OI evidence check- IMAI District Clinician Manual October 26-27, 20101 |

Linking IMAI with palliative care in M/XDR-TB

Linking IMAI with palliative care in M/XDR-TB

Aka "Using IMAI tools for palliative care of M/XDR TB"

Drs Akiiki Bitalabeho and Sandy Gove

for the IMAI team and palliative care expert group

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Palliative care: symptom management (during acute and chronic care) and end-of-life care

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IMAI and Palliative CareIMAI and Palliative Care

The first IMAI PC tools were field-tested in 2003.

Palliative care is integrated in all IMAI materials and trainings- for every symptom, consider the specific treatment required and and symptom management.

All cadres of health workers should be trained in palliative care.

Included in pre-service, in-service and second level training materials. Aim is to ensure knowledge and skills for palliative care at all levels and for all health workers.

Clinical mentoring to assure quality of care.

Palliative care in the community: Target is community-based caregivers, community health workers, family and patient (self-management).

Health centre

Community-based care

Central/RegionalHospitals

District hospital

Emphasis on decentralization, to headtoward univeral access, equity.

Health centre

Community-based care

Central/RegionalHospitals

District hospital

Relevant IMAI PC tools for 3 levels

Chronic care approach prepares clinical teams to partner with the patient

Patient centeredPatient self-management is supported by:• Education and booklets• Preparation of treatment and prevention supporters for ART and TB (adherence)•Peer support groups•Involvement by expert patients/lay providers – as trainers, on clinical team

Technically sound home-based care with good supervision by facility teams

Patient self-management and caregiver booklets, cards for each ART regimen

Flipcharts for patient education

IMAI-IMCI tools empower patients and communities

Central, Regional,

University,

DISTRICT HOSPITAL

COMMUNITY

Clinical care- nurses, pharm techs; ART aid.Sometimes clinical/ health officer

Community-carers, family-based care, self-management, community health workers, peer support groups, CBOs

Doctors/health officers/ inpatient RN

Specialisedreferral

HEALTH CENTRE

Drugs, diagnostics, commodities, logistic support

National, Regional and District Management- includes tools to map services, NGOs

Referral, B

ack-Referral; C

linical mentoring;

Supervision by facility

Emphasis onstrongfacility-

community link

IMAI/IMCIIMAI/IMCI

OI evidence check- IMAI District Clinician Manual October 26-27, 20108 |

Simplify for

lower cadres

Integrate (multiple

interventions)

Operationalize-Sequence of treatment,

care and prevention

Developtools

Harmonized

Normative guidelines + Country experience + Evidence check

ARTCotrimoxazoleClinical staging

PITC policyPositive prevention

PMTCTOI management

PaediatricsSTI

Antenatal, Postpartum, L&DGender

TB, TB-HIVMalaria treatment

IT bednets

Chronic careMental healthIDU, alcoholOral health

Cancer- palliative careSafe water

Safe injectionsNutrition

IMAI/IMCI tool development

Acute Care Chronic CarePalliative Care:Symptom management

WHO IMAI- IMCI- IMPAC integrate:

Prevention integrated with care and treatment (by age, serostatus- all)Support for healthy pregnancy & childbirth (IMPAC)

Infant, child nutrition & development (IMCI-HIV)

• General principles• Chronic HIV Care with ART and Prevention

• PreART care, ART• PMTCT• Positive dignity, health and prevention

• TB care with TB-HIV Co-management• MDR TB

Not disease specificAll ages

HIV+, HIV-PITCTB casefinding OI'sCough, difficult breathingSTI'sDiarrhoeaSkin problemsMental health, alcoholNeurological problemsFever/malaria

IMAI general principles of good chronic care: applicable for long-term

TB, TB-HIV, MDR-TB management

1. Develop a treatment partnership with your patient.2. Focus on your patient’s concerns and priorities.3. Use the 5 As—Assess, Advise, Agree, Assist, Arrange.4. Support the patient education and self-management.5. Organize proactive follow-up.6. Involve "expert patients", peer educators and support staff at

your health facility. (lay providers)7. Link the patient to community-based resources and support.8. Use written information—registers, treatment plans, patient

calendars, treatment cards—to document, monitor, and remind.9. Work as a clinical team (and hold team meetings). 10. Assure continuity of care.

Simplification and decentralization of treatment delivered through primary health care

TB led the way with decentralized delivery at health centre and community level based on decades of experience

Home-based palliative care/hospice approaches when IMAI started often did not involve the health centre

In a short 6 years, HIV care and ART have caught up • Now substantial experience and success with delivery by nurse-led teams in

health centres and district outpatient clinics, with strong community-based treatment support

• This has gone to scale in a number of countries> 300 health centres in Ethiopia, hundreds of health centres in Tanzania use country-

adapted IMAI tools to decentralize ARTMore than 50 countries with high HIV burden have adapted IMAI-IMCI toolsAlmost all countries have adapted Palliative Care guideline module but not as

extensively implementedTB-HIV co-management including TB-ART co-treatment now simplified for

primary health care delivery – also used expert patient trainersSimplified MDR TB management, based on same chronic care approach, now can

be supported at district hospitals and select accredited health centres

Management of MDR-TB: A field guide

• In the context of a national response to MDR- and XDR-TB

• Target: health workers in TB clinics in district hospitals and some accredited health centres

• Draws on the experience of Partners In Health (PIH) in Lesotho-

- active training and service delivery

Based on the Emergency Update 2008 of Guidelines for programmatic management of drug-resistant tuberculosis WHO/HTM/TB/2008.402- companion document to these guidelines

• Diagnose MDR-TB• Initiate second-line anti-TB

drugs• Monitor MDR-TB treatment• Chronic care approach using

IMAI general principles of good chronic care (long-term care); defined sequence of care.

Other relevant IMAI tools

Guidance and tools:Psychosocial support– see Chronic HIV CarePeer support groupsTherapeutic peer supporting groups Clinical mentors- prepared to support symptom management, as

well as specific disease managementExpert patient trainers– to train and later on clinical team

(importance for stigma reduction)3 interlinked patient monitoring systems

Learning programmes: Preservice Inservice (first level palliative care training course)Continuing education; support for self-learning Relevant evidence collection

OI evidence check- IMAI District Clinician Manual October 26-27, 201014 |

Role of district clinician in district networkRole of district clinician in district network

The implementation of many clinical interventions for public health at primary care level requires district hospital clinicians able to manage:

uncomplicated as well as complicated patients

those who fail initial empirical treatment interventions

those with severe illness requiring urgent treatment and inpatient care, including inpatient management of pain and other symptoms

OI evidence check- IMAI District Clinician Manual October 26-27, 201015 |

Palliative carewithin the IMAI DCM

Palliative carewithin the IMAI DCM

Part of the second level learning programme

Fieldtested in 5 countries (Zambia, Tanzania, Uganda,

Ethiopia, India-currently occurring in Rwanda)

Volume 1 submitted to GRC

OI evidence check- IMAI District Clinician Manual October 26-27, 201016 |

Target audience and assumptions(stable from start of development;

matches child pocket book) :

Target audience and assumptions(stable from start of development;

matches child pocket book) :

Limited resource settings ONLY

HR assumptions: – Targets medical officer, clinical officer, senior nurses, and other senior

health workers working at a district hospital in limited resource setting. – Multipurpose practitioners such as a medical or clinical officer but do not

have specialist clinicians such as an internist, paediatrician or psychiatrist (although it may be possible to consult with one).

Limited essential drugs (see drug section at end of the Manual; this is subject to adaptation based on the national essential drug list).

Limited equipment No mechanical ventilation for medical patients

Limited laboratory and other investigations

OI evidence check- IMAI District Clinician Manual October 26-27, 201017 |

Volume 1Quick Check and Emergency treatments

Manage Severely Ill Patient- including TB patients in severe respiratory distress, septic shock

(approximately the first 24 hours of care)Manage Acutely Injured Patient Infection Control, Procedures

Drugs- all including for palliative care

Volume 2

Acute, subacute illnessMultisystem diseases: OIs, NTD, Kaposi sarcoma

Chronic management: HIV/ART : including TB-HIV co-management

TB: TB treatment, DR TB PMTCT-FP

Alcohol, other substance usePrevention

Palliative care- applicable to DR TB, special considerationsPatient monitoring, pharmacovigilance, notifiable diseases

Symptom managementIn other sections of

District Clinician Manual

Symptom management• What is the same, what is different for PLHIV, DR TB, cancer?

End-of-life care• What is the same, what is different for PLHIV, DR TB, cancer?

Psychosocial support• What is the same, what is different for PLHIV, DR TB, cancer?

Programmatic approach• What is the same, what is different for PLHIV, DR TB, cancer?

Symptom management appears throughout

IMAI District Clinician Manual

OI evidence check- IMAI District Clinician Manual October 26-27, 201021 |

Some improvements to IMAI DCM suggested yesterday by expert review

Some improvements to IMAI DCM suggested yesterday by expert review

Difficult breathing in chronic lung conditions- include continuous oxygen

Decisions on end of life care– Decision on discontinuing DR TB treatment

• Team, not individual clinician• Choice of the patient, with full information especially of toxicity, resources, quality of life • No blanket decision on failure of treatment

Will examine issue of polypharmacy in palliative care and drug interactions with DR TB treatments

Expect further input to happen on management toxicity from M/XDR TB treatment

Statements on human rights (with current references) at start of palliative care chapter

Expecting other inputs from this meeting

Control bronchospasm:– Give salbutamol by metered-dose inhaler with spacer or mask or, if available, by nebuliser.

Stop bronchodilators if the patient is not able to use them anymore, or if breathing is very shallow or laboured.

– Consult to consider giving prednisone 40 mg by mouth daily for 5–7 days. Relieve excessive sputum:

– If cough with thick sputum, give steam inhalations. – If more than 30 ml/day, try forced expiratory technique (“huffing”) with postural drainage.

For bothersome dry cough, if an opioid not already being used, give codeine phosphate 30 mg four times daily, if no response, oral morphine (2.5– 5 mg)

For cough or difficult breathing

In end-of-life care, a small dose of morphine can reduce dyspnoea. Monitor respiratory rate closely, but do not let fears of respiratory depression prevent trying this drug.

– For a patient not on morphine for pain – give morphine sulphate 2.5 mg everyfour hours.

– For a patient already on morphine – increase the dose by 25%. If this does not work, increase by another 25%.

To relieve symptoms of heart failure and to treat pitting oedema, give furosemide 40 mg daily. To relieve anxiety or terminal agitation, consult to consider giving diazepam.

If patient is terminal and is dying from COPD, lung cancer, AIDS, or any terminal pulmonary problem (but NOT acute pneumonia or TB that can be treated with antibiotics), there are additional measures to relieve dyspnoea:

Health centre support for home-based care:Medication/medical

Additional hospital palliative care relevant for M/XDR TB

• Oxygen (if adequate supply)

• Additional analgesic options- IV morphine

• IV/subcutaneous infusion

• Differential diagnosis and skilled management of symptoms

OI evidence check- IMAI District Clinician Manual October 26-27, 201025 |

IMAI tools to support implementation of palliative care

IMAI tools to support implementation of palliative care

Will be progressively updated as the GRADE-based WHO guidelines on pain and other symptom management are produced (if funding and interest from donors and partners)

– These GRADE reviews will happen over years

Integrated tools serve as efficient 'vehicle' for implementation of palliative care for HIV, TB, cancer, COPD patients

OI evidence check- IMAI District Clinician Manual October 26-27, 201026 |

Updating the IMAI District Clinician ManualUpdating the IMAI District Clinician Manual

Annual print of updated manual (every July Vol 1, December Vol 2)

New WHO guideline

Section revised

Update of applicable section of manual- on EZ collab- within 3 months

New WHO guideline

Section revised

Advantages of 'sharing' IMAI-IMCI palliative care tools

Co-sponsorship and co-supervision can bring real advantages.

Using the same simplified guidelines, training, and management support for palliative care for HIV, cancer, TB, COPD, other conditions

Stronger implementation through shared programmes of work, between several international and national programmes

More coverageMore opportunity to maintain quality

Responds to reality of greater integration at district level:District management team members often 'cover' several programmesHealth workers multipurpose

Patients need integrated, holistic care; most have more than one problem. Integrated clinical management provides better care.

IMAI is very open to collaboration and improvement of the tools and to better serving TB patients and their families