Need for Palliative Care Education in India: Can Online Palliative Care Education Bridge These Needs?

NEED FOR PALLIATIVE CARE EDUCATION IN INDIA

According to the 2015 Quality of Death Index report, the palliative care provision in India is poor due to a low-demand and low-supply situation.[1] Low demand is because both the public and health-care providers have limited knowledge about palliative care. In the last two decades, there have been many short and long palliative care training programs offered by many institutes across India. However, their penetration has been marginal and it has not contributed toward generalized sensitization of health-care providers on palliative care. Moreover, the 2014 Global Atlas of Palliative Care has shown that there is <1 trained palliative care physician for one million population in India.[2] Lack of sensitization and awareness about palliative care among the health-care providers has resulted in poor quality of life, higher health-care costs, and inappropriate treatment at the end of life. Therefore, there is a pressing need for mass palliative care sensitization of health-care providers.

A scoping search of Indian literature showed that there are only 11 studies that have explored the palliative care education need in India. In a study conducted at AIIMS Delhi among postgraduate students, out of 186 respondents, 56% had not received any basic training in palliative care. Nearly 81% of the respondents wanted palliative care education to be included in the undergraduate curriculum.[3] In a similar study conducted among pediatric postgraduates at Chennai, out of 180 postgraduates studied, 88% had never received any training in any aspect of palliative care.[4] In another study conducted among the medical students, only 9.2% of the students were aware about palliative care.[5] A similar study conducted among all health-care undergraduate students showed awareness of only 11%.[6] These findings were corroborated by two studies which showed low incidence of palliative care awareness among pharmacy and nursing students.[78] The two studies conducted at Mumbai showed poor palliative care awareness among primary health-care providers, and they significantly lacked skills and knowledge to provide palliative care.[910]

ONLINE PALLIATIVE CARE EDUCATION PLATFORMS AVAILABLE IN INDIA

A survey conducted in India about the acceptance of online palliative care education in India showed that 89% responded affirmatively for online learning.[11] A few online platforms in India that provide online palliative care education are listed below.

1. The 3-month online course offered by the British Medical Journal provides interactive online palliative care education content. It has modules covering the principles of palliative care, symptoms, communication, geriatric and pediatric palliative care, noncancer palliative care, end-of-life care, etc., The participants have to undergo formative and summative assessment and receive a course completion certificate. The Narotam Sekhsaria Foundation has funded this initiative

2. The palliative care mobile application “PalliKare” is designed by Karunashraya, Bangalore Hospice Trust. It is a free-to-download and use application available both in Android and iOS platforms. It is especially useful for doctors and nurses with limited knowledge or experience in palliative care, especially for those practicing in rural and remote settings. The application is designed for India that takes into account the medications available in India and their cost and nonpharmacological interventions that can be accessed in India

3. The e-cancer India palliative care modules were developed jointly by Karunashraya Bangalore Hospice Trust, Cardiff University, and e-cancer. There are 21 modules on various aspects of palliative care in the form of both text and video versions created by various palliative care experts from India. These are interactive videos with case-based discussion, which are available freely for the Indian health-care providers from the e-cancer website

4. The Extension for Community Health Care Outcomes (ECHO) platform is another online palliative care education platform for India. The 1^st ECHO course in the field of palliative care in India was “Treat that Pain” which was conducted as two seasons by Pallium India. The theme was multimodal pain management. The objective was to share the knowledge and experience of experts in the field and to facilitate good clinical practices. The topics were pathophysiology of chronic persistent pain; neuropathic and difficult pains; pharmacological management; and the rational and safe use of the WHO analgesic ladder, including stocking and dispensing of opioids, physical therapies, interventional techniques, and psychological aspects of managing pain

5. EQuIP-India is an ECHO-style Quality Improvement (QI) online training program offered to selected teams from oncology or palliative care institutions, enabling their capacity to lead QI projects within their chosen areas of patient care, for example, improving access to care, ensuring adherence to treatment, implementing standards, bringing efficiency in the workflow, incorporating pain policy, and facilitating earlier discharge. The EQuIP India is a project-based experiential learning conducted by the Stanford Medicine and QI-Hub India, based at the National Cancer Grid (NCG), India

6. The Project ECHO Protection and Preservation Committee is the first ECHO on pediatric palliative care in the world hosted by the joint collaboration of a local nongovernmental organization (NGO) from Hyderabad, Pain Relief and Palliative Care Society, and an international NGO, Two Worlds Cancer Collaboration. The ECHO is a virtual platform that facilitates sharing knowledge, experiences, and challenges of pediatric palliative care between those practicing it and those who want to do more of it in their present work scope. It allows real-time discussion, which is valuable considering the global expertise shared by the speakers from all over the world and translating it to appropriate cultural and regional subtext by the participants. Access to video recordings, learning points, and related resources makes it more than “just a one-time session,” and these resources are available in the web for future access. Apart from pediatric palliative care, there were other ECHO online palliative care programs such as renal supportive care

7. Palliative Care Always – India – is an online, free-access, self-paced, high-quality Stanford Certificate Course for health-care practitioners, patients, and caregivers with a global as well as Indian perspective on palliative care. It is an initiative by the NCG, India, in collaboration with Stanford Medicine. The topics are covered through evaluated modules on symptom management, effective communication, psycho-social support, expressions of empathy, transitions in goals of care, shared decision-making, and end-of-life care. The special section – “Focus on India” – put together by a team from the NCG deals with the cultural nuances, family dynamics, policies, and systems influencing palliative care practices in India.

CAN ONLINE PALLIATIVE CARE EDUCATION BRIDGE THESE NEEDS?

Palliative care education is divided into specialist education, generalist education, and palliative approach. Specialist education includes longer courses where the provider solely practices the specialty and can address complex palliative care needs of the patients. The generalist education includes short courses which will enable the specialists or general practitioners to practice palliative care alongside their primary specialty or general practice. They see patients with less complex needs and act as a liaison between the specialists and other health-care providers. The palliative approach is where all the health-care providers dealing with chronic and life-limiting conditions should have basic palliative care skills, understand the principles of palliative care, and apply it in their practice. The online palliative care education would help in achieving a palliative care approach in a large population of health-care providers quickly and efficiently.

The potential advantages of an online education program are access, convenience, and ease of learning in a phased manner. However, the downside is the lack of supervision and clinical mentorship for a beginner can be challenging. Moreover, the content has to be standardized, peer reviewed, and presented in an interactive manner to facilitate learning. Although the online education platform can provide a theoretical knowledge, it has to be complemented by hands-on training. The online palliative care education may facilitate mass sensitization and awareness about palliative care. However, its translation into clinical practice without hands-on training will be challenging.