Browsing by Author "Gwyther, Elizabeth"

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    A survey of the knowledge and perceptions of South African medical practitioners concerning the use of medical cannabis by patients
    (2022) du Plessis, Karlien; Gwyther, Elizabeth; van Dyk, JC
    Background: South Africa has recently legalized the cultivation, possession and use of cannabis by adults in South Africa. There has been much debate, discussion and controversy about cannabis as a treatment for pain and other symptoms and a demand for use of cannabis amongst patients. Medical personnel feel understandably uninformed and confused by the discrepancy between the available information and the increasing interest that patients and their families have demonstrated towards cannabis. They are therefore challenged to ensure they are equipped with knowledge to advise patients about the safe use of cannabis in the palliative setting. Aim & Objectives: The aim of the study is to identify the knowledge and perceptions concerning medical cannabis for palliative care patients amongst South African doctors. The objectives are to survey South African medical practitioners with regards to their knowledge and perceptions concerning the use of medical cannabis. To review the current literature as to what is the recommendations regarding the use of cannabis and how to inform doctors regarding the possible benefit and harm. To draw on the evidence and regulatory statements to advise practitioners as to an approach for a palliative care patient with regards to the use of medical cannabis in the palliative setting. Methodology: Physicians working in the field of oncology and palliative care completed an anonymous online questionnaire concerning the use of medical cannabis for palliative care patients. The survey assessed the participants demographic detail, as well as what their thoughts were regarding the use of cannabis. Also, what possible benefits as well as the concerns they had and the ease with which they speak to patients about the use of cannabis. Results: The response rate was 33.3%. The respondents were 40 medical doctors, 21 men and 19 women. Among those medical doctors, the majority (62.5%) had more than 10 years of experience. Almost half of the doctors (45%) stated that patients asked for their opinion on use of cannabis at least weekly. The majority of medical doctors interviewed (77.5%) stated that they attempted to obtain information regarding the use of cannabis for palliative patients. While 70.5% of the practitioners considered cannabis as beneficial, only half would suggest it to patients for palliative care and chronic pain. When questioned about concerns, 60% were concerned about side-effects and 20% reported that cannabis could potentially do more harm than good. Need for more evidence. Conclusion: Cannabis is not a registered medication for use in the medical setting due to lack of evidence. Patients and doctors are looking for information regarding the use of cannabis in palliative care, possible benefits as well as side effects. The use of cannabis is largely patient driven and there is a need to overcome the legal and logistic barriers in order to do more research in the use of cannabis for palliative patients so that medical practitioners can advise their patients from evidence-based data.
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    An assessment of the current status of integration of palliative care into primary health care centers in Alexandra community
    (2019) Soogun, Olusoji; Gwyther, Elizabeth
    Introduction-The WHA resolution in 2014 to strengthen PC as a continuum of health care service delivery mandated member states to incorporate PC into their NHS using the PHS. An assessment of a health system will only be complete when the four elements of the PHS that (entrenches palliative care) are assessed alongside preventative, curative and rehabilitative care. Aim-To assess the current status of integration of PC into the PHC centers in Alexandra community in Johannesburg, South Africa. Objectives - 1) to identify the existing policies including budgets available in the clinics relating to PC, 2) to identify the availability of PC essential medicines in the PHC and 3) to survey the HCPs training in PC. Methodology- Each objective has different targets. Objective number 1) has clinic managers as its targets. Objective 2), HCPs and people involved in procuring and prescribing essential medications and objective 3), all the HCPS. Data was collected using structured questionnaires administered by the researcher and analyzed using statistical tables. Results-The clinic mangers are not aware of NPFSPC, there is no provincial policy, budget or any existing policy on PC in any of the clinics. The essential medicines are available in the clinics, only recent graduates has undergraduate trainings in PC, no HCP has any post graduate training in PC at any level (Certificate, Diploma or Masters) as recommended by the WHA resolution to member countries. Skills in PC is close to zero in the PHCs. Conclusion-The study confirm the findings in previous literature and highlights the needs for PC policies and continuous training in PC for HCPs, essential medicines for PC are in the clinics contrary to findings in other LMIC.
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    Assessing the palliative care needs of elderly patients seen at the University College Hospital, Ibadan, Nigeria
    (2020) Omoyeni, Eunice Nkechi; Gwyther, Elizabeth; Soyannwo, Olaitan A
    Background Nigeria, with a population growth rate (2000-2005) of 2.5% and with 5% of the total population aged 60 years and above, has the potential for a rapid growth rate of the older population in coming years.1 The implication of this in a country with large population as reported by the National Population Census 2006, limited number of health care professionals and care homes, is difficulty in meeting the various needs of the elderly, hence, the importance of identifying the palliative care needs of the elderly. Aim The study was set out to assess the palliative care needs of and provision of care to elderly patients seen in the selected clinics of the University College Hospital, Ibadan, Oyo state, Nigeria. Objectives 1. To describe characteristics of elderly patients seen in the selected clinics. 2. To explore the current use of the hospital palliative care team in the care of geriatric patient. 3. To explore the current use of the hospital palliative care team in the care of geriatric patient. Methods A descriptive cross-sectional study was conducted over a 3-month period using an interviewer administered questionnaire after full consent was given by participants. The questionnaire was a combination of the Africa Palliative Care Outcome Scale (APCA-POS), the Edmonton Symptom Assessment Scale (ESAS) and Hope Spiritual Assessment Tool. Demographic information regarding gender, age, nationality, abode and referral to the Care Centre was obtained. Scaled questions from selected tools were ticked with respect to physical, psychosocial and spiritual needs and expectations of palliative care. The validated data collection tools (APCA-POS, ESAS, HOPE) were used in the questionnaire. Ethical approval was obtained from the relevant organizations. Data was analysed using IBM SPSS statistics 21. Results 424 participants completed the questionnaire and most patients (330; 77.8%) were recruited from the geriatric wards with a 2:1 female to male ratio. Most participants fell in the 60 -69 year-old age group. The most common symptom was pain in 240 patients with moderate pain in single or multiple areas. A high percentage (45.8%) were moderately worried about their disease condition and only 66 out of 422 freely discussed this feeling with their family members. Other symptoms observed were nausea, vomiting, constipation and loss of appetite. Conclusion The study showed the palliative care needs of the elderly and calls for collaboration between the palliative care team and the physicians in the geriatric unit for better management of the needs of the elderly.
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    How is palliative care part of the right to health? The South African evidence
    (2019) Gwyther, Elizabeth; London, Leslie; Heap, Marion
    Palliative care is an appropriate and compassionate response to the needs of patients with life threatening illness. International human rights law establishes palliative care as part of the right to health. But what does this mean in practice? How is palliative care part of the right to health at the country level and in everyday patient experience? This thesis addresses this question with evidence from South Africa. South Africa is important for a number of reasons. The government, despite the country’s progressive Constitution (No 108, 1996) which entrenches the right of access to health care has yet to take responsibility for palliative care. Most recently, the South African government co-sponsored the World Health Assembly (2014) resolution on palliative care and thus has a commitment to implementing the resolution. The thesis employs General Comment 14 on the Right to Health to frame the four nested studies that were carried out to address the key research question. General Comment 14 (2000), adopted by the United Nations Committee on Economic, Social and Cultural Right, describes the normative content of the right to health (Article 12 International Covenant on Economic, Social and Cultural Rights) to include four overlapping elements – availability, accessibility acceptability and quality. Aim of the research: to evaluate current provision of palliative care in South Africa in terms of the Human Rights considerations of availability, accessibility and quality. Study One commences the thesis by estimating the need for palliative care in South Africa. Using mortality data for 2010 for conditions determined a priori to require palliative care, approximately 0.52% of the population were estimated to require palliative care, which translates into an average need of 698.5 persons per 100000 or 1 in 143 people every year. While this is a considerable burden, it is also likely to be a significant under-estimate, given limitations to the methods identified in the study. Study Two examines availability of services to meet the need for palliative care. A survey was completed by 131 palliative care organisations between March 2011 and October 2011. Only 3% of services were located within the public sector. The estimated number of patients who received care during the year was 46,347. This is approximately 18% of the need identified earlier in Study One. Availability of morphine, as a marker for palliative care, was found to be dependent on employment of and level of palliative care training of doctors and was especially poorly supplied in the rural areas. Thus, the availability of Palliative Care appears to be limited by health system factors. Study Three investigates access to palliative care in Cape Town, via two pathways 1) referral of patients requiring palliative care and 2) palliative care in their current care settings. A prospective cohort study over six months followed up 162 participants from three groups: 1) patients with metastatic cancer; 2) patients living with HIV with a CD4 count of < 200 cells/mm3 ; and3) patients diagnosed with motor neuron disease (MND). A questionnaire and a validated patient-reported outcome scale, the African Palliative Care Association (APCA) African Palliative Outcome Scale (POS), was administered at first visit. Thereafter participants were followed up telephonically once a month. Few patients (5%)were referred to palliative care services even though a significant number of patients died during the course of the study, indicating a failure to access palliative care when needed. Patient outcomes for people living with HIV improved significantly whereas the majority of patient outcomes in the cancer and MND groups did not improve. Thus, the accessibility of palliative care to patients already in the health system appears to be poor, except when palliative care is integrated into primary care, as is the case for patients with HIV on ARV treatment. Study Four evaluated the quality of care delivered to patients requiring palliative care in accredited hospice and non-hospice non-governmental services in five of the nine provinces of South Africa. A survey was conducted with 459 patient participants and 253 family members who were followed up over a 4-6 week period. Perceptions of quality care were explored through narrative questions and patient-reported outcomes were assessed using the APCA African POS. The results show significant improvement in patient reported outcome measures in both hospice and non-hospice groups, with pain and worry showing the most improvement. Content analysis of the narrative questions identified 5 themes: Quality of Care, Place of care, Staff values and attitudes, Information-sharing and Problems experienced by participants Conclusion: The thesis presents evidence that despite nominal commitment by the state, palliative care is not yet implemented as part of the right to health in South Africa. The need is great but availability of palliative care services is insufficient to meet the need. Access is poor even where palliative care is available but is facilitated by integration of palliative care into primary care services. However, when access is achieved, quality of care is generally good and patient outcomes improve over time with evidence that palliative care values patients as individuals. The study considers concepts relating to dignity and human rights in health as core to both human rights and palliative care. Implications: In South Africa, the planned National Health Insurance Policy lists palliative care as a service in the primary health care setting. In addition, a National Palliative Care Policy has been approved with strategies to integrate palliative care into public health facilities. As General Comment 14 has proved useful for the thesis, for the future, it may also provide a framework to monitor state accountability on the basis of Availability, Accessibility, Acceptability, and Quality of palliative care that can be transferred to other countries.
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    Palliative care needs and outcomes of patients with hepatocellular carcinoma: the case of Uganda cancer institute and Mulago national referral hospital
    (2022) Nabachwa, Florence Nalutaaya; Gwyther, Elizabeth
    Background: Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality in Uganda. A previous qualitative study suggested multidimensional needs. It was important to ascertain these needs and the patients' outcomes. Aims / Objectives: To determine the Palliative Care needs and outcomes of patients with Hepatocellular Carcinoma enrolled on program at Uganda Cancer Institute (UCI) and Mulago National Referral Hospital (MNRH). Methods: A longitudinal, quantitative, descriptive study was conducted from eligible in patients using convenience sampling on those who had a clinical diagnosis of HCC and were aged >18. A structured questionnaire using validated tools was administered by face to face interview at baseline then by telephone follow up at 1, 2 and 3 months. These tools include socio-demographic disease information, APCA POS and symptom assessment. Ethics approval was granted by University of Cape Town and Uganda Cancer Institute. Results: Fifty participants were recruited and among these 68% < six months' duration of illness and 74% were male. All participants were identified as stage 3 or 4 disease with 72% having an ECOG performance status 0 – 2. Fourty two percent of participants received chemotherapy and out of these 18% completed the study. Seventy-two percent of participants scored moderate to severe pain (>3/5) with a Median of (IQR) 4(3 - 5) on APCA POS and for those completed the 90 days has a Mean of ± SD 0.7±1.2. Only 34% accessed morphine and 36% accessed a specialist in PC at baseline and none at a 90 day accessed a PC specialist. Abdominal fullness and early satiety were among the common symptoms at baseline and scored in 70% of participants. At the baseline 66% expected cure, with information obtained during the study their perceptions changed. The degree of understanding of the illness at baseline scored 22%, not understanding at all was 34% hence the majority 78% at 90 days had a full understanding of the disease. While 28% felt hopeless at baseline this improved on subsequent follow-ups. Insufficient spiritual support was more marked at 90 days scored in 56% of the participants. The study showed high attrition rates >50% at 1 month) as mainly due to high mortality. Conclusions: The majority of patients were young men presenting with a late stage disease and from rural areas with significant financial constraints. There are significant unmet needs including pain, heightened existential distress and lack of clear information or goal setting which require further strengthening of PC within the medical and oncology services.
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    Postgraduate Palliative care education: Evaluation of a South African Programme
    (2011) Ens, Carla D L; Chochinov, Harvey Max; Moses, Steven; Thompson, Genevieve; Gwyther, Elizabeth; Jackson, Catherine; Harding, Richard
    AIM: We aimed to assess the postgraduate palliative care distance education programme of the University of Cape Town (UCT) in terms of its perceived ability to influence palliative care delivery. METHODS: A mixed-methods approach, consisting of two surveys using open-ended and multiple-choice options, was conducted from January to December 2007 at the UCT School of Public Health and Family Medicine. All students registered in the programme from 2000 - 2007 were invited to participate; 83 (66.4% of all eligible participants) completed the general survey, and 41 (65.7%) of the programme's graduates completed the graduate survey. The survey scores and open-ended data were triangulated to evaluate UCT's palliative care postgraduate programme. RESULTS: General survey scores of graduates were significantly higher in 5 of the 6 categories in comparison with current students. The graduate survey indicated that curriculum and teaching strengths were in communication and dealing with challenging encounters. Graduates also stressed the need to develop a curriculum that incorporated a practical component. CONCLUSIONS: In addition to current postgraduate training, palliative care education in South Africa should be extended to undergraduate medical students, as the benefits of UCT's programme were limited to a small cohort of practitioners.