In December 1999 Dr Bruno Gagnon
Traveled to:
Instituto Nacional de Cancerologia
Bogota, Colombia

Dr Bruno Gagnon
Palliative Care Physician, Montreal General Hospital, Montreal, Canada

Highlights

There is to be an international collaborative effort to open a Palliative Care Unit at the University Hospital of "La Universidad de la Sabana"

Dr. Andres Avila, Colombia

When planning palliative care services, the family structure of the society needs to be evaluated.

Dr Bruno Gagnon

Full Report

Travelling Fellowship Report
By Dr. Bruno Gagnon, Montreal General Hospital

to Instituto Nacional de Cancerologia Bogota, Colombia

December 1999

On December 14, 1999 Dr. Bruno Gagnon and Dr. Jairo Moyano were received by Dr. Carlos Castro, the Director of the "Instituto Nacional de Cancerologia" of Bogota, Colombia. The objective of this meeting was to discuss the usefulness of a Palliative Care Unit in a Tertiary Oncology Center since no such unit exists at this time in this center. Dr. Gagnon mentioned first that Palliative Care is now recognized as a necessary and integral part of complete oncology care as defined by the World Health Organization. He presented the advantages of such a unit:

1. quicker stabilization of patients suffering of pain and other symptoms;

2. the team approach to the planning of care which allows earlier discharge home for patients able to return to the community;

3. organisation of a better setting for terminal patients unable to return home;

4. improvement of expertise in the care of terminally ill patients achieved by creation of a suitable teaching and research environment.

This exchange of ideas hopefully will permit the opening of the Palliative Care Unit. Dr. Gagnon offered his future support and help in structuring this new unit by exchange of documentation and experiences. Drs. Castro and Moyano expressed their satisfaction with this meeting and they look forward to future collaboration.

Conference organized by "La Asociacion Colombiana de Cuidados Paliativos"

In the evening of December 14, 1999, Dr. Gagnon participated in a conference on Palliative Home Care "Avances en el Cuidado Domiciliario del Paciente con Cancer Avanzado" organized by "La Asociacion Colombiana de Cuidados Paliativos", "La Unidad de Cuidados Palliativos del Instituto Nacional de Cancerologia" and "La Clinica de Dolor y Unidad de Cuidados Palliativos de la Clinica Reina Sofia". Mr. Alfredo Leon and Mrs. Adriana Garavita presented experiences of their home care program called "Atencion Domiciliaria de Colsanitas". Their program is four years old and includes various home care services such as rehabilitation, follow-up post surgery, antibiotherapy and palliative care. To date more then 2,500 patients were treated at home, of whom 49 were in the terminal phase of their illness. 90% of family members and patients reported complete satisfaction. Dr. Gagnon observed that advanced cancer patients have a wide range of needs, including:

1. The control of pain and other symptoms vary greatly from being very simple for some patients, to extremely difficult for others.

2. The family structure of the society needs to be evaluated since it is imperative that there be at least two caregivers present in the home to allow patients to die at home since this will help to avoid exhaustion of the family members.

3. The access to a family physician doing home visits is also an essential element of a complete team of nurses, pharmacists, occupational therapist, etc. This basic team will also take advantage of access to a palliative care specialist.

4. The coordination of resources within a palliative care program will allow optimal use of limited resources.

He then presented the results of the evaluation he carried out with Dr. Eduardo Bruera of the Edmonton Palliative Care Program, set up with the goal of responding to the needs of all advanced cancer patients in the region of Edmonton.

The program has a central office where the patients' care is coordinated and oriented toward the existing resources. The program consists of a14- bed Acute Palliative Care Unit for patients with difficult pain and symptom syndromes and/or distressing family and social situations. It also includes three hospices (56 beds total) for terminally ill patients unable to stay at home, as well as a full palliative care specialist consulting team in each of the two tertiary hospitals and four palliative care specialist consultant home care teams.

This program allowed a change of place of death for advanced cancer patients from tertiary hospitals toward home and hospices. The number of days that advanced cancer patients spent in tertiary hospitals decreased by 90%.

He also briefly presented the new program being developed in Montreal to establish a continuum of care between tertiary hospital and home care program for advanced cancer patients.

The evening ended with an open discussion that permitted exchanges regarding the challenges of palliative care in Colombia.

Conference on the use of Methadone in Advanced Cancer Patients

On Wednesday December 16, 1999 Dr. Gagnon presented the results of his research on Methadone in advanced cancer patients. He reviewed the literature focusing on equianalgesic potency of methadone with morphine and hydromorphone, the efficacy of methadone on neuropathic pain and other types of pain. He presented the evidence that methadone may be a special narcotic because of its ability to block the NMDA receptors which are suspected to be implicated in the development of opioid tolerance and in the poor response to opiods encountered in patients with neuropathic pain. An exchange of experiences with the use of methadone by the two centers resulted in an idea to establish collaborative efforts leading toward a multi-centric research protocol comparing Methadone and Morphine as a first line agent in the treatment of cancer pain.

Establishing an International Collaborative Effort to open a Palliative Care Unit with University Hospital of "La Universidad de la Sabana"

Dr. Gagnon met with Dr. Andres Avila, professor of oncology of the Faculty of Medicine, Universidad de la Sabana. Dr. Avila shared his interest in opening a new Palliative Care Unit in the University hospital of de la Sabana. Dr. Gagnon agreed to begin establishing such collaboration between Mcgill University and the University of de la Sabana and also between the two governments, the Canadian and Colombian. It may be possible to obtain a starting grant from the Canadian Agency for International development (LINCO).

Submitted by: Dr Bruno Gagnon