Palliative care is an approach, which improves quality of life of patients and their

families when facing life threatening illness, through prevention, assessment,

treatment of pain and physical, psycho-social and spiritual problems.

Hospice This is a Latina word that means hospitality. Patients and families are

treated as guest. They have choice and can participate in discussions to make

treatment and management choices.

Hospice is a modal care that believes patients have rights and are able to help care

for themselves

The major aim of hospice is to put life in the remaining days of a patient. It gives

the possible quality of care for patient and their families form diagnosis of illness

through critical episodes, end of life and bereavement support.

Clinical service- Hospice care for patients with HIV/AIDs and / or cancer mainly

in their homes. Patients with HIV/AID are cared for during acute painful

conditions such as cryptoccocal meningitis and other opportunistic infections and

during and life phase. Cancer patients are looked after from diagnosis until death

and beyond for the families. The clinic services have also provided practical

training for various cadres of palliative care specialists.. It

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Palliative care aims at improving quality of life for people living with HIV/AIDs

and cancer as well as their families. This is done by minimizing suffering through

active compassionate and comprehensive care support. It is an additive to

traditional care.

Focuses of palliative care:

 Palliative care focuses on the following: pain, shortness of breath, fatigue,

constipation, nausea, loss of appetite, difficulty sleeping and depression.

 It also helps the patient to gain strength to carry on with daily life.

 It improves the patient’s ability to tolerate the medication.

 It helps the patient t have control over h/her care by improving h/her

understanding of h/her choices for treament

Principles of palliative care

1. Holistic approach. This involve use of modern methods relieve pain e.g. oral

morphine, also physical, psychological, social, spiritual and cultural supports

are involved..

2. Patient centered. Sustain hope with realistic goals in order to help patient and

families cope in appropriate way through the different phase of the illness.

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 3. Teamwork and partnership. It is not easy to address all patients’ needs alone.

An interdisciplinary team should be established to deal with all the problems.

4. Appropriate ethical consideration. There are many ethical issues that arise in

care of all patients. Sick to do well or do harm patients’ rights must be

considered to decide fairly.

5. Continuum of treatment. This involves management of pain and other

symptoms.

Holistic care: this is care of whole person and is more than only drug and physical

care

Components of holistic care

1. Physical care: assessment and management of pain and other symptoms. It s

important because if physical symptoms are with them if they controlled other

aspects will be different to carry.

2. Psychological care: effective communication skills are utilized in care of these

patients. Tey require much support.

3. Spiritual are: this is important to terminally ill and it includes allowing patients to

express their spirituality, praying with them if they request for arranging for an

appropriate leader to visit them.

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 Family support: terminal phase of illness is often very difficult for patients’

family. Support therefore needs to be off patients’ rights must be considered

to decide fairly.

4. Continuum of treatment. This involves management of pain and oed to the family.

It includes spending time, listening and giving support to them.

5. Social care: this incorporates discussion of social and family issue e.g. young

children who will be orphans and financial issues

Modals of palliative care

1. Heal facilities based/ home based care: health facilities send health care workers or

team to visit homes. It may also train community volunteers to provide basic

nursing care, emotional and spiritual support and the ensure referrals when needed.

2. Outreach clinics: specialist palliative care health workers travel to other center to

provide palliative care.

3. Roadside clinics/ stopovers: patients can be seen and care providers at various

locations agreed upon by the health workers

4. Day care: patients come to health facilities for a few hours during the day for

meals, recreation, and medical care, support monitoring, counseling, emotional and

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 spiritual support. At same time it gives the caretaker time to relax and get some

relief.

CHALENGES FOR IMPLIMENTING PALLIAT IVE CARE

 Perception and recognition: many people still fear palliative care because they link

it to death and many do not want to admit t hat they are dying. It is also common

with health worker, policy makers and others

 Policy development; sustainable, affordable and effective palliative care must be

an integral of a country’s health system. To achieve this there must be coordination

with all health sectors. Some policies prohibit use of oral opiods, so advocacy for

change is important

 Education: health providers and community members need to be educated on

diagnosis, classification and application of holistic approach. Training should be in

medical/nursing schools

 Drug availability: here are limited recourses including limited drug budget a

palliative drugs are given priority because they are for symptoms relief. It is

important for these drugs to be included in the essential drug list.

Note: the objective of hospice Africa and Uganda in 1993 are now

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1. To provide palliative care services to patients and families with a 20km radius of

Kampala. And to promote this care throughout Uganda.

2. To carryout education programs in palliative medicine to health professionals at

underground and post graduate levels throughout Uganda so that this form of care

be available to all patients in need.

3. To solve as a model of palliative care for initial of hospice/palliative care in other

African countries.

How do people know about organization?

Patients admitted in Hospitals are referred to the organization on a special referred

form, others hear about it from friends, relatives, and mass media or community

volunteers. Hospice care for patients in their homes if they live within 20km from

the Hospice facility. Patients are visited 3 times while in Hospital and when stable

on the Hospice drugs, they are discharged with supply of drugs to last for a month.

On discharge the patients and the family are explained fully the reason for the

drug an importance of taking them as prescribed, undesirable effects of the drug,

how and to overcome them.

What does the patient family do when the drugs are finished?

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The patient and family are instructed to send a close relative a few days before the

patient runs out of the supply.

The person should be someone who is able to understand and is able to explain

fully how the patient is fairing on or if the patient is strong enough can be brought

to the center for review.

Manpower the organization has currently a strong team of staff and these include

professionals like, doctors, nurses, pharmacists/ dispensers, social workers, priests,

administrators also ancillary staff, drivers and registered volunteers.

Education / training: HAU has an education and training programs, which were

established in 994 and included the management of HIV/AIDs and cancer patients

during critical illness and end life in their own home.

Health professionals all over Uganda and Africa have been trained.

Courses

There are short and long course ranging from one week to nine months Diploma in

palliative care.

Trained clinical officers and nurses at Diploma level in palliative care can

prescribe morphine without the Doctors’ supervision. This is the first in Uganda

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and the workload is because HAU has been able to advocate for the use of

morphine in Uganda for terminally ill patients. Also there is a distance

Diploma courses of 8 months attitude at Makerere University.

To achieve the goals and objectives HAU has worked and continues to work with

the minister of health WHO, AIDs commission Makerere University, other public

institutions, civil service organization (UBO). Through advocacy HAU has made a

chance of attitude towards those patients who are with life illness and are ready to

take time to identify their needs and help them where possible in the work place.

STRESS

Is the response of the body to any agent threatening of physical, psychological,

social, cultural, physiological wellbeing of an individual such as agent are called

stressors.

Manifestation of stress.

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 Tiredness and weakness

 Constipation

 Headache

 Pain or discomfort

 Palpitation

 Irritability

 Restlessness

 Loss of memory

 Lack of concentration

 Depression

 Tension and worries

Low libido

People who die prone to stress;

 All people in life at whatever level e.g. patient, drivers, adolescent, employers,

candidates, pregnant mothers.

Stress of careers

Caring for terminally ill patient is not easy one can also be stressful.

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 There is danger of caregivers to become overwhelming, ignore signs of ill health

and tail to seek help

Stressors in palliative care

 Complaint, patients and their families may complain of very many drugs

including the care given

 Anger, bereaved relative may blame the palliative care providers for the

inadequate pain system pain control to their patient

 These two can be managed by giving relative chances to talk about complaints

and be there to listen to the concerns. Also acknowledge any mistake made by

the team and apologies, the relatives are interested in only an explanation,

apology, counseling and support where necessary.

 Handling uncertainty;

Much of the palliative care is uncertainty e.g. the prognosis is difficult to

predict. Endless interruptive, unpleasant explained home visit palliative care

emergencies and break down of communication.

Discussions are made with inadequate information in an environment where

advice from the colleagues may be conflicting.

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 This can be addressed y the team making an effort and acknowledge uncertainty.

Patients and family members should be involved in decision making as equal to

pertness. Team members should share uncertainty with colleagues, patients and

their relatives and work with flexibility.

 Ethical problems:

There is an increase in ethical problems

 This is addressed through organizing family meeting.

 Time management

The work load may be over whelmed in compared with time available. Some

team to members lack training in time management

 This issue can be solved through use of support; efficient secretarial and

administration staff to recognize works effectively. Improvement on the staff

issues and learns to save time not on certain events.

 Emotional cost of caring

Palliative caregivers are involved in different emotional conversation with the

dying and sharing his or her distress

 Keeping up to date

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 It is stressful if a professional feels inadequate to operate palliative care service

due to lack fo up to date knowledge

 This is managed by involvement of clinical supervision and monitoring through

discussions such as weekly acre center journal clubs and attending special use

palliative care course

 Team work

The rate of nurses and DR can overlap in palliative care. It creates a potential

for conflicts and misunderstandings

A nurse may question Dr’s decision for better patient care. A DR may fail it

critics hence conflict and handling of attitude

 This can be addressed through team member’s role and goals for cares should

be clear enough for all understanding. Effective leadership encourage ac culture

where every team member knows their value and responsibility

 Home work interaction

Team members who always who a lot need as much as support attention than

those who are frequently absent.

Always find final way of blaming work with the family life

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 This can be addressed by lifestyle, if incorporates management overlie to enable

periods of relaxation, exercise companionship and other activities which can

help distance oversells from the work situation. Also it include having balanced

in our life between home family

Ways of coping up with stress

 Recognize that you are stressed and recounting one can begin to deal with it

 Develop your own stratagems

 Being supported in one of the most collegial support groups to deal with

feelings and anxieties generators in working settings

 Seek counseling if indicated to help, classify cancer

 Plan a daily relaxation program with meaningful quiet time to reduce tension

e.g. read, listen radios

 Establish a regular exercise program

 Get enough sleep

 Massages

 Learn to accept family or your own

 Recognize the most people to o the best they can

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 Learn to ask for help and show your feelings

 Study assertiveness technique to overcome feeling of powerfulness in relation

with what other says

 Accept what cannot be changed because there are certain limitations in every

situation

Complications of stress

 Hypertension

 Mental illness

 Peptic ulcer

 Insomnia

Factors that lead to stress

 Loss of job

 Loss of beloved one

 Stigma

 Poverty

 Over work load

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  Failure in life

 Chronic illness

 Personal negligence

 Family misunderstandings

PAIN

This is unpleasant and emotional experience associated with actual or potential

tissue damage.

It is what the patient says hurts or unpleasant sensory and emotional experience.

CLASSFICATION FO PAIN

Pain can be divided into two i.e. normal or nerve pain.

a) Nociceptive pain (normal): this indicates that nerve pathways are intact and the

feeling of pain is a normal response to stimulus.

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 Somatic There is tissue injury to the skin, muscle, bone, or organ. This pain is

experienced as nagging, throbbing, and aching. An example of it is a toothache,

burns etc respond well to standard pain medication according to the WHO ladder.

Visceral or organ pain explained as crampy bowel pain or nagging it benefit from

additional medication.

b) Neuropathic pain (nerve pain): there is damage to the nerve pathways causing

abnormal response to stimulus. It may be resistant to opioids. It is explained as

burning, shooting, prinking, electric shock, numb. Examples are neuropathy due to

ARV mediation, which is described as burning pain. It can also be HZ pain

referred to as shooting, pricking, and cold, numb, electric shock.

Physical findings show hypersensitivity or numbness. Sometimes non-painful

stimulus e.g. touch feels pain usually needs additional medication

Neuropathic pain is common in cancer and AIDS patients especially on

ARVS .onset and timing helps to determine if it is Disease or Drug related. it may

be due to virus or opportunistic infections e.g. HZ. Other causes include DM,

vitamin deficiency and syphilis .In cancer this pain may be due to Tumor

compression or infiltration e.g. burning and shooting pain from buttock to leg due

nerve root compression by sacral tumor radiation injury surgical trauma e.g.

burning pain on skin post mastectomy.

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 Chemotherapy Induced damage to nerves e.g. cisplantin causes tingling pain in

feet.

MANAGEMENT OF NORMAL PAIN

This is by WHO analgesic ladder. If one Drug fails to relieve pain move up ladder

STAGE 3(strong opiods)

 Liquid morphin,
.
 Morphin slow releasing
tablets

STAGE 2 (WEAK OPIODS)

 codein

STAGE 1(NON OPIODS)

 Aspirin

 Paracetamol

 Diclofenac

PRESCRIBING ANALGESICS

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STEP 1: NSAIDS And paracetamol have an analgesic action, they are useful for

bone and soft tissue pain ,

They should be taken with food.PCM acts centrally.

STEP2: CODEIN is opiods. it is a weak opiods and expensive and has a

maximum dose which if exceeded the dose side effects occur A laxative must be

used as well. it is useful in the control if Diarrhea and cough.

STEP 3: PETHIDINE is not recommended because it has a short duration of

action (3 hours) and it is needed to be given by an injection .Oral morphine is an

analgesic of choice in strong pain.

PRINCIPLES OF MANAGING PAIN:

 By the clock

 By the patient

 By the ladder

 By the mouth

By clock:

Persistent pain requires preventive therapy. When pain has returned, higher doses

may be required to keep the patient pain free.

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By patient:

Doses are individual’s basis.

By the ladder:

Treatment must move from one step either up or down or appropriate.

By mouth”

Oral treatment is preferred to be on treatment for long time and probably at home.

Adjuvant therapy:

These are drugs which can be used to relieve pain though they are not analgesics

e.g.

 Laxatives to relieve constipation caused by opiods

 Antiemetic to relieve vomiting

 Steroids to relieve nerve compression

 Anxiolytics and Ant depressants.

Tolerance is not a problem,

It is stated that pain is an antagonist for opiods

ADDICTION AND DEPENDENCE

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 This does not occur because oral morphine does not give sudden addiction. The

dose can be reduced after the patient has complained of drowses.

STICK TO KNOWN DRUGS

There are well tried medications recommended for terminal patients, new drugs

can cause side effects.

MANAGEMENT OF NEUROPATHIC PAIN:

 Determine the cause and type of pain, this needs thoroughly history taking and

examination, determine location timing, pattern, duration and severity.

 Treat cause or source of pain if possible. tumor pressure (Radiotherapy or

Dexamethasone to reduce size),Peripheral neuropathy due to ARVS(Refer to

the center to change the combination),Infection or nerves by HIV(Consider

referral for ARVS),Abscesses (Abx, incision and drainage),Herpes

zoster(consider acyclovir)

 symptom treatment (Use analgesic ladder in combination with adjuvant

medications e.g. amitryptylin or phenytoin,)

 Spiritual, social and emotional components.

This can worsen existing pain explore and counsel then support, massage and

music can also help.

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 Pharmacological treatment of pain: This pain is partially sensitive to opiods so

there must be a combination of NSAIDS+ Morphine+ an Adjuvant.

COMMON ADJUVANT DRUGS

 ANTIDEPRESSANTS

 Imitriptylin, This has been used in treatment of neuropathic pain for 20 years,

start with a low dose of 12.5 nocte ,pain is usually relieved in 3-7 days but

doses can be increased gradually depending on the patients response

Side effects

Palpitations, drowsiness and dry mouth

Caution: Patients with hepatic impairment, heart disease. Glaucoma and urine

retention should closely monitored

 ANTICONVULSANTS

 CARBAMAZEPINE

: Dizziness, drowses, ataxia, bone marrow depression

Cautions: It interacts with ARVS so should be avoided or combinations changed

 PHENYTOIN

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This was the first ant conversant to be used neuropathic pain. Dose is 100mg

b.d until pain goes off but can be increased gradually ,pain is relieved within 24

hours in a day.

Side effects

Ataxia, slurred speech blurred vision and nystagmus

Cautions: It interacts with ARVS and other drugs

like caf, aspirin, and metro etc

STEROIDS

These help in treatment of cancer pain syndrome e.g. Ingratiation or

compression. It also elpps in headache due increased intracranial pressure, bone

pain, bowel obstruction and metastatic spialcord compression .They reduce

inflammation around the tumor thus reducing pressure n the nerves

DEXAMETHASONE

This is asteroid of choice due to fewer side effects.

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 Dose 6-12mg daily morning or lunchtime. Taper weekly to lowest

effective dose. In AIDS patients who are immune suppressed these should

minimized and if used paper quickly.

ASSESSMENT, MANAGEMENT AND CONTROL OF SYMPTOMS

ASSESSMENT

Symptoms are caused by multiple factors’ they range from impact of

disease its self, side effects of drugs and other phonological conditions which

may be complications of the diseases or not related to the diseases at all

HISTORY TAKING

The following are considered for proper history taking

 Setting the environment and place of taking history

 Introducing yourself and asking patients name

 Maintenance of privacy

 Taking notes after re assuring the patients that you are writing what heis saying

to help you remember as you carry out management

 Make time available to discuss with the patients where you will get his opinion

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 Explanation of whatever is done and the intention of each.

HISTORY OF PRESENTING COMPLAINT

 Record and us patient’s actual words. Ask the patient to list most troublesome

complaints first

 Diagnose cause of symptom because this will determine the possible treatment

 Ask appropriate questions and listen showing care for the patient

 Ask the onset of symptoms. Was it sudden, gradual? What make it worse or

beter, Does it affect sleep , there is fever or loss of weight?

 Drug history. What has the patient been using or what has he tried before in

treatment, has it woeked

 Allergies, drug reactions, smoking, alcohol

EXPLANATION

Use simple term for the patient to understand the symptoms, why they occur

and hw they will be managed.this reduces anxiety, explain treatment to the

family to gain co-operation. Respect patient’s wish

Agree on priority

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 Allow patient to set priority and help him set goals which are achievebble.

DISSCUS TREATMENT OPTIONS

Discus possible forms of treatment and their implication with the patient and

allow him take an informed consent

Pain and pain control

Who is terminally ill patient/

This is a patient who following accurate diagnosis advance of death is certain

and not too far for whom treatment is change from current to palliative and

supportive.

NEEDS OF A TERMINALLY ILL PATIENT

 Pain control

 Symptom control

 Empathetic and honest adviser

Pain is the problem and fear of patient and careers. If it is not relieved it is

impossible to offer empathy and support because the patient is frustrated and

the hole mind is focused on the pain and other symptoms.

CLASSIFICATION OF PAIN

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 Opiods responsive

These respond to opiods and it is usually the treatment of choice given most

times alone with no other type of analgesic

 Opiods semi-responsive

These partially respond to opiods so they may need to use other types of

analgesic will be needed in this type of pain.

 Opiods resistant

These will not respond to opiods and it will be a waste of time if patient treated

with these drugs other type of analgesic will be needed in this type of pain.

GENERAL MANAGEMENT OF PAIN RELIEF ASSESSMENT

History should be taken in detail. Allow patient to explain in detail what he

really feels. History of each pain is taken separately including its character,

duration, whether intermittent or constant, is it inside or outside the body, does

it affect sleep or mobility, what analgesics has he tried, did he get relief or did

the pain come back when the analgesic was stopped?. The following steps are

followed;

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 Onset

 Precipitating factors

 Quality

 Relieving factors

 Severity

 Timing

Examination

This helps to identify and locate source of pain. It’s common to find a person

with more than one pain. Use charts to plot clearly where the pain is found.

Explanation

Explain to the patient and relatives possible mechanisms of pain and proposals

of treatment. Set realistic aims e.g.

-To create a pain free night

-Pain free at rest during the day

-Allow pain free movement

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Counseling is important to that expected outcomes and treatment options are

clear to the patient and careers, honestly and openness is important.

MODIFICATIONS OF PATHOLOGICAL PROCESS

This is an attempt to reduce progress of the diseases and effect on neighboring

tissues thus less pain.

Radiotherapy; this is useful palliative treatment of pain from metastasis to

bones. Lower doses are used since it is not curative

Chemotherapy: if tumor is sensitive to these cytotoxic drugs and if they are

accessible and affordable or they can help in relief of pain.

Hormone therapy: Cancer of breast and prostate can respond to this treatment

e.g. Stilbesterol or Tamoxifen.

Corticosteroids: Can modify disease process and nerve involvement by

reducing edema.

Surgery: if a patient is fit enough and tumor is accessible, removal can relieve

pain.

ELEVATION OF PAIN PATHWAYS

This may be physical means e.g. position, relief of anxiety, openness and

honesty ,then use of analgesics

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INTERRUPTION OF PAIN PATHWAYS

Local anesthesia, nerve block but these are rarely used in Uganda.

MODIFICATION OF LIFESTYLE ACTIVITIES

Avoid pain precipitating activities or immobilize by splints

ANALGESIC: This must used rationally for medications.

MORPHIN: This is available in Uganda in available formulations.

LIQUID MORPHIN; Strengths 5mg /ml, 10mg/ml 50mg/ml. Start with 5mg

q.i.d and double the dose nocte in very weak patients start with .5mg q.i.d, then

double the dose nocte this allows the patient to sleep through the night without

pain.

If pain is not relieved increase by 50% of the previous dose,

Discontinue all steppe 2 analgesics when starting on stage 3 but step 1 can be

continued if there is bone pain, peripheral pain and membrane stretching.

It can be absorbed in buccal cavity

MORPHIN SULPHATE SLOW RELEASE TABLETS (MST)

Strengths 10mg , 30mg and 60mg

Effect lasts for 12 hours and this is good for working patients

It is expensive and not affordable for most patients

They can be given per rectum if the patient cannot take orally.

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MORPHIN SURPPOSITORIES

These are not practical because they have to be inserted 4 hourly for a patient

who cannot swallow

INJECTABLE MORPHIN

10 -15mg/ml ampoule:This is rarely used in palliative care since it needs a

skilled personnel

PHARMACODYNAMIC OF MORPHIN

Absorption : morphine solution can be absorbed in the buccal cavity but

mainly through the bowel , MST are not absorbed in buccal mucosa .If the

patient is unconscious or cannot swallow , liquid morphine can be absorbed in a

buccal mucosa or MST rectory

Liquid morphine has a Firstar on set on action [15-30 mins] MST [1 hour] so

liquid morphine gives immediate relief

METABOLISM

90% is converted in the liver if the liver is impaired, conversion is reduced.

This determine need for q.i.d doses of oral morphine

EXCTRETION

This is through the kidney. In renal impairment this leads to accumulation and

chances of side effects. Renal functions decrease as the patient Detroiters so

those have to be reduced

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 SIDE EFFECTS OF MORPHINE

1. Initial drowsiness

2. Initial nausea and vomiting

3. Constipation

4. Urine retention

5. Twitches

COUNSELLING ON MORPHINE USEE

Patients and relatives fear use of morphine leading to failure of controlling pain.

These are common questions and answers to them

Qn; does the introduction of morphine mean the end is near?

No, its used when other analgesics have failed and a patient can continue

carrying on his daily activity

Qn; can a patient become addicted?

No, this cannot occur I there is pain. Pain act as antagonist

Qn; do all cancer patients respond to morphine/

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Some pain eg nerve pain may not respond, other drugs are used along morphine

Qn; will morphine make me sleep al the time?

This can occur in the first day. If it goes on for more than one day we will

reduce the dose

Qn; can I stop the drug if there is nausea and constipation?

No, these are expected side effects. Nausea will last for a few doses, for

constipation we shall give you some drugs to treat it

AREAS OF CONTRAVANCY REGARDING MORPHINE

Tolerance

Need for increased dose of drug)

This occurs even with other drugs e.g. antihypertensive. It is less likely with

morphine and intervals of increasing dose are long. If a dose controlling pain is

reached patient is maintained on that. Further increase in dose may be due to

progression.

Respiratory depression

This is a wide spread fear among medical personal. It is rarely seen if oral

morphine is used properly. Dose is titrated according to pain.

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Small doses of morphine can be used to relieve severe dyspnoea.

Pain is physiological antagonist to respiratory depression

Dependence

This is when the patient feels that he cannot live without the drug. It rarely

occur with oral morphine since it does not give a sudden high.

Psychological dependence (addiction). There is craving and compulsive seeking

behavior

Physiological dependence. If drug is removed patient develop withdrawal

symptoms. This is less because doses used are low and life span of cancer

patients is short

Therapeutic dependence. This may occur if cause of pain is not removed.

Morphine may be needed for life. If cause is removed dose has to be titrated.

LAWS GOVERNING NARCOTICS

INTERNATIONAL REGULATION opiods are regulated under 1961

convention amended by 1972 protocol

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 Uganda is a party to this convention. The main purpose of this treatment is to

ensure availability of opiods for medical and research use while preventing

abuse.

 Anacated laws consider the following

 Production (cultivation)

 Manufacturers

 Distribution

 Registration of all handlers

 The international board ensures that countries comply with the convention.

 Government needs to estimate the quantity of opiods the country will use each

year (NDA MOH)

 International board confirms the estimates before government is permitted to

manufacture or import opiods. Quantity imported should not exceed estimates.

¼ ly reports concerning opiods imported, manufactured and distributed in the

country are needed so accurate records must be kept.

 International board communicates through MOH and NDA. NDA regulates

handling of drugs

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 RESTRICTED OR CLSS A DRUGS

These include opiods e.g. morphine and pethidine. Specific procedures, storage

requirements and records are put in place and adhered to. This is to prevent

diversion. Records must be kept for two years for inspection

Loss of class A drugs

This must be reported to the chief inspector of drugs (NDA) within 7 days

Expired, rejected or returned class A drugs

 Unused drugs must be returned to the prescriber or dispenser.

 If expired or rejected for any other reason return to pharmacy in charge who

contact the drug inspector

 Expired drugs should be destroyed by the pharmacy in charge WITNESSED

BY THE DRUG INSPECTOR

 Destruction follows the WHO guidelines

 Details of quantity destroyed and reason must be written in the class A register

Importation of class A drugs

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 Manufacture and wholesale of class A drug require an annual import license.

Currently NDA allows only national medical care (government) and joint

medical store (NGO) to import narcotics.

 Private retail pharmacies and hospital access through the above license

Storage

Powdered morphine and finished morphine should be store din

 Immovable separate cupboard

 Double locked cupboard and restricted to the public

 The key kept by pharmacist, dispenser.

Transport

 All enterprises and individual involved in the distribution system should be

licensed and authorized

 This prevents drug landing into hand of drug traffickers. An anti narcotic drug

squad ensures this does not happen

Prescription

Only the following are allowed to prescribe class A drugs

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 Registered medical Doctor

 Registered dentist

 Registered veterinary Doctors

 Specialized palliative care nurse or clinical officer

 Midwifes

 Prescription form must have all the details because it is a legal document.

Prescription is valid for 14 days. Supply must not exceed one month. It must be

in duplicate

Prescription requirements

The following must be included;

 Name, age, sex and address

 Total doze of drugs prescribed in words and figures

 Stipulated form of drug e.g. Tablets, injections, and oral solution

 Specific strength where possible e.g.; 5mg/5ml or 50mg/5ml of oral morphine.

Penalties

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 Any person in the possession of classified groups unlawfully is liable to;

 A fine not exceeding Uganda shillings of 2m

 Imprisonment of a term not exceeding 2yrs

 Both maybe applied

TRAUMA

Loss and grief

The experience of loss is difficult and pain. Grief and loss is an experience that

everyone is likely to have at some stage in life. Although many bereaved people

receive help in the community from families, friends or both, this is not

automatically so.

However, even when bereaved people are supported by friends and families,

there remains certain situations in which counseling has added benefits and this

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 is especially true when several members of the family have suffered the same

loss.

Children who have lost a parent(s) are especially vulnerable and often needs

support which counseling can give. Counseling people with loss and grief helps

them to deal with the deep feelings of loss which may be experienced soon a

death or indeed at any stage thereafter. One reason that bereavement is so

difficult is that we rarely have the opportunity to talk openly and honestly about

death it’s self and even more rarely our own death

Definitions

Some of the terms used in loss and grief are;

 Bereavement is the set of reactions to the loss of a loved one.

 Grief is deep sorrow following a loss or emotional and objective reactions to a

loss of any type.

 Mourning is the period of time it takes to grieve

 Anticipatory grief is the grieving that occurs before the actual loss

Grief reactions

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 People will respond to grief in different ways. These include; feelings, physical

sensations, thoughts and behavioral. Common grief reactions are; shock, denial,

loneliness, guilt, meaninglessness, anger, bargaining, depression, sleeplessness,

lack of appetite, stomach upset, crying, isolation, withdrawing and inability to

make decisions. It is important for the councilor to be aware of these reactions

so that s/he can help the bereaved persons to go through the grieving process

What are the stages of the grieving process?

These stages can occur in either the present sequence or any variety of

sequence. One stage can last for a longer time while uninterrupted. The loss

process can last anywhere from 3months to 3yrs. These stages of grief are

normal and are to be expected. Working out each stage of the loss response

ensures a return to emotional health and adaptive functioning. Getting outside

support and help during the grieving process will assist in obtaining the

objectivity and understanding.

Stage one; Denial

 We deny that the trauma or loss has occurred

 We ignore the signs of trauma or loss

We begin to use;

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 Magical thinking, believing that by magic, this memory will go away.

 Regression. Believing that if we act child-like, others will reassure us that

nothing is wrong.

 Withdraw. Believing that we can avoid facing the losses and the truth

 Rejection. Believing we can reject the truth and avoid facing the loss

Stage two; Bargaining

 We bargain or strike a deal with God or others to make the pain go away.

 We promise to do anything to make this pain go away.

 We agree to take extreme measures in order to ask this pain disappears.

 We lack confidence in our attempts to deal with the pain looking elsewhere for

answers.

We begin to;

 Shop around believing we look for a cure for our pain.

 Take risks believing we can put ourselves in a jeopardy way to get an answer

for our pain

 Take more care for others believing we can ignore out our needs.

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 Stage three; Anger

 We become angry with God, it ourselves, or with others over our pain

 We pick out a scapegoat on which to vent our anger e.g. the doctor, nurse,

hospital e.g.,

We begin to use;

 Self blaming believing we should blame ourselves for the blame of our trauma

 Switching blame believing we should blame others

 Aggressive anger believing we have a right to vent out the blame rage

aggressively

Anger is a normal stage; it must be expressed to be resolved. If it is suppressed

and help in, it will become locked away or replaced leading to depression that

further drains away our emotional energy

Stage four; Despair

 We become over whelmed by the anger, pain and hurt of our loss. We are

thrown into the depth of our emotional response.

 We can begin to have uncontrollable spells of crying, sobbing and weeping.

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 We can begin to into spells of deep silence, Morose, thinking and deep

melancholy.

We begin to experience;

 Guilt believing we are responsible for our loss

 Loss of hope believing we have no hopes or being able to return back to order

in life and calm.

 Loss of faith believing that because of this loss, we can no longer trust.

Stage five; Acceptance

 we begin to reach a level of awareness and understanding of the nature of our

loss

We can now;

 describe the terms and conditions in our loss

 cope with our loss

 Handle the information surrounding this loss in a more appropriate way.

We begin to use;

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 Adaptive behavior, believing we can begin to adjust our lives to the necessary

changes

 Appropriate emotion, believing we begin to express our emotional responses

freely and are better able to verbalize the pain, hurt, and suffering we have

experienced

 Patience and self-understanding , believing we set a realistic time frame in

which to learn to cope with our changed lives

Factors that make grief harder and last longer

These factors include;

 The type of relationship that the survivor had with the deceased. A good

relationship make it harder to let go than a difficult one

 The circumstances of death for example if death was by natural cause,

accidental, suicide, or homicide and whether death was near or far away from

home

 Personal history such as part losses and separations for example early parental

loss.

 Individual personality and beliefs

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 Social factors such as when the loss is socially unspeakable for example AIDS

or suicide; when the loss is socially negated e.g. abortion, and stillbirth or when

social support is absent for whatever reason

 Unacknowledged grief. Gay men and lesbians have unacknowledged partners

and so it is more difficult to acknowledge grief. Children’s grief is often

unacknowledged.

How to help a client to get through a grieving process

 Acknowledge grief and provide time to grief.

 Provide continuing support

 Talk openly and explicitly about the death

 Help the client identify and express feelings

 Help the client actualize the loss ( some cultural practices such as funeral rituals

may help I this)

 Discuss practical issues arising from death

 Acknowledge individual differences especially among same family members

 Help the client understand their coping strategies

 Identify other sources of support and refer appropriately.

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 Types of grief

The following are given by holistic home nurse visits

 Social worker visits

 Spiritual advisors

 End of life education for the patient and family

 Bereavement support

 medication related to terminal diagnosis

 pain and symptom management

 possibly incontinent supply, wound care, nurse visit, physical visit, nutritional

support, and other benefits

Who qualifies for hospice?

 patients who have chosen palliative care as a goal but not accurate

 terminally ill/ life limiting diagnosis

 patients who close the finical hospice benefit

 where there is a willing care giver not necessary family member

Bereavement counseling to AIDs/ cancer patient

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 The ultimate goal for counseling is to help the patient and family to accept that

death is final

 Never lock a patient and family to talk about their fears and how they can be

eased

 Help the patient to think, talk about achievement and time spent in the past]help

the patient and family members to identify people or organizations who can

provide support, e.g. friends, relatives

 Provide information on how to deal with distressing symptoms.

 Explore the patient’s religious and cultural belief and help contact appropriate

source of spiritual support especially a church leaders, and traditional leaders

 Encourage the patient to talk about what would happen to family after h/her

death

 Found out whether the patient has discussed h/her family what will happen

 Acknowledge the importance of losses

 Help to encourage and ensure that the patents are allowed to remain in control

of the discussion even when patient has lost consciousness, family members

should hold discussion in patient’s presence

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 Explore alternative source of income

 Bring family members together to discuss about the future plans.

Bereavement counseling after death

 Encourage the person to think about the dead by using photographs for

memories

 Involve extended family members, friend, and volunteers to keep on visiting the

bereaved person

 Keep a daily feeling and memories of a level

 Discourage family members in illegal issue

 Encourage family members to have enough time

 Educate the bereaved family about good nutrition and other drugs

 Encourage the bereaved family to be patient, tolerant, and gentle about oneself

during the grief

 Encourage them to relax

 Encourage them to socialize with others

GIEF AND BREAVEMENT IN CHILDREN

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 School going children require special attention following the death of their

parents than pre-schooling ones.

 The grief one comes and goes, it is heavily dependent on age, past experience

and personality.

 They grief at pain of loss by crying and wanting to be alone

 Sometimes the bereaved child experiences deep sadness e.g. something remains

her or the patient who dialed.

 They may not react visibly but pain remains consistent

 Many children are not encouraged to grieve but as they grow older, sense of

loss may be felt and expresses in different ways which may even extend into

adulthood.

Concept of grief and loss in children

 Children’s ability to cope with death depends on their age and cope

development.

 Most children see dead birds/animals at the road or in the field

 They often see death on TV and hear about it over radios, home, school, and

community.

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 A child living with HIV will also think about their own death/she may have

experienced a lot of losses.

 After death children need information, reassurance a safe place to express their

feelings to get involved in what is vital to them during counseling.

Practical way of supporting a grieving child

 Story telling is a use full tool that helps children deal with loss, grief and

translation

 One need a lot of support and counseling if she or he has to go through the

bereavement period back to normal life without developing complications of

grief

 Encourage the family to communicate with the child in their care to allow them

expose their emotions through dressing, writing, telling stories, and games

 Prepare a child and tell the truth. For unprepared child can develop over

whelmed by sudden loss and may react with shock and confusion.

 Prepare the child to cope better because they are not aware of what is

happening.

 Listen and speak to the children in a way which is appropriate to the child’s

age
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 Maintain consistence grieving children experience multiple loss e.g. schooling,

separation from new home

 Allow a child to grief at his own pace as each individual is unique and should

be relaxed and handled as an individual

 There is need to be assured that you are listening and caring about how s/he is

feeling at that time.

 Death is a natural pattern of life. Relate death to flowers, birds, animals which

may help the child to hide away from death and may help the kid to accept

reality.

 Children react differently hence the need to be patient and understanding.

 The understanding children are given choices going to hospital viewing the

body and attending the funeral.

 Encourage sense of continuity of school which can make the child feel life is

getting back to reality.

Complications

 When life issues are not expressed/ unacknowledged, he child’s ability to grief

is inhibited. There is no forward movement until the issues are resolved or the

feelings are relieved.

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Signs of complicated grief

 Chronic depression

 Substance abuse

 Suicidal behavior

 Prolonged grief

 Chronic physical symptoms without medical reasons

 Severe disease

 Risk taking

 Persistent sleep disorder

 Persistent denial

 May develop symptoms of deceased

 If above symptoms persist seek help and provide ongoing counseling

MOURNING

 As cultures varies in the way of dealing with bereavement, the victuals involved

in mourning also vary according to individuals, families and communities

 Some differences in customs are:

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 Expression of the grief directly an openly in contrast with no mess no loss

attitudes

 While some families prefer to die at home others in the hospital

 Men should not cry as opposed it is sorry for men

 Some family members have to contact the rituals in contrast with men or

category of clan members or relatives may conduct rituals

Cultural approach of mourning

 It is characterized by a lot of punishments oneself or sacrifices maternally,

funereally, spiritually and morally, it varies from tribes to tribes or awning

 Unfortunately sometimes the period set for mourning and some of the bereaved

family members become stuck in becomes cold and resort to mourning.

 Below are some of the indications of someone who is mourning

 Idealizing and bystarding the dead family members i.e. remembering the dead

person to be much better or worse than h/she actually was

 Some issues in the family cannot be resolved

 The fact concerning the dead is often confused and sudden or unreal.

 Members never stick or focus on the dead person as h/she was still alive.

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 Frequent visits to the grave

BAD NEWS

Bad news is any unpleasant or terrible information

Breaking bad news

Breaking bad news about terminal illness requires skills like:

 Listening

 Observation

 Empathy

 Ability to find right words to use

The way is which bad news is delivered/ broken is extremely important for their

well being

The process of breaking bad news

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 Breaking of bad news is a difficult communication task that requires effective

communication skills.

Importance of breaking bad news

 Maintain trust

 Reduce uncertainty (hardest of emotions to bare)

 Prevents installing false hopes

 Allows appropriate adjustment (practical and emotional) so that the patient can

make informed consent.

 Prevents conspiracy of sciences which destroys family communication and

prevents mutual support.

Difficulties in breaking bad new

These may include social, patient, and health worker elated factors.

 Social factors may be: age difference,

 Gender

 Magnetized e.g. elderly and poor

 Tendency to associate life limiting illness with bad lack

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 Separation from the society or community

 Societal attitudes towards dying.

Patient’s factors

 pears about concerns about present life limiting illness

 impact of illness on patient

 patient’s hopes and expectations towards illness

Health worker/ careers related:

 feel incompetent especially in being able to communicate the information

properly

 fear of causing pain, no one wants to hear that they are going to die

 avoid blaming patient/relatives can get angry of the health worker and blame

them for in effective care or that treatment has been stopped

 fear of medical hierarchy

 feel that they have failed the patient by using them

 wanting to shielded the patient by the patient by telling them that everything is

well

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 fear of the unknown

 fear of feeling a weak ward about showing empathy as a professional

 fear of being embraced about showing when someone is very upset

 not having enough time, though it is always possible to plan when you can sit

down and talk to patient or relative

 fear of saying “I don’t know”

The process of breaking bad news

This includes the following. Location, establishing of the existing knowledge,

communication skills, and the truth.

 Location:

Ensure that there is privacy, a separate room is most ideal but if this is

practical draw certain around the patient’s bed (but these are not sound

proof). Talk in a low torn setting close to the patient ensures that you

have time to talk to the patient without lasting, avoid interruption or

disruption.

 Establishing of the available knowledge

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 Ascertain (find out) what the patient knows about the condition. Special

attention should be paid to special terms for example (tumor, cancer).

 Communication skills

Use open ended questions a gentle torn of the voice is important as is the

face of the information given. Use suitable no-verbal communication. Be

consistent and use simple language. Try to andenab the person to come

to their own conclusion if possible

 Tell the truth:

Never tell a lie to patient but be very gentle with the actual breaking of

bad news. After informing the patient of bad news try and give hope

inform about what can be done to control the symptoms and improve

quality of life.

Don’t give a false hope for cure/ the patient; check whether the patient

has understood what has been said by having them repeated what you

have told them.

Give reassurance about continue support and arrange another

appointment to visit them again

Encourage them to ask questions.

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 If the patient agrees, tell h/she and families together do so. This can

avoid mistrust and gives them opportunity to support each other but the

patient permission must be obtained especially in case of AIDs

Six stapes protocol of breaking bad news

These include;

 Getting started

 Finding out how much the patient knows

 Finding out how much the patient wants to know

 Sharing information

 Responding to patient’s feelings

 Planning and following through

1. Getting started

 Sacrifice or invest sometimes

 Identify a suitable place where the interview will take place in privacy

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 Establish Who will be around, how you start and the patient to feel more secure

which will aid communication, latter in conversation e.g.

The result of your test is back.

Would you like me to explain to you know how?

Would you a friend or a relative to be there when we are going through things?

HOW DO YOU START?

 First ensure the patient privacy and comfort and the patient by name.

 Introduce yourself if the patient does not know you

 Its useful to begin asking questions how are you feeling today?

 This shows that you are interested in him/her condition

 This also encourages the patient to talk and allow you time it access something

abut current symptoms and reaction e.g. if a patient is in pain or nauseated .This

should b addressed if possible before starting the sensitive conversation.

2. Finding out how much the patient knows

 Establish what the patient already knows about the conditions.

 Ask how serious they think the condition is

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 Listen to patients reply correctly

 Check his understanding of medical status

This will give you information about the patients

Emotional state

Examples o questions:

What did the previous doctors tell you about this illness?

Have you been concerned that this may be something serious?

3. Finding out how much the patient wants to know:

 Majority of the patients know when things are not going on well and by asking

the patient wants information can be discussed over and full views.

Examples of questions

1. Would you like me to tell you the full details of your illness (diagnosis?)

2. If your condition is serious, how much would you like to know about it?

4). Sharing the information

 It is important to start from the patient part of view to reinforce the information

that patient has given you before progressing further

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 The process of educating the patient commences and aims at bringing the

patients perception of the situation to the medical facts

 Information should be given in small charts, simple language should be used

and medical terminologies should be avoided as much as possible

 Check the patients understanding frequently and clarify where necessary

 Through the session provides the support especially active listening which is

important in the patient’s agenda

5). Responding to the patients feeling

The success and failure of breaking bad news largely depends on how the

patient reacts and how he responds to those reactions and feeling. Some of

common ways in which the patient reacts to bad news include

 Disbelief

 Shock

 Anxiety

 Anger

 Hope

 Relief

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 Fear

It’s impossible to predict how an individual will react so it is therefore important

that the health professionals posses and utilizes, communication skill when

responding to the patients feelings or responses

Allow or give enough time to support the patient.

6). planning:

 The final stage of this process consist of an organ standing of the problem list is

essential through effective listening and reflecting. The patient will therefore

know that you have an overall appreciation o their immediate problems. Honest

is very important .This is an appropriate time to formulate and explain a plan or

strategy which include among others preparing for the worst and hopping for

the best.

 Throughout this time, the copying strategies of the patient should be identified

other sources of support for the patient and include them.

Before leaving the patient, it is essential that a contract for future be mad

SUMMAY OF KEY POINTS;

 If bad news is Brocken in intensive way, where the patient cannot handle at that

particular time, it can be very harmful to the patient.

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 Patients generally prefer gentle truth ,so as a health professional try to suffer the

initial impact

 Avoid negative words and give just the information the patients can handle at

that time

 Knowledge of what is happening to the patient’s life helps them to priotize and

plan for future.

 Important of most health care professionals

 Breaking bad news can occur in variety of situations

 These include :

Cancer diagnosis

Loss of a limb

Death of loved one

Counseling of an operation

A WILL

This is a document which expresses the wish of the person how his or her is to be

after death.

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The will can contain other things that the person would like to be buried with.

How can one make a will?

 A will can be made by only one male or female married or single but the person

should be; 21 years and above, of sounding mind, aware that he or she is

making it.

 A will should be in writing. It can be had written by one self. If the person

making the will cannot write h/she can ask another person who she/ he trust

what to write.

 A lawyer can also writ it on payment.

 Check patient understands frequently.

 Clearly where necessary.

 Through the session provide support especially through active listening which

is important in establishing a patient’s gender.

Content of a will

 State your name and place where you live

 Date when you are making it

 List of all the property to be shared and all you have should also be shown

65
 Name of your wife/ wives and all your children

 State how your properties should be shared

 State if anybody owns your property or if you own someone’s property

 State who should be a guardian of your children if they are still young

 Name all the papers and sign to avoid forgeries

 2-3 people witness should see you signing on, thumb print making on the will.

They are not supposed to read it.

 The witness should indicate their full names, addresses, occupation on the will

and sign

 Anyone owing the property on the will should be known

Note: the will can be subjected to change in case of any new development but it

should be state in the old will.

PREPARING THE FAMILY FOR DEATH

 This is a task which should be done by acknowledgeable people

 The fear and feeling of death are reached

 The family may have many fears the condition o patient weakness such as.

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 Fear o note being able to cope with the death event

 Fear of being responsible of the illness In someway

 Fear of being alone in the house at the moment of death

 Fear of the patient dying in pain and agony

 Fear of how life will go on where loved one has died

 Fear of recognizing that the patient is dying

 Fear about the meaning of death especially to an under prepared family

 Concern about unfinished business or task which the patient understands

Signs of approaching death with appropriate care

 Decreasing social interaction

 Pain

 Decreasing fluid and food intake

 Change in elimination

 Respiratory in elimination

 Accompanying the above following should be observed

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 Heart burn and pulse stop

 Breathing ceases entirely

 The eyes may totally be fixed in one direction, eye lids may be opened or

closed

Points to care

 Explain to family what is happening and encourage them to allow the patient to

rest

 Encourage the patient o be observant

 Continue with skin care with explanation and teaching

 Keep the surrounding familiar

 Encourage the family to continue taking with the patient, say farewell, give

permission to let go of the peacefully.

 Encourage the family to use therapeutic touch e.g. handling hands

 With the patient

 Dying is a special time for both patient and family

 We must be aware of what each one is going through

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 It is time of recognition forgiveness, sharing, feeling of grief and time to draw

in sorrow and suffering

 The patient is losing all what he hold in his life and family. We must therefore

be sensitive and support family accordingly.

COMMUNICATION PROCESS

LISTENNING

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