Room for Improvement in Kerala’s Palliative Care Delivery

Sir,

We read with great interest the work by Lijimol et al. ‘Improving access and quality of palliative care in Kerala:A cross-sectional study of providers in routine practice.’^[1] We congratulate the authors for highlighting the palliative care practices in Kerala and take this opportunity to seek clarification on a certain discussion made in the article.

Palliative care is an approach that identifies, evaluates and manages the difficulties, be it physical, psychological, social or spiritual, experienced by patients and family suffering from life-threatening diseases and thereby improving their quality of life. Even though pain mitigation is only one of the components of palliative care, measurement of opioid use by palliative centres is often regarded as a standard for estimating access to palliative care. The standard audit tool for Indian palliative care programs identifies an uninterrupted supply of oral morphine and its documentation as an essential requirement of any palliative care program.

In India, morphine can only be dispensed by an approved provider affiliated with a Recognised Medical Institution (RMI). We feel perplexed by the statement that ‘only 36% of the studied non-government (NGO) and none of the GO PCPs were able to prescribe and provide oral morphine as RMIs. All GO hospitals are deemed RMIs, but mostly, GO PCPs would refer patients to taluks, districts and general hospitals as well the Regional Cancer Centre in Trivandrum for opioids.’The fact that NGO PCP has better access to morphine than government palliative care providers is surprising given that a study done by Rajagopal et al. in 2015 reported that government institutions accounted for only 31% of the total palliative centres in Kerala but distributed 48% of total morphine in the state.^[2] Referral of patients to a higher centre would also be an impractical solution as most often the patients are unable to travel to these faraway centres.

Another statement which disturbed us was this – ‘Through this referral network or in-house RMI status, only 57% (57/100) and 55% (55/100) of the GO and NGO PCPs reported ‘always’ or ‘often’ having an uninterrupted supply of oral morphine for their patients.’ Lack of access to adequate morphine in Kerala is especially alarming. We worry that the situation in rest of India would be profoundly appalling. To conclude, we would like to appreciate the effort gone into compiling such a great work assessing the different aspects of palliative care in Kerala, however, we believe that the above statements would benefit from additional insights from the authors.