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Advance Directive in end-of-life care.

Dr Babu Paul (IAS Retd.) was the chief guest at the Palliative Day observance at Caritas Hospital, Kottayam last week.He talked about palliative care with respect to the ethical aspects involved. He disclosed an advance directive which he had made for himself. See video excerpt below (~ 2min, Video courtesy Dr Manu John, Palliative care Dept, Caritas Cancer Institute, Kottayam).

Transcript:

I am 72, going on 73.I am happy in my current situation but ready to be called home by my creator any time now. I therefore make the following wish list.

I may not be kept alive by artificial life support systems except as a purely temporary measure up to 6 hours and for unavoidable medical reasons.

I should not be resuscitated…..

In Summary the doctors are allowed to undertake comfort measures. I would prefer not to be shifted to any hospital….No artificial or IV feeding at all. May my body go in peace and my soul rest in peace.

As advance directive in mental health care is being introduced in India by the new act, it needs to be remembered that we are only at a stage of advance directives slowly evolving even in end-of -life care in our country.

article on new bill on end of life care (manorama 19/07/2016)

2014 in review

The WordPress.com stats helper monkeys prepared a 2014 annual report for this blog.

Here’s an excerpt:

A San Francisco cable car holds 60 people. This blog was viewed about 850 times in 2014. If it were a cable car, it would take about 14 trips to carry that many people.

Click here to see the complete report.

School Psychiatry: Charting the landscape of mental health interventions in schools.

Schoolpsychiatry

My presentation at Central Tranvancore Psychiatric Society (CTPS) monthly meet at Kottayam yesterday, was on the topic of mental health interventions in schools. Prof Varghese Punnose, HOD, Dept of Psychiatry, Gov Medical college, Kottayam was the chairperson.

See above a matrix of existing mental-health provisions in schools of Kerala and see slides of my presentation below.

Panel discussion: rehabilitative, community-participatory and social security aspects of Schizophrenia-care.

See above some brief sound excerpts (~7 minutes) from a panel discussion organised at Gov. Medical college, Kottayam (MCK) as part of World Mental Health Day 2014. (audio was captured by me using mobilephone microphone:-)

The panelists were as below. Dr Lakshmi Gupthan (MCK) was the moderator.

1. Adv. G Jayashankar, Kottayam District Legal Service Cell (focused on mental health act, Reception order, Rehabilitation services)

2. Fr. Micheal Joseph, Kottayam Social Service Society. (focused on team based and participatory approach, community based rehabilitation through home based care)

3. Dr. V K Usha, Prof. Psychiatric Nursing Dept. (focused on family based interventions, emphasized need for including family members into the multidisciplinary care team)

4. Dr. Ipe Varghese, HOD Social work Dept, BCM College Kottayam. (focused on the need for advocacy for building social security nets in this era of diminishing carers in families and generating evidence for local interventions)

Photo courtesy: Dr Rajeev K M (MCK),  From L to R Dr Usha, Dr Ipe, Fr Micheal, Adv. Jayashankar, Dr Varghese Punnose, Dr Laksmni.

kmc

A prototype dementia-care approach through DMHP.

My presentation at SIPSCON 2014 (Indian Psychiatry Society(IPS), Kerala State  Branch, Annual conference) focused on the emerging idea of integrating mental health care through community nurses in the palliative care program. A model for integrating home-based care for late-stage dementia was presented.  See slides below. Also see newspaper reports on same: The Hindu Report; MalayalaManorama Report. [Incidentally it is two years since this blog was stated in October 2012. It is matter of great happiness that the blog got a mention in the address of the IPS State President at the annual meeting at Kochi. See text of the presidential address here. [added on 22.01.2015, the same published as article in Kerala Journal of Pstchiatry see here ]

Does Kerala still have a deficit for psychiatrists?

If the data from The National Survey of Mental Health Resources carried out by the Directorate General of Health Services, Ministry of Health and Family Welfare which was done in 2002 (appendix 1, page 10 of this parliamentary document has data from it) is appraised now (12 years have passed), it might be safe to assume that as far as Kerala is concerned there might be no deficit for psychiatrists!

The survey pegs the ideal basic requirement for professionals as under

i. Psychiatrists : 1.0 per 1,00,000 population
ii. Clinical Psychologist : 1.5 per 1,00,000 population
iii. Psychiatric Social Workers : 2.0 per 1,00,000 population
iv. Psychiatric Nurses : 1.0 per 10 psychiatric beds.

Based on this ratio, places that were already having excess psychiatrists were Chandigarh (+22), Delhi (+18), Goa (+12), Pondicherry (+5).

States with most number of psychiatrists were Maharashtra (486), Tamilnadu (262), Kerala (238), Karnataka (198), Andhra Pradesh (180).

Kerala had a deficit of only 80 psychiatrists at that time (12yrs back) from a requirement of 318, calculated based on 1 psychiatrist/1 lakh population, for a population of 318 lakhs (census 2001). Since then population of Kerala has increased by another 15 lakhs to 333 lakhs as per 2011 census.

But with the recent annual turn over of 40 postgraduate seats for psychiatry in the state (which has greatly increased because of the beginning of postgraduate training in the private medical colleges) it might be safe to believe that the deficit for psychiatrists in the state may have been cleared!

Implication of this aspect with respect to mental health policy of the state need to  be considered. Certain aspects which need assessment are

  1. Ascertaining the geographical distribution of psychiatrists in the state and redeployment in Thaluk (sub-district) level and under represented areas,
  2. Continued deficit of allied professionals (see table below),
  3. Abandoning the hitherto doctrine of increasing mental health service-personnel by training primary care physicians.

Table 1 (created based on data from 2002 survey)

psy

Some health-policy trends worth emulating for DMHP-Kerala.

The following are recent trends in the health sector of Kerala. These are directions which are worth emulating for DMHP.

  • The DMHP is understaffed. It comprises of a 4-5 member team for a district -while programs like the palliative program for each district has anywhere from 100 -200 staff. The Kottayam district palliative program that I am aware of (see training program @Kottayam) has more than hundred community nurses supported by about 7 doctors from the health dept. One feature of the staff remuneration is that only the doctors are permanent staff of the government while all the community nurses are employed on contract – which essentially means less salary, no perks and other benefits and no permanency of tenure. It is know that such an arrangement leads to poor staff motivation, translates to poor quality of care and high staff attrition. The community nurses of the palliative program have organised themselves and constantly lobbies for change. The government has also taken cognizance of it. There is a possibility of regularizing this cadre.

Report 1 (Indian express Aug 11th, 2014, Kerala), click here for full report

cancer1

The lesson to be learned for DMHP is that the DMHP could also aspire for such permanent cadre. As of now only permanent personal in DMHP are health service doctors who join program on deputation-all other staff are on contract including doctors in CHMP (NRHM version of DMHP)

  • Creating a permanent cadre is a tough ask for the government because of the financial implications. Kerala has had moratoriums on fresh recruitment of staff and it is known that financial ministry is averse to creation of new posts. There is high chance that the chief minister’s assurance to the nurses will remain on paper as just a promise. One potential way it can be achieved in a smaller scale is by re-designation and redeployment of existing and vacant or redundant posts. See this happening in the context of creating new departments in medical colleges.

Report 2 (The Hindu Aug 17th, 2014, Kerala) Click here for full report.

mch

Lesson for the DMHP is that it can easily aspire for permanent cadre by doing away with the deputation system while designating existing vacant posts  as special cadre for out-of-hospital care. Redeployment of mental health professionals who are concentrated in  mental health centers should be explored as a policy option. Such transition should be made attractive to the early adopters via incentives drawn from innovative  financing using DMHP money. 

  • Strengthening District hospital cancer care units in mission mode is a recent development. This is happening in addition to well developed cancer care institutes, medical college oncology departments and a successful community cancer care program in the form of well staffed palliative care program.

Report 3 (Mathrubhoomi, Aug 17, 2014, Kerala) See full report here.

cancer2

Lesson for DMHP is that most District hospital Psychiatric units are not functioning optimally. This is despite the fact that we have a fairly good functioning institutional care in MHCs, medical college psychiatry departments and emerging community programs (DMHP/CMHP) in all districts. I am aware of at least 3-4 district hospitals which do not have a psychiatrist.  Other district hospitals which have only one psychiatrist provides just nominal OP care with hardly any IP care. With innovative funding from the DMHP coffers, district hospital Psychiatric units could be invigorated like the  Sukhuratham- Project for cancer care in district hospitals.

(More trends will be added in future)

Added on 22-09-2014

Less than 2 months after the chief-minister had promised the palliative care contract staff that their services could be regularised, the state has puunged into a financial resource crunch. The finance minister has said that there are 30,000 extra employees working with the gov and their would be gradual removal of personell and no new creation of post in this fiscal year!

See here. An excerpt –

Kerala government adopts austerity measure; rules out creation of new jobs, 7.5 thousand jobs to be scrapped

DC CORRESPONDENT | September 23, 2014, 05.09 am ISTIST

Thiruvananthapuram: As part of the intense belt-tightening measures, the state government has decided not to create any new posts, institutions or agencies during this fiscal year, till March 31, 2015.

The finance department will also abolish 7,500 or 25 per cent of the total surplus staff of 30,000 before the end of this fiscal.

What’s more, no expenditure proposals for this fiscal will be entertained after November 15. Special workshops will be held during October for the clearance of files and departments have been asked to get sanction for their expenditure proposals during these workshops.

“Where post creation is unavoidable, it will be done only after examination by two committees,” additional chief secretary (finance) K.M. Abraham said. First the proposal will be put to a committee headed by the expenditure secretary, a representative of the General Administration department and the head of the concerned department. If the proposal is cleared by this committee it will be sent to the consideration of another committee led by the additional chief secretary (finance).

Facilitated self-referral as a case finding tool in outreach clinics.

Detecting common mental problems in primary-care via promoting self-referral: A CMHP experiment of influencing pathways to care by solicitation with a symptom list.

slip2

One out of every five people who attend a primary health centre has one or the other mental health problem. The fact that it does not come to  the clinician's attention is unfortunate. Many reasons can explain this -at the clinician's level (skill acquity), the setting (differentiation of symptomatology), the patient (presentational clarity) and so on.
How health-care services can become accessible or inaccessible is one question which public health researchers are particularly concerned about. Pathways to care with its associated filters at the various interfaces of the health-care system is one useful framework to understand how care reaches or eludes the needy. Such understanding can help inform, influence and improve the accessibly of our services.
Pathways to care analysis at Community Mental Health Program (CMHP, Kottayam district) informed us that 11.7% of patients (see chart) were self-referred to the clinic. It means they found out about the schedule of the monthly clinics by themselves. They got the  information  by  reading  -the notice board at each Community Health Center(CHC), the newspaper announcement about the clinics, the notice board at the nodal centre (near ward 4, Medical college hospital) about the clinics.
We thought of augmenting the self-referred pathway by directly influencing the treatment seeking of people who come to the OPD. A small slip (see picture) which listed common mental health problems  was given to every patient at the OP registration counter at CHCs with a request to meet us at the "counseling room" (https://communitypsyindia.wordpress.com/2014/02/15/). We did it at CHCs where the CMHP had less than 20 patients for followup.
We found encouraging results as many patients came forward to meet us at the clinic after reading the slip. Sleeplessness and excessive worry were the common presenting symptom in people who came via this pathway.
It is therefore concluded that handing out a slip with symptom list of common mental health problems, at primary care OP is one way to improve detection of minor mental disorders and provide early intervention. Services and access to care can be improved by this simple approach.One barrier that was noted was - many of the older people found it difficult to read the fine print in the slip.

Horizontal interaction with palliative care program: TOT session @Kottayam.

 A TOT (Training Of Trainers) session for the palliative-care-program staff of Kottayam district, Kerala was organised by the DMHP (District Mental Health Program).IMG_0007The half day program was piggybacked on the schedule of their bimonthly district level meeting.

120 nurses and 5 medical officers who are part of the palliative care team of the district were the participants. As per felt-needs understanding of the CHMP team, home care of severe dementia and severe intellectual disability was decided as the focus area for training. Specific sub-areas focused for dementia care were  management of behavioral problems in severe dementia and addressing caretaker issues. Training in self-care for adolescents and adults with severe mental retardation was the other sub-area selected. Validation of this need was sought by circulating a needs assessment performa among the pattiative care nurses (70 respondents) and the cumulative data is as follows.

Needs Assessment Questions Yes No
Do you see people with mental health problems as part of your routine work? 90%
Are severe-mentally-ill patients who are home bound included as patients in the home care program? 90%
Have you received any training till yet in care of home bound patients with severe dementia and mental retardation? 31% 69%
Do you anticipate difficulties/challenges in care of above mentioned patients? 50%
What are those difficulties? *See below
Have you received any training in counseling for caretakers in distress? 50%
Have you heard about the CHMP which is been running in the district since last one year? 50%
Have you referred any patients to CMHP clinics? 18.5%

* Most responses were about the anticipated difficulties in communicating with the subset of this patients. There was apprehension that the patients may not cooperate because of their illness. They might resist everything….difficult to explain things to them….there will be no involvement from the patient’s side…the patients may refuse medications, how to deal with that….how to deal will issues of care takers.

All questions and responses were collected originally in Malayalam.

See below our team psychologist taking session on selp help training.

IMG_0003

Nobody will say that the medical and social needs of the elderly patient with severe dementia and children with severe intellectual disability will be justifiably met by attending a once monthly outpatient clinic. But that is all the community based care that is available for mental health in Kerala now. The District Mental Health Program (DMHP) in all 14 districts of Kerala work in a montlhy outreach clinic mode. This is beside the fact that Kerala as a state is far ahead in India in having a functional DMHP in all its 14 districts as against most other states where the program is still a non-starter.

The care for the chronically ill, who will not be able to come to the clinic, will be a nagging problem for all field-psychiatrists who are part of the program in most districts in Kerala. We at Kottayam district, did a database search of our patients (270 patients out of the ~725 who have registered with the program since its inception one year back). 12 patients with Dementia and about 35 children with Intellectual disability were found.

Some form of home based care is the only option for this subset of population. But where are the personnel for doing that?

We had knowledge that the palliative care program has a strong field presence in the state. This fact was also evident in the analysis of the referral pattern to our clinic. We get 10.60% of our referral from the field staff of which many are from the palliative program (see below). Horizontal integration with the palliative care program is a potential solution for homecare of the severe mentally ill.

chartimage

The palliative program has its visible presence in all districts of Kerala with amble support from the local self governments. Working with palliative team for delivering mental health services was successfully demonstrated in the Malapuram district of Kerala and often it is hailed as the “Malapuram Model” (see my previous blog post where it gets a mention).

Some concluding comments:

1. I was surprised by the large human resource capital of the palliative program available for a district (120 nurses for Kottayam district and about 7 medical officers of health department who are incharge as nodal officers). The DMHP with 3 support staff for the field-psychiatrist for an entire district pales in comparison!

2. While interacting with the District Program Manager (DPM) of Kottayam it was suggested that whatever field work that is felt as requirement for the DMHP, it could be carried out through the palliative care nurses. Potential areas like home based monitoring of drug compliance or enlisting service of the palliative care nurse as the first contact personnel when symptoms in patients worsen were discussed.

3. The field nurses of the palliative care had knowledge of many patients in the community who were not taking psychiatric treatment or discontinued medications. This interaction is sure going to benefit these patients as they will soon be referred to the outreach clinics of CMHP. Previously only 50% of the palliative staff in Kottayam had knowledge about CHMP program, now that everybody in the palliative team has come to know about it, opportunities for working together is sure to increase 🙂

added 0n 03/03/2016

lancet-psychiatry article on “palliative psychiatry”

 

Kerala bends the curve on hard liquor consumption.

Kerala has bent the curve on hard liquor consumption. Figures from the annual sale figures of alcohol from the state speaks for itself. As the data has been collated from many sources based on BEVCO (BEVerages COrporation of Gov. of Kerala, which has monopoly over sales) figures, it is fairly accurate. (Graph created using http://www.chartgo.com/)

bevco3

Many reasons have been put across for this change. Increasing awareness programs from government , reducing availability of liquor etc. However incremental taxes on alcohol could be the primary reason as shown by increase in tax revenue for the government (see chart below). Alcohol has become increasingly costly. Increase in beer consumption if viewed a gateway phenomenon can indicate more use among young people, however if it is viewed as behavioral change among seasoned drinkers it can indicate how punitive tax structures are helpful in harm reduction.

Recent government decision to shut down bars because of poor quality of service  has resulted in mixed reactions. Sociologists have commented that …. that neither prohibition nor cutting down of availability is going to bring down Kerala’s liquor menace which is causing serious social and family problems. According to them, the problem in Kerala is not liquor as such but it is the underlying social and psychological factors that are forcing Keralites to hook to booze.

It is indeed a multidimensional problem. Will need more analysis in coming years.

Sales figures from 2010-14.

Year

Hard liquor

Beer 

Gross sales value

Revenue for Gov.(Tax etc)
2010-11 217.41lakh cases (15.6% increase from previous year) 85.61 (0.4%) 6730.30 crores(21.52%) 5232.53 crores
2011-12 241.78 (11.06%) 97.82 (14.2%) 7861.74 (16.8%) 6292.48
2012-13 244.33 (1.2%) 101.64 ( 3.8%) 8818.81 (12.17%) 7240.89
2013-14 240.67 (-1.5%) 108 .00 ( 6.26%) ?9353 ?7511

updates:

http://www.newindianexpress.com/cities/kochi/A-Peg-or-Two-Down-but-Tipplers-in-Kerala-Still-Drank-Like-Fish/2014/07/08/article2319603.ece

CSR of BEVCO http://m.newindianexpress.com/kerala/335246

alcohol consumption reduce after bar closure alc