International
Palliative Care Network
Lecture Series 2013
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International Palliative Care Network
Lecture Series 2013
Models of Care and Strategies
to Provide Early Palliative Care
Delivery
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International Palliative Care Network
Lecture Series 2013
Development of Palliative Care in Lebanon
Presenters:
Dr. Hibah Osman
Ms. Loubna Batlouni
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International Palliative Care Network
Lecture Series 2013
Balsam- Lebanese Center for Palliative Care
Beirut, Lebanon
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International Palliative Care Network
Lecture Series 2013
Hibah Osman
Medical Director
Blasam- Lebanese Center for Palliative Care
h.osman@balsam-lb.org
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Lecture Series 2013
About the Presenter
Hibah Osman is a family physician and a
palliative care specialist. She is founder of
Balsam-Lebanese Center for Palliative Care
and serves as its Medical Director. She
recently received the Hospice and Palliative
Medicine Certificate from the American Board
of Family Medicine. She is in private practice
and leads the palliative care team at the
American University of Beirut Medical Center.
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International Palliative Care Network
Lecture Series 2013
Loubna Batlouni
Outreach Coordinator
Blasam- Lebanese Center for Palliative Care
l.batlouni@balsam-lb.org
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International Palliative Care Network
Lecture Series 2013
About the Presenter
Loubna Baltouni is the Outreach Coordinator
at Balsam- Lebanese Center for Palliative Care.
She is a public health professional with an
interest in health promoting palliative care.
She is responsible of awareness raising,
advocacy, and capacity building activities at
Balsam.
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International Palliative Care Network
Lecture Series 2013
Conflict of Interest or Funding Source
• None
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International Palliative Care Network
Lecture Series 2013
Outline
• Palliative Care Milestones in Lebanon
• Evolution of Models of Care
• Palliative care delivery in Lebanon:
 Challenges
 Facilitators
• Introducing Balsam
 The team
 The services
 Some figures
• Provision of Home-based Palliative Care- Balsam’s experience:




Challenges at the healthcare provider level
Facilitators at the healthcare provider level
Challenges at the caregiver level
Facilitators at the caregiver level
• Future of Palliative Care in Lebanon
 Recognition of palliative care as a specialty
 Advocacy activities of the National Committee
• Acknowledgement
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Lecture Series 2013
Lebanon
•
Area: 10452 km2
•
Population: 4.5 million
•
Health system:
 Highly Privatized
 National Social Security Fund
 Ministry of Public Health
 Out of pocket expenditure
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International Palliative Care Network
Lecture Series 2013
Palliative Care Milestones in Lebanon
1995:
• Pain relief and Palliative Care identified as a priority during the World
Health Organization National Cancer Control Workshop
• Morphine quota: 0.5Kg
• Patients registered to receive opioids: 95
1999:
• A full day symposium on Palliative Care and Ethics organized by the
Lebanese Cancer Society:


Recommendations submitted to the World Health Organization
Action plan submitted to the Ministry of Public Health
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Lecture Series 2013
Palliative Care Milestones in Lebanon
2000:
• Two-day workshop organized by the Lebanese Cancer Society to discuss
the principles and barriers

Need to introduce pain relief and palliative care in undergraduate medical curricula
identified
2001:
• Nine fellows attended the “Education of Physicians on End-of-life Care”
course in the United States and one week of bedside training
• Morphine quota: 4.5Kg
• Patients registered to receive opioids: 600
• Pain Relief and Palliative Care Group launched by the Lebanese Cancer
Society
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Lecture Series 2013
Palliative Care Milestones in Lebanon
2004:
Legislative changes:
• Physicians have the right to stop treatment if it is deemed “futile” by two
physicians
• ‘Do Not Resuscitate’ orders can be legally written in a patient’s chart
• Morphine supply can be provided for a 4 week period (previously 2 weeks)
2009:
• Opioids can be prescribed to cancer and non-cancer patients
2010:
Non Governmental Organizations that offer home-based palliative care are
established:


The Lebanese Center for Palliative Care – Balsam
The Home Hospice Association of Lebanon – Sanad
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International Palliative Care Network
Lecture Series 2013
Palliative Care Milestones in Lebanon
2011:
• The Lebanese National Committee for Pain Relief and Palliative Care was
established




Standards for pain relief and palliative care
Strategies to engage professionals in the care process
Models for service delivery
Mechanisms to empower the patient and the family
2012:
• A conference was held to share the work of the National Committee’s
subcommittees




Education
Practice
Research
Policy
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Lecture Series 2013
Palliative Care Milestones in Lebanon
2013:
• An issue in the Lebanese Medical Journal will be dedicated to Palliative
Care and will report on the recommendations of the National Committee
for Pain and Palliative Care
• Palliative medicine recognized by the Ministry of Public Health as a
medical specialty
• First hospital based palliative care service established in Lebanon at the
American University of Beirut Medical Center
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Evolution of models of care
• Palliative care was not available in any setting in
Lebanon
• Non-governmental Organizations that offer homebased palliative care were established (2010)
• The American University of Beirut Medical Center is
building a hospital-based palliative care team (2013)
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Palliative care delivery in Lebanon
Challenges:
• Palliative care services not reimbursable by government nor by insurance
companies


•
•
Laws do not facilitate advanced healthcare planning or goal setting,
advanced directives are not legally binding
Difficulties related to opioids availability and prescription




•
•
Organizations offer home based palliative care at no cost and are donor funded
Fear of covering home-based palliative care because they cannot be easily monitored
Opioids can only be prescribed by oncologists and pain specialists
Formulations of opioids available in the market are extremely limited
Number of pharmacies that dispense opioids is limited (~30 pharmacies)
Patients go through a complicated process to obtain opioids (multiple signatures
needed)
Lack of training among health professionals
Very few palliative care specialists in Lebanon
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International Palliative Care Network
Lecture Series 2013
Palliative care delivery in Lebanon
Facilitators:
• Advocacy activities of the National Committee for Pain Relief and
Palliative Care
• Support and responsiveness of the Lebanese Ministry of Public Health
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Lecture Series 2013
Introducing the “Lebanese Center
for Palliative Care- Balsam”
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The Lebanese Center for Palliative Care – Balsam is a non-governmental
organization that works to relieve patient suffering and improve quality of life.
Balsam provides holistic support to patients dealing with life-threatening
illness by providing medical services as well as psychological, social, practical,
and spiritual support within the family and home environment.
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Balsam
• Multidisciplinary Team:
Physician
Clinical psychologist
Clinical pharmacist
Nurses
Social worker
• Home-based services
24 hours a day 7 days a week
At no cost
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Information about Balsam patients from
September 2010 till December 2012
•
•
•
•
•
•
68 patients admitted (10 partial support, 58 full support)
88% had a cancer diagnosis
53 % of patients are females
88% are Lebanese
65 is the patient average age
age range is 20 to 90 years old.
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Lecture Series 2013
Information about Balsam patients from
September 2010 till December 2012
Patients admitted by month of referral
Patient-days per year
10
7
7
6
5
5
4
3
2
2
2
3
2
890
2490
Dec-12
Nov-12
Oct-12
Sep-12
Aug-12
Jul-12
Jun-12
May-12
Apr-12
Mar-12
0
Feb-12
Jan-12
0
Dec-11
0
Nov-11
Jul-11
0
Oct-11
0
Sep-11
0
Jun-11
May-11
Feb-11
0
Apr-11
0
Mar-11
0
Jan-11
1
Dec-10
Nov-10
Oct-10
Sep-10
2
1
Aug-11
2
1
3
Number of patient-days
in 2011
Number of patient-days
in 2012
•Monthly increase in admission rate
•Yearly Increase in patient-days
•Demand goes up as public awareness about the importance of palliative care increases
•Obvious need for palliative care in Lebanon but very few providers offer the service
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Provision of home based palliative care services
Challenges at the healthcare provider level:
• Concerns about losing their patients
• Concerns about losing income
• Not convinced that the palliative care team could offer
services they could not offer themselves
• Limited understanding of palliative care
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Provision of home based palliative care services
Facilitators at the healthcare provider level:
• Regular communication with treating physicians
• Consistently involving treating physicians in major decisions
• Restricting service to home-based care
• Exposure to effective symptom management techniques
increased trust in the palliative care approach
• Having nurses from the hospital working with Balsam helped
remind hospital providers about the availability of palliative
services
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Provision of home based palliative care services
Challenges at the caregiver level:
• Equate opting for palliative care to “giving up”
• Unclear about what the palliative care team could offer them
• Concerned about loosing their relationship with their treating
physician
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Provision of home based palliative care services
Facilitators at the caregiver level:
• Provision of equipment or practical support was the easiest
way to gain entry. Trust was then built gradually.
• Maintaining regular communication with their treating
physician reassured patients
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Future of Palliative Care in Lebanon
The recognition of palliative care as a medical specialty will
open the door to:
• Hospital based palliative care services in medical centers
• Community based palliative care services in primary health
care centers
• Education programs and training opportunities about
palliative care and pain management for healthcare providers
• Coverage of palliative care services by the government
followed by private insurance companies
• Palliative care physicians will be allowed to prescribe opioids
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Future of Palliative Care in Lebanon
The work of the National Committee for Pain and Palliative
Care will open the door to:
• Amendments of laws and policies restricting palliative care
practice and pain management
• The development of a national strategy
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Acknowledgements
• The Lebanese Ministry of Public Health
Minister Ali Hassan Khalil
Director General Dr. Walid Ammar
Members of the National Committee for Pain
Relief and Palliative Care
• Balsam donors and supporters
Individuals
Organizations
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Lecture Series 2013