARE POLICY FOR KERALA,
Palliative Care Policy for Kerala

APPENDIX II

WORLD HEALTH ORGANISATION RECOMMENDATIONS.

The World Health Organization (WHO) recommends that, to be effective, any
palliative care policy has to address all three sides of the following triangle with the
State Policy at the base, their broad objective being to improve access to palliative care
to all those who need it.

The WHO also gives the following specific guidelines

1. Governments should establish national policies and programmes for
palliative care.
2. Governments of member states should ensure that palliative care
programmes are incorporated into their existing health care systems;
separate systems of care are neither necessary nor desirable.
3. Governments should ensure that health-care workers (physicians, nurses,
pharmacists, or other categories appropriate to local needs) are adequately
trained in palliative care.
4. Governments should review their national health policies to ensure that
equitable support is provided for programmes of palliative care in the home.

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PALLIATIVE CARE POLICY FOR KERALA,
5. In the light of the financial, emotional, physical, and social burdens carried
by family members who are willing to care for cancer patients in the home,
governments should consider establishing formal systems of recompense for
the principal family caregivers.
6. Governments should recognize the singular importance of home care for
patients with advanced cancer and should ensure that hospitals are able to
offer appropriate back-up and support for home care.
7. Governments should ensure the availability of both non-opioid and opioid
analgesics, particularly morphine for oral administration. Further, they
should make realistic determinations of their opioid requirements and
ensure that annual estimates submitted to the INCB reflect actual needs.
8. Governments should ensure that their drug legislation makes full provision
for the following:
regular review, with the aim of permitting import, manufacture,
prescribing, stocking, dispensing, and administration of opioids for
medical reasons;
legally empowering physicians, nurses, pharmacists, and where
necessary, other categories of health-care worker to prescribe, stock,
dispense, and administer opioids;
review of the controls governing opioid use, with a view to
simplification, so that drugs are available in the necessary quantities
for legitimate consumption by patients.

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PALLIATIVE CARE POLICY FOR KERALA,
Palliative Care Policy for Kerala
APPENDIX III
DRUGS TO BE ADDED TO THE “ESSENTIAL DRUGS LIST” OF GOVT. Of KERALA FOR
PALLIATIVE CARE SERVICES
PRIMARY CARE HOSPITALS (DISPENSARY & MINI P H C)
Sl. No. NAME OF THE DRUG STRENGTH
I. ANTI INFLAMMATORY & ANTIARTHRITICS
1 T. MELOXICAM 15 mg
2 T/C. DEXTROPROPOXYPHENE+ PARACETAMOL 65 mg + Paracetamol
VI. ANTI ALLERGIC AND DRUGS USED IN ANAPHYLAXIS
1 T. DEXAMETHAZONE 0.5 OR 4 mg
2 INJ. DEXAMETHAZONE 8 mg vials
3. T. CETRIZINE 10mg
VII. ANTI EPILEPTIC DRUGS
1 T. SODIUM VALPROATE 200mg
X. ANTI FUNGAL DRUGS
1 T. FLUCONAZOLE 150 mg
XXI. G I T DRUGS
1 Liq. Paraffin + Milk of Magnesia
2 T. METOCLOPRAMIDE 10 mg
3 T. BISACODYL 5 mg
4 SODIUM PHOSPHATE ENEMA
5 CAP. OMEPRAZOLE 20 mg
OTHERS
1 T. ALDACTONE 100 mg
2 T. ETHAMSYLATE 500 mg
3 LIGNOCANE GEL
ANTI DEPRESSANT/ ANTIPSYCHOTICS
1 T. IMIPRAMINE 25 mg
2 T. FLUOXETINE 20 mg
3 T. HALOPERIDOL 5 mg

SECONDARY CARE HOSPITALS (BLOCK PHC & CHC)

I. ANALGESICS & ANTIPYRETICS
1. T. MELOXICAM 15 mg
2. T/C. DEXTROPROPOXYPHENE+ PARACETAMOL 65 mg + Paracetamol
3. T. CODEINE 10MG
4 T. MORPHINE 10 mg/ 20 mg
VI ANTI ALLERGICS AND DRUGS USED IN ANAPHYLAXIS

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PALLIATIVE CARE POLICY FOR KERALA,
 1. T. DEXAMETHAZONE 4 mg
X ANTIFUNGAL DRUGS
1. T. FLUCONAZOLE 150 mg
IXX PSYCHOTROPIC DRUGS
1. T. FLUOXETINE 20 mg
XXII DIURETICS
1. T. ALDACTONE 100 mg
XXIII G. I .T DRUGS
1. T. METOCLOPRAMIDE 10 mg
2 LIQ. PARAFFIN + MILK OF MAGNESIA
3 SODIUM PHOSPHATE ENEMA
4 BISACODYL SUPPOSITORY

THALUK HOSPITALS
I ANALGESICS, ANTIPYRETICS, ANTIINFLAMATORY, ANTIARTHRITICS
1 T. MELOXICAM 15 mg
2 T/C. DEXTROPROPOXYPHENE+ PARACETAMOL 65 mg + Paracetamol
3 T .CODEINE 10 mg
4 T. MORPHINE 10/20 mg
5 Inj. MORPHINE 15 mg /ml
XI ANTI ALLERGIC USED IN ANAPHYLAXIS
1 Tab. DEXAMETHAZONE 4 mg/ml
XII ANTIFUNGAL DRUGS
1 FLUCONAZOLE 150 mg
XXV G.I.T DRUGS
1. LIQ. PARAFFIN + MILK OF MAGNESIA
2. SODIUM PHOSPHATE ENEMA
3. BISACODYL SUPPOSITORY
TERTIARY HOSPITALS
I ANALGESICS, ANTIPYRETICS, ANTI-INFLAMMATORY, ANTIARTHRITICS
1 T. MELOXICAM 15 mg
2 T/C. DEXTROPROPOXYPHENE+ PARACETAMOL 65 mg + Paracetamol
3 T . CODEINE 10 mg
4 T. MORPHINE 10/20 mg
5 Inj. MORPHINE 15 mg / ml
XI ANTIFUNGAL
1. FLUCONAZOLE 150 mg
XXV G.I. T DRUGS
1. LIQ. PARAFFIN + MILK OF MAGNESIA
2. SODIUM PHOSPHATE ENEMA
3. BISACODYL SUPPOSITORY
26
PALLIATIVE CARE POLICY FOR KERALA,
Palliative Care Policy for Kerala

APPENDIX IV

Minimum training required for doctors-in-charge of Recognised Medical Institutions

(RMI) for storage and dispensing of oral Morphine

Educational Qualification: -
The doctor should have MBBS with successful completion of internship and Indian
Medical Council Registration
He/ she should have successfully completed the foundation course at a recognised
centre for Palliative Care training, The course should have a minimum of .ten days
‘hands on’ training in Palliative Care with three days interactive theory sessions

Recognised Training Centre: -

For recognition by the government as a training centre in palliative care for doctors and
nurses, the training unit should have the following minimum facilities
a) Out patient Services
b)Home care services
c) Inpatient Unit or access to Inpatient care facilities
d) A minimum of 100 patient contacts every week.
e) A minimum of 20 % of the working time of the doctors and nurses
identified as trainers should be kept protected for the training
activities.
The trainer doctor:
Should be a qualified doctor with Indian medical council Registration. She/He should have the
experience of at least one year as a full time Palliative Care Physician at a centre described above.
Or
She / He should have six months experience as a full time Palliative Care Physician at a
centre described above after successful completion of a minimum of six weeks training in
Palliative Care at a recognised training centre

It should be mandatory for the recognised training centres to submit a report of training
activities to the government every year.
The Government will notify the training programmes conducted by the Recognised Training Centres.

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PALLIATIVE CARE POLICY FOR KERALA,
 Palliative Care Policy for Kerala
APPENDIX V

Human Resource Development in the Government Sector as part of

Capacity Building in Palliative Care.

I. Human Resources Development of doctors and other health staff on pain and palliative
care services.
Considering the higher prevalence of the Non Communicable Diseases including cancers
in Kerala, and due to the increase in the percentage of the elderly population and the
associated conditions requiring the palliative care services, it is essential that the health
staff including the Doctors are equipped with adequate technical and humanitarian skills
for dealing the pain and palliative care services in a systematic manner.
Training programmes for the Health staff can be organized as separate programme
indented for the above purpose, and also in the various ongoing training programmes of
the Health services department it can be included as a component.
AN OVERVIEW OF THE TRAINING PROGRAMMES CONDUCTED BY THE HEALTH SERVICES
DEPARTMENT.

A. RCH training:
i. Integrated skill development training. It is the purpose of this training to develop
comprehensive skill development in their respective area of work. It is intended to
develop clinical skill, communication skill and managerial skill connected to their
respective job responsibilities. Since all these trainings are long duration trainings
extending few weeks, it may be possible to allocate at least few theory and
practical sessions on pain and palliative care.
a. For JPHNs : Duration -Two weeks. (12 Working days) . It includes theory
classes, along with hospital and field level on the job training. Theory classes, and
hospital based and field level training on the pain and palliative care can be very
well incorporated as part of this package.
b. For JHIs, HIs & HSs : One week training.
c. For LHIs & LHS s; Three week (18 Working days)
d. Medical Officers : Two weeks training.
e. Staff Nurses : Two weeks training.
f. Pharmacists : Two weeks training.
Palliative care can be incorporated in the RCH trainings taking place in all the 14 districts.

B. Training Programmes implemented through the State institute of Health and Family
Welfare Thiruvananthapuram and Family Welfare training center, Kozhikode, and
training center Trippunithura , Ernakulam.
i. Trainings included in the plan schemes: Generally these trainings for various
category of health staff are being implemented through the state institute of the

28
PALLIATIVE CARE POLICY FOR KERALA,
 Health and family Welfare located at Thiruvananthapuram. In various training
programmes sessions on the pain and palliative care can be included.
Also based on the requirements next year onwards special pain and palliative trainings
can be included for doctors and other paramedical on co ordination with Institute of
Palliative Medicine, Kozhikode and Regional Cancer Centre, Thiruvananthapuram.
ii. State training Policy trainings: Based on the training need assessment of the health
Services Department for the last three years state training Policy trainings were
planned and being implemented to major category of the health staff ( For clinical
and field level workers )including doctors.
Two sessions on palliative care can be included in these training programmes.

C. Training programmes implemented through the state level cancer control

Programme.
Utilizing the plan fund under the head of the cancer Care, for last few years state level
orientation training of 2-3 days duration for the medical officers working in the peripheral
institutions are being provided. It is the aim of these trainings to make them familiar with
the components of the national cancer control Programme. The importance of the
awareness generation, prevention, early diagnosis, and case management, and the
importance of the pain and palliative care in the cancer are being covered in these short
duration trainings. Utilizing the services of these trained doctors district level training of
two days were conducted for the field workers and supervisors in most of the district.
In co ordination with the regional Early Caner Detection Centres (ECDCs) of the RCC
cancer detection camps are also being arranged in many districts.
Based on the requirements training programmes in palliative care to be formulated and
implemented through this scheme.

D. Training Programmes organized through the KSACS:

HIV /AIDS training including that on care and support are being provided to doctors ( 3
days duration )and various category of Paramedical staff( 2 days duration) through the
KSACS. Awareness training for Anganwadi Workers and Kudumbasre volunteers is also
provided. Palliative care of course is a component of the care and support part of the
HIV/ADS programme. Sessions on the importance of the palliative care in general and
HIV/AIDS in particular can be organized through the KSACS trainings.

E. Special training for Medical Officers and paramedical staff for providing the
institution based palliative care services.
Considering the requirements of the palliative clinics in the peripheral institutions, skill
development trainings can be provided for more number of doctors and other
paramedical staff, so that adequate service centres can be started. The existing training
programmes may be evaluated and modified if necessary by a review committee (and the
duration of the training programme may be reduced if possible) and necessary training
programmes may be planed and implemented at the Institute of palliative Medicine,
Kozhikode and Regional Cancer Centre, Thiruvananthapuram.
29
PALLIATIVE CARE POLICY FOR KERALA,
II. Awareness Generation Training (AGT) of One day duration: May be newly planned
and organized for the LSGI representatives, for the other departmental officials etc.

National Rural Health Mission and palliative care:

Next year onwards preparation of the implementation plans will be done by the village
Health and sanitation committees, at village levels. District action plans are in reality the
consolidation of the village plans. If there is a genuine requirement of the pain and
palliative care services in the periphery, it can be very well included in the village/
panchayath / district action plans and fund requests can be made.

The multi purpose health workers in their annual household survey can make an
assessment of the patients requiring palliative care in their respective field areas. Then
under the National Rural Health Mission( NRHM) framework for every village, while
preparing health and sanitation plans, the requirement of the pain and palliative care
services can also be brought into the planning process from the grass-root level through
the health workers.

III. Integrating the component of the Pain and Palliative care services into the Medical,
Nursing, Dental and Paramedical curriculum
Considering the field level requirement of the pain and palliative care services at the
various levels of the Health care services, a basic understanding of the theory and practice
of the palliative care is to be made available for all the Medical and Para-medical students
as part of their regular course For the above purpose specific allocation of the theory class
hours and facility for attending the pain and palliative clinic to be made mandatory.
Medical council, Nursing council and other paramedical councils may take necessary
steps for this.

IV. Post Graduate Training in palliative care

All the postgraduate students in clinical departments in various medical colleges in the
state should undergo a minimum of two weeks training in palliative care as part of their
regular training program.

Action will be taken to initiate post graduate courses in palliative medicine and nursing in
Kerala.

________________

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PALLIATIVE CARE POLICY FOR KERALA,
Palliative Care Policy for Kerala

APPENDIX VI

Proposed Structure of Monitoring Committees

Sate Level Monitoring Committee

Chairman/Chairperson : Minister for Health and Family Welfare

Vice Chairman/Vice Chairperson : Health Secretary
Convenor : Director of Health Services
Members : Director of Medical Education
Director of Social Welfare
Director of Local Self Government Institutions
Drugs Controller
Representative, Indian Association of
Palliative Care – Kerala Chapter
Representatives from Training Centres
(Institute of Palliative Medicine, RCC)
Convenor, Advisory Panel on Palliative care to
the Drugs Controller, Kerala

Frequency of meeting: The state level monitoring committee should meet at least 1 – 2
times an year.

District level Monitoring Committee

Chairman/Chairperson : President, Jilla Panchayath

Vice Chairman/Vice Chairperson : District Collector
Convenor : District Medical Officer
Joint Convenor : Secretary, District level Palliative Care Initiative
Members : Superintendent, District Hospital
Deputy Director Panchayath Department
District Social Welfare Officer
Representatives from Govt. Hospitals at Taluk
level and above having palliative care clinics
Representatives from Training Centres in the
district
Representatives from CBOs (Through the District
level Palliative Care Initiatives)

Frequency of meeting: The district level monitoring committee should meet at least 3 – 4
times a year.

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PALLIATIVE CARE POLICY FOR KERALA,
Local Self Government Level Monitoring Committee

Common body / platform formed (see policy)

Chairman/Chairperson : President, LSGI

Convenor : Medical Officer in Charge,
Local Govt. Health Facility
Joint Convenor : Secretary, Local Palliative Care Unit
Members : Nurse/Doctor from Local Palliative Care Unit
: Health Supervisors

Frequency of meeting: The LSGI level monitoring committee should meet at least once
every month.

_____________________

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PALLIATIVE CARE POLICY FOR KERALA,
Palliative Care Policy for Kerala

APPENDIX VII

Proposed Budgetary Sources

I. 11th Five Year Plan

Efforts have been taken for the inclusion of the public health programmes for the
Non Communicable Diseases, Elderly care, Palliative Care etc in the 11th Five year
plan. If the above schemes may be included as

A. Centrally Sponsored Schemes

• National Rural Health Mission (NRHM)

• National Disease Control Programmes (Cancer, AIDS etc.)

B. State sponsored Schemes

• Directorate of Health Services, support to

1. Training
2. Home care services and field level activities
3. Institutional support to develop palliative care facilities

• Directorate of Medical Education, support to

1. Training
2. Institutional support to develop palliative care facilities

A separate budget at DME and DHS for palliative care is necessary

II. Local Self Government Institutions (LSGIs)

Budget allocation to health care including palliative care from both
1. Plan funds
2. Own funds

____________________

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PALLIATIVE CARE POLICY FOR KERALA,