This document discusses palliative care, including its definition, aims, models, barriers to development, and challenges in Indonesia. Some key points include: - Palliative care aims to relieve suffering and improve quality of life for patients with life-limiting illnesses through pain and symptom management as well as psychological, social, and spiritual support. - Barriers to palliative care development include lack of funding, opioid availability issues, public and government awareness, and education/training programs. - Palliative care in Indonesia is developing but still faces challenges related to policy, education, attitudes, and social conditions. It is primarily available in major cities near cancer treatment centers. - Effective palliative care requires an inter

1. Palliative Care
Concept
dr. Siti Annisa Nuhonni, Sp.KFR (K)
Physical Medicine and Rehabilitation Department
Dr. Cipto Mangunkusumo Hospital
Faculty of Medicine, University of Indonesia
Makassar, February 16, 2019

2. • DEFINITION
Palliative care is all active actions to alleviate
the burden of sufferers, especially those with
life-threatening illness. Active actions include
relieving pain and other complaints, as well as
improving the psychological, social and spiritual
burdens.
• AIM
To relieve sufferings in order to maintain and
improve the quality of life at the final stage and
patient could die in dignity
PERAWATAN PALIATIF
‘Paliative Care’
( W H O , 2 0 0 0 )

3. • Affirms life and regards dying as a normal
process
• No intention to hasten or postpone death
• Relieve pain and other distressing symptoms
• Maintain psychological and spiritual balance
• Help patients to live as actively as possible until
death
• Team approach for both patient and family to
overome burden, including bereavement
counselling
Basic pattern of palliative
services According to WHO

4. • Although sometimes described as ‘low-tech
and high touch’, palliative care is not
intrinsically against medical technology. Rather it
seeks to ensure that compassion and not
science is the controlling force in patient care.
High tech investigations and treatments are
used only when their benefits clearly out-weigh
any potential burdens.

7. Distribution of Palliative Care Needs for
Specific Illness in Adults and Children
Global Atlas of Palliative Care at the End of Life (World
Hospice and Palliative Care Association, 2014)

8. Sankaranarayanan R, Ramadas K, Qiao Y. Managing the changing
burden of cancer in Asia. BMC Med. 8 Januari 2014;12:3.

9. Sankaranarayanan R, Ramadas K, Qiao Y. Managing the changing
burden of cancer in Asia. BMC Med. 8 Januari 2014;12:3.

10. Palliative Care
Service Priority: CARE
 There is a change in principle
- from cure to care
- from interventions to prevention and
rehabilitation
- from fulfilling the desire to the principle
of effective & efficient
 Based on rational considerations of medical,
psychological and social aspects

11. Those Who are Involved

12. Palliative Development in Indonesia
GOVERNMENT
(MINISTRY OF
HEALTH, ETC)
ORGANI-
ZATION
(MPI)
SOCIETY

13. FOUNDATION OF PALIATIVE
CARE LAWS IN INDONESIA
• Decree of the Minister of Health
Number: 812 / Menkes / SK / VII / 2007
about Palliative Policy
• In early 2019 a Minister of Health
Regulation will be issued on the National
Guidelines for Palliative Services

14. Hospital Care
Home Care Hospice Care
Samsuridjal Djauzi dkk, Perawatan Paliatif dan Bebas Nyeri pada Penyakit Kanker, Panduan untuk Petugas Kesehatan,
RSKD Jakarta 2003
1. Palliative Care Organization at the Hospital,
arranged in the form of an Integrated Palliative
Services Team
2. Palliative Care Flow
In every palliative service facility, it is necessary to have
professional human resources in accordance with their
competencies.

15. Barriers in Developing Palliative Care
Financial and Material
Resources
• Poverty, homelessness
• Lack of palliative care funding
Problems related to
opioid availability
• Inadequate regulatory and
govermental system
• Prohibitive cost and lack of
funding
• Stigma of opioid (opiophobia)
Lack of public awareness and goverment
recognizion of palliative care
• Poor information, understanding about palliative
care
• Insufficient numbers of palliative care expert
• Mainstream health services “curing” than “caring”
Lack of palliative care education and
training programme
• Lack of finance for palliative care training and
education
• Difficulties in recruiting doctors, nurses, allied health
care profesionals with specialist palliative care
training
Lynch T, Clark D, Centeno C. Barriers to the Development of Palliative Care in the
Countries of Central and Eastern Europe and the Commonwealth of Independent
States. J Pain Symptom Manage. Maret 2009;37:305–15.

16. Development and Challenges of
palliative care in Indonesia
• The Ministry of Health of Indonesia has
predicted around 240.000 new cases of
cancer per year, with 70% of the patients
already incurable at the time of diagnosis
• Recently, most cancer patients eventually
died in hospital, suffering unnecessarily
due to a high burden of symptoms and
unmet needs of the patients and their
families
Putranto R, Mudjaddid E, Shatri H. Development and challenges of palliative
care in Indonesia: role of psychosomatic medicine. Biopsychosoc Med. 2017;

17. Development and Challenges of
palliative care in Indonesia
• Palliative care has been improving since 1992 in
Indonesia and developed a palliative care policy in
2007 that was launched by the Indonesian Ministry
of Health.
• Currently, palliative care services are available in
several major cities where most of the facilities for
cancer are located.
Putranto R, Mudjaddid E, Shatri H. Development and challenges of palliative
care in Indonesia: role of psychosomatic medicine. Biopsychosoc Med. 2017;

18. • In 2016, the Ministry of Health issued a
national standard for cancer palliative
management and, as stated previously,
morphine is only available in the hospital
setting.
• Challenges related to government policy,
lack of palliative care education, attitudes
of health care professionals, and general
social conditions in the country.
Putranto R, Mudjaddid E, Shatri H. Development and challenges of palliative
care in Indonesia: role of psychosomatic medicine. Biopsychosoc Med. 2017;
Development and Challenges of
palliative care in Indonesia

19. Sumatra (4 ): Banda Aceh, Medan, Padang, Palembang
Java (7): Jakarta, Bandung, Semarang, Yogyakarta,
Surakarta,
Surabaya, Malang
Bali (1): Denpasar
Sulawesi (2): Manado, Makassar
Kalimantan (1): Banjarmasin
Pathology Centers in
Indonesia

20. Indonesian Cancer Foundation takes part in

21. Strategic Approach in Medical
Rehabilitation Services
ADL
QOL
QOL
ADL
Non Palliative Palliative

22. Quality of Life
‘Quality of life is what a person says it is.’
Quality of life refers to subjective satisfaction
experienced and/ or expressed by an individual; it
relates to and is influenced by all the dimensions
of personhood – physical, psychological, social
and spiritual

23. • Physical concerns (symptoms, pain)
• Functional ability (activity)
• Family well being
• Emotional well being
• Spirituality
• Social functioning
• Treatment satisfaction
• Future orientation
• Sexuality/intimacy (including body image)
• Occupational functioning
Dimensions of Quality of Life
Doyle, Hanks, Mac Donald
Pall, Med – 1995 – pg 64

24. Problems Faced by Palliative Patients
Pain Open wound
Cough/
breathlessness
Gastrointestinal
tract problems
Bleeding
Psychiatric
problems
Insomnia &
other sleep
disorders
Communication
barriers
Support from
family and
friends
Mobilisation
Other
symptoms
( H H C - Y K I )

25. SYMPTOMS AND SUFFERINGS OF
PALLIATIVE AND CANCER PATIENTS
• Pain : 68,9%
• Gastrointestinal tract problems : 60,0%
• Skin problems : 55,6%
(open wounds, stoma, decubitus)
• General weakness : 53,3%
• Respiratory problems : 51,1%
(cough, breathlessness)
• Weakness of limbs : 51,1%
• Urinary tract problems : 42,2%
• Confusion : 35,5%
Dharmais Cancer Hospital, 2001

26. • HOMECARE
• PAIN
• NUTRITION
• MEDICAL
REHABILITATION
• 75,5%
• 68,9%
• 64,4%
• 57,8%
Dharmais Cancer Hospital, 2000
PROBLEMS IN THE FAMILY

27. Palliative Care Team
1. Profession of every team member is
known for its scope of work
2. These professionals are merged on
the same team
3. Together they compile and design the
ultimate goal of treatment through
steps in several long term goals

28. Palliative Care Team...
4. If necessary, leadership can be divided
among team members, depending on which
priorities are needed to be executed
5. The team itself is the driving force of all the
patient's activities
6. Interaction process is the key of success

29. Is homecare a new
phenomenon

30. Palliative Care at Home
• Concept: not different
Need total cooperation and family’s
role, because the main control of care
is in the hands of the family

31. DIFFICULT TIMES
 The relay process of “handing over” homecare from
medical personnel to the family
 Needs well planning and precise details
 Mentally and physically ready
 Needs knowledge and skills to tend the patient
 Needs the facilities to be prepared at home
 Ease of medical emergency services
 Ensure ease of communication with nurses and doctors
Palliative Care at Home...

32. Walsh 1987 :
• The choice of home care depends on different
cultures
The decision of home care cannot be forced
Families and patients have the right to choose the
best and be able to do it
Palliative Care at Home...

34. • Homecare is very complex and not easy to be
applied
• Caring for a palliative patient is new to every
family
Caregiver

35. Quality of Life model applied to family
caregivers
Physical well-being
Fatique
Sleep disruption
Nausea
Appetite
Constipation
Aches/pain
Social well-being
Isolation
Role adjustment
Financial burden
Role/relationships
Affection/sexual function
Leisure activities
Burden
Employment
Psychological well-being
Anxiety
Depression
Helplessness
Difficulty coping
Fear
Useless
Concentration
Control
Distress
Spiritual well-being
Meaning
Uncertainly
Hope
Religiosity
Transcendence
Positive Change
Quality
of Life
Principles and practice of palliative care & supportive oncology 4th ed,
2013

36. Caregiver’s most common worsened
health effects as a result of caregiving
(72)
Energy and sleep 87%
Stress and/or panic attacks 70%
Pain and aching 60%
Depression 52%
Headaches 41%
Weight gain/loss 38%
Principles and practice of palliative care & supportive oncology 4th ed,
2013

38. Family Meeting
• Determine the goals and benefits of the meeting
with the patient’s family
• Set the time and place for the family meeting
• Specific documents should be prepared before
the meeting
• Follow the applicable family meeting standards

39. Pre-meeting with Family
• Identify and invite family members and friends
related to the patient
• Review medical records and target of care
• Identify conflict potentials
• Discuss matters to get consensus
• Determine the leader
• Identify the spokesman
• Emphasize on empathetic active listening

40. • The process of death
• Discussing about death
• Where to die

41. CONCLUSION
1. Through palliative care, we change the
role of a patient into a whole human
being.
2. Through palliative care, we transform
the stages leading to death into times
filled with life.

42. 4. The role of palliative care in the society is very
applicable at the family level, and also at the
local healthcare level
5. The execution of palliative care in the society
is not an easy thing, except when it is done
with care and precision.
6. Palliative care in the society has an integral
part of patient care as a whole
CONCLUSION...