Esther Luo, Ho Chi Minh City, Viet Nam, Developing a Strategic Plan for Sustainability in Palliative Care in Vietnam

Blog 3 In addition to visiting home care patients and facilitating small group discussions on palliative care topics, one of the most exciting events was the development of a strategic plan making palliative home care program sustainable. We utilized the SWOT analysis (strengths, weaknesses, opportunities, and threats) to evaluate our palliative home care initiative. We divided into smaller groups for the SWOT analysis. Our Vietnamese clinicians astutely identified the challenges for sustainable palliative care including securing adequate funding resources, providing further palliative care training to doctors and nurses, and policy advocacy, opioid availability, and implementation.
Funding sources for international palliative medicine is not easy. In 2008, the Open Society Institute conducted a study to identify national and international palliative care funders that support hospice and palliative care activities in Africa, Central, Southern and Eastern Asia, Central and Eastern Europe, the Commonwealth of Independent States;, Latin America and Caribbean, and the Middle East. Of the 354 donors identified, 21% are active donors in Central, Southern and Eastern Asia.
Training palliative care doctors had already began in cities of Vietnam including Ho Chi Minh City and Hanoi. As I mentioned earlier, Dr. Eric Krakauer had already trained many local Vietnamese physicians and nurses on palliative care topics. In addition, two physicians were selected as international palliative care fellows at the International Palliative Care Program in San Diego in the recent years.

The Ministry of Health began its palliative care initiative in 2005 and conducted a rapid situation analysis of the need for palliative care for patients with cancer and HIV/AIDS. Based on these data, the Vietnam palliative care initiative was planned based on the WHO's public health strategy for national palliative care program development. Efforts to make opioids such as morphine available in Vietnam resulted in collaboration with the International Pain Policy Fellowship Program at the University of Wisconsin, a workshop in opioid policy in 2007 in Hanoi. Within one year of the workshop, the Vietnamese Ministry of Health liberalized opioid prescribing regulations that reflected international standards. Despite the current progress, cancer hospitals like the one we visited continue to face shortages of consistent opioid supplies.

Lastly, implementation of a sustainable palliative care internationally is challenging. However, the palliative care program already implemented in Ho Chi Minh City's Cancer Hospital is an example of the possibility of sustainable palliative care. With available resources, dedicated faculty (both American and Vietnamese), and enthusiastic learners and the support of the hospital administration and ministry of health, we are beginning to see the results of years of hard work. From no palliative care, to a dedicated inpatient palliative care unit, to a home care program, and dedicated fellowship training, I believe palliative care will become sustainable in the Cancer hospital in Ho Chi Minh City!

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Teaching Palliative Care, Esther Luo, Ho Chi Minh City, Viet Nam April 2011

Blog 2 Teaching international Palliative Care
One of the skills I am learning during this trip is how to teach palliative care to an international audience. How does one present a power-point presentation with an interpreter? How does one teach home care not knowing the Vietnamese language? How does one facilitate small group palliative care teaching using an interpreter?

As it turns out, it was not as complicated if one remembers some of the basic principles. Some of the golden rules about presentations still apply. For example, "what's in it for me?" "Who's telling?" and "How do you tell it?" are important questions to answer in order to capture the audience and keep their learning proactive and motivated.
What's in it for me?

I was amazed to see the amount of interest in learning palliative care in an Asian country like Vietnam where death is often a taboo topic. When I asked this question recently to a physician researcher in HIV/AIDS epidemiology, she replied, "We are not as worried about such necessities such as food and are able to focus on other things that are important to the quality of life such as eating healthier, exercising, and palliative care." "For example," she continued, "in her apartment complex, there is a yoga club for the residents and it is for free." As Vietnamese people's economics and home security continues to improve, the focus on quality of life is palpated even more vividly. Even though the field of palliative care in Vietnam is a new field, the Ho Chi Minh Cancer Hospital is embracing it without any reservation. Under the mentorship of Dr. Eric Krakauer, two cohorts of approximately 32 physicians have already received basic training in palliative medicine. Upon the opening of the new inpatient palliative care unit, many clinicians including both physicians and nurses want to learn more palliative care skills.
Who's telling?

I was lucky to participate in the building of the palliative care home care program in Ho Chi Minh City's Cancer Hospital with two giants in international palliative medicine: Eric Krakauer and Frank Ferris. Given both of their extensive experience, knowledge, and expertise in this field, it was not too difficult to retain a captivated audience. Under their wings, fellows like myself, had a rare and unforgettable opportunity to experience their teaching styles and an opportunity to model after them. Teaching in an international setting means learning how to work with your interpreter, speaking clearly, concisely, and slowly, and demonstrating respect for your international audience. Having had experience with translation in the past and giving multiple presentations as an internal medicine chief resident, I was more at ease with these two aspects. Demonstrating respect was easier said than done. Even though we were here teaching them about how to do home care, it was paramount to respect the Vietnamese physician and nurses knowledge about their health care system and listen to their ideas on how best to incorporate the home care program in order to make it sustainable.

How do you tell it?

We taught using various methods including large group presentation, small group facilitation, and role play. For me, the most challenging and rewarding was facilitating in my small group. Each day after we saw our home care patient in the home, we returned to the hospital to discuss the case further in our small groups. A very useful tool we employed was called the "Squares of Care." This tool was developed by Frank Ferris as a model to guide patient and family care (Ferris et al. J of Pain and Symptom Management 2002). We had physicians and nurses complete separately the squares of care and then compare their information. Each square represented common issues faced by patient and family members during illness and bereavement. By using this model, we were able to teach our Vietnamese physicians and nurse how to make a palliative care assess including both the physical symptoms as well as the psychosocial assessment of our patients. Another technique we used in our small group teaching was role play. One of the role plays we did in our group included an interview of a patient and doctor visit. One person played the role of the doctor and the other person played the role of a metastatic breast patient who wanted to know whether where was going to be cure for her cancer.

My personal reflection on teaching as our two weeks of home care training came to an end was: "this is amazing work and what a privilege to have this international experience as part of my fellowship training!"

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Esther Luo, Ho Chi Minh City, Viet Nam, April 2011

In 2005, the Ministry of Health of Vietnam launched a palliative care initiative for which Dr. Eric Krakauer has been the primary technical advisor. Dr. Krakauer is also an attending physician on the MGH Palliative Care Service and Director of International Programs at the Harvard Medical School Center for Palliative Care. The Ho Chi Minh City Cancer Hospital, where Dr. Krakauer has provided intensive training and technical assistance for the past two years, has taken the lead in developing palliative cancer care in Vietnam. I came to Vientam with Dr. Krakauer and Dr. Frank Ferris, Director of International Programs at The Institute for Palliative Medicine at San Diego Hospice, to assist the Ho Chi Minh City Cancer Hospital develop a palliative home care team.

We formed three home care teams comprised of American clinicians and Vietnamese physicians and nurses. In my home care group, I was paired with Mary Wheeler, an American hospice nurse. Together, we worked with three other Vietnamese physicians and six nurses. All the nurses had recently started working in the newly established 10 bed inpatient palliative care unit. From day one, I sensed a tremendous amount of energy, passion, and desire to bring palliative care to the patients at their homes.



Our first patient was a 73-year-old retired nurse diagnosed with metastatic lung cancer in 2006. In 2010, she had received 6 cycles of chemotherapy. She currently lived home with her daughters who were her caregivers. We traveled by van to visit her in her home. Our nurses carried with them a "medical bag" which included things such as stethoscope, blood pressure measurement, hand sanitizer, and gloves. She reported symptoms including back pain, dyspnea, and decreased appetite. We quickly learned that she was reluctant to use morphine for pain and dyspnea. Instead, she was using Diclofenc for pain. Her daughter told us that she "knows everything about her disease." The daughter also wanted to keep their mother at home and only treat her symptoms. She is Catholic and there was a rosary hanging close to her bed. Our nurses conducted the bedside interview while our Vietnamese doctors talked with her family.



During my debriefing session in the afternoon, we asked our group about their experience and concerns about doing home care. The doctors were concerned that they will be asked questions they cannot answer by the patient or the family members. The nurses had concerns about seeing patients at home since many of the patients are used to seeing only doctors. The nurses felt inadequately prepared in their communication skills in caring for patients with cancer and physical examination skills. In our small group we talked about the concept of a team and how this can help both the physician and nurse to out to each other for help. We did some role playing as a way to practice communication skills when talking to patients and their family members.


For two weeks, we traveled to patient's homes and conducted evaluations in the morning. In the afternoons, we discussed our cases using the Squares of Care developed by Dr. Frank Ferris. The most amazing thing was to see the collaboration between the Vietnamese doctors working side by side with their nurses.

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