Integrated Training for NTP (iTrain)

CASE HOLDING
Palliative Care
 Session Objectives
By the end of the training, the participants will be
able to:

 Ensure provision of quality of life of patients

with TB.
 Ensure that patients and their families are given
holistic management during TB treatment to
attain treatment completion.
 Empower patients to participate in the
management of TB.
 Ensure that patients and their families will not
be abandoned even if cure is not anymore
possible.
Department of Health NCRO – National TB Control Program
 Outline
 Introduction
 Definition of Terms
 Policies
 Topic
I. Preparation for Initiation of Treatment
II. Initiation of Treatment
III. Supervision of Treatment
IV. Case Management
V. Monitoring Treatment Response
VI. Management of Treatment Interruption
VII. Community-Based Care
VIII. Palliative Care
IX. Determining Treatment Outcome for TB

Department of Health NCRO – National TB Control Program

 Policies
A. Palliative care shall be integrated in the
management of TB.

Department of Health NCRO – National TB Control Program

B. Dept. Memo No.
2017-0250- Provision
of Patient-centered
Supervision
Treatment for DR-TB

Annexes page 51

Department of Health NCRO – National TB Control Program

To operationalize the provision of patient-
centered supervised treatment, the following
strategies shall be implemented:
1. Make the clinic hours in the iDOTS treatment facility
flexible;
2. Decentralize patients to the nearest health facility;
3. Engage treatment partners such as but not limited
to, staff of the health center, Bgry. health station, health
care workers who are part of the DOH Deployment
programs, Brgy. Health workers, community heath teams,
cured TB patients, physicians or nurse in the
company/school. Clinic or volunteer health worker in the
community or in the Brgy. where the patient is residing.
Dept. Memorandum No. 2017-0250

Department of Health NCRO – National TB Control Program

 Definition of Terms
Palliative Care
"an approach that improves the quality of life
for 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 assessment
and treatment of pain and other problems,
physical, psychosocial and spiritual“

- WHO

Department of Health NCRO – National TB Control Program

 Background
In November 19, 2010, a declaration on Palliative
Care and MDR/XDR-TB was done in Geneva.
1. Access to palliative care for individuals with
MDR-TB/XDR-TB is a human right and promotes
dignity.
2. Palliative care in the context of MDR/XDR-TB
should be integrated into the management of
MDR/XDR-TB from the time of diagnosis until
patient reaches cure or the end of life.

Department of Health NCRO – National TB Control Program

Palliative care should start as soon as the
patients present for care and should emphasize
on maintaining quality of life at any age and
stage of illness.

Palliative care approach is an essential part of

patient centered care approach in TB
management.

Department of Health NCRO – National TB Control Program

 VIII. Palliative Care
Who will do the task?

All health
service
providers

Department of Health NCRO – National TB Control Program

 Procedures
A. Providing Care for Relief of Symptoms
All patients diagnosed to have TB must be provided
care to alleviate symptoms. The health care
provider shall:
1. Counsel and educate patient and family about TB disease
and enjoin him/her to participate in the management of his
disease (e.g. decision on where to seek treatment, decision
to faithfully adhere to treatment, etc.)
2. Monitor adverse events, counsel and give ancillary drugs to
control adverse events.
3. Instruct patient and his/her family members to implement
infection control in the household and community.

Department of Health NCRO – National TB Control Program

B. Managing Patients who refused and are not
responding to available DR-TB treatment
1. Plan on how to approach patient, his/her
family and significant others in disclosing the
plan to suspend anti TB treatment and other
options if treatment will not be initiated.
2. Discuss with the patient and family the
management plan to alleviate symptoms of TB
and to ensure that respiratory infection control
is in place.
3. Offer options to control patient’s symptoms to
maintain quality of life and dignity when giving
anti TB treatment is not an option.

Department of Health NCRO – National TB Control Program

The following are the end of life support
measures:
End of Life Support Management

Relief of Dyspnea • Give Oxygen support

• Give Morphine according to
established clinical protocols in
literature

Relief from pain and other symptoms
• Give Paracetamol, or codeine with
paracetamol, gives relief from
moderate pain. If possible, stronger
analgesics, including morphine, should
be used when appropriate to keep the
patient adequately comfortable
• Refer to WHO-developed analgesic
guides, pain scales and a three-step
‘ladder’ for pain relief for further
guidance.

Department of Health NCRO – National TB Control Program

 End of Life Support Management

Infection control Measures • • Continue infection control practice

with reinforcement on
environmental and personal
measures including the use of N-95
mask for caregivers.

Nutritional support • • At the end of life, give small and

frequent feeding. It is expected that
intake will reduce as the patient
deteriorates.
• • Treat nausea and vomiting that
interferes with nutritional support.

Regular Medical Visits • Visit patient to address medical

needs and to ensure that infection
control is being followed.

Department of Health NCRO – National TB Control Program

 End of Life Support
Continuation of ancillary medicines
Provision of psychological support
Other supportive care
Department of Health NCRO – National TB Control Program
Management
• Give butamirate citrate, morphine,
codeine to control cough.
Give metered dose inhalers to control
bronchospasm
Manage anxiety and depression.
• Provide counseling to patient and
family to assist in planning for
decisions related with end of life
and provide emotional support
especially in which strong stigma is
attached to the disease
• Give oral care
• Prevent bedsores among bed borne
patients
• Advise use of egg crate mattress
• Change position of patient regularly
• Keep the bed dry and clean
 End of Life Support Management

Respect for patient’s beliefs and values •
during treatment, and especially at the
end of life
Respect patient’s belief, values and
practices and avoid imposing
personal views that prevent the
patient to seek and find comfort in
the services delivered by faith-
based organizations.

Hospitalization, hospice care, or • Refer to palliative care

nursing home care specialist/team for further care.

Department of Health NCRO – National TB Control Program

C. Implementing Palliative Care

1. Organize a team to provide palliative care.

2. Train staff to promptly identify and address
adverse events due to first and second line anti-
TB drugs and due to complications of advanced
TB disease and other co-morbidities.
3. Train staff in counseling to address the psycho
emotional and spiritual needs of the patients
and their families.
4. Provide free ancillary drugs and other regulated
drugs such as opioids (e.g. Morphine),
benzodiazipines, antipsychotic (e.g. haloperidol)
drugs.
5. Secure an S2 license to have access to regulated
drugs.

Department of Health NCRO – National TB Control Program

Summary of Procedure

A. Providing Care for Relief of Symptom

B. Managing Patients who refused and are not

responding to available DR-TB treatment

C. Implementing Palliative Care

Department of Health NCRO – National TB Control Program

Familiarize with the following:

 MDTRB survivor speaks (video

presentation)

Department of Health NCRO – National TB Control Program

Integrated Training for NTP (iTrain)

END OF
PRESENTATION