1. International Palliative Care Network Lecture Series 2013

2. 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

3. Development of Palliative Care in Lebanon
Presenters: Dr. Hibah Osman Ms. Loubna Batlouni
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International Palliative Care Network Lecture Series 2013

4. 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

5. International Palliative Care Network Lecture Series 2013
Hibah Osman
Medical Director
Blasam- Lebanese Center for Palliative Care
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International Palliative Care Network Lecture Series 2013

6. International Palliative Care Network 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

7. International Palliative Care Network Lecture Series 2013
Loubna Batlouni
Outreach Coordinator
Blasam- Lebanese Center for Palliative Care
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International Palliative Care Network Lecture Series 2013

8. 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

9. Conflict of Interest or Funding Source
None
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International Palliative Care Network Lecture Series 2013

10. 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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International Palliative Care Network Lecture Series 2013

11. International Palliative Care Network Lecture Series 2013
Lebanon
Area: 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

12. 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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International Palliative Care Network Lecture Series 2013

13. 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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International Palliative Care Network Lecture Series 2013

14. 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

15. 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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International Palliative Care Network Lecture Series 2013

16. 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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International Palliative Care Network Lecture Series 2013

17. Evolution of models of care
Palliative care was not available in any setting in Lebanon
Non-governmental Organizations that offer home-based 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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International Palliative Care Network Lecture Series 2013

18. Palliative care delivery in Lebanon
Challenges:
Palliative care services not reimbursable by government nor by insurance companies
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
Laws do not facilitate advanced healthcare planning or goal setting, advanced directives are not legally binding
Difficulties related to opioids availability and prescription
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

19. 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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International Palliative Care Network Lecture Series 2013

20. Introducing the “Lebanese Center for Palliative Care- Balsam”
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International Palliative Care Network Lecture Series 2013

21. International Palliative Care Network Lecture Series 2013
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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International Palliative Care Network Lecture Series 2013

22. International Palliative Care Network Lecture Series 2013
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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International Palliative Care Network Lecture Series 2013

23. International Palliative Care Network Lecture Series 2013
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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International Palliative Care Network Lecture Series 2013

24. International Palliative Care Network Lecture Series 2013
Information about Balsam patients from September 2010 till December 2012
Patients admitted by month of referral
Patient-days per year
Number of patient-days in 2011
890
Number of patient-days in 2012
2490
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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International Palliative Care Network Lecture Series 2013

25. 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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International Palliative Care Network Lecture Series 2013

26. 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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International Palliative Care Network Lecture Series 2013

27. 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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International Palliative Care Network Lecture Series 2013

28. 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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International Palliative Care Network Lecture Series 2013

29. 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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International Palliative Care Network Lecture Series 2013

30. 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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International Palliative Care Network Lecture Series 2013

31. International Palliative Care Network Lecture Series 2013
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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International Palliative Care Network Lecture Series 2013