Includes bibliographical references. / Palliative care, for those dying from a life-threatening disease, has developed to become a definite discipline in mostly developed countries. Through this palliative care has become accepted as a human right to all in need of end-of-life care. The stark reality in developing countries is that palliative care is in the early stages of development, with the result that if it is available at all, it usually is very basic. These countries which have restricted resources available are faced with an increased and overwhelming demand for palliative care because of the AIDS pandemic and also an expected massive increase in the incidence of cancer and non-communicable diseases. This raises the question how this demand will be met? The WHO is again looking at primary care as the way of meeting increased health care demands, including palliative care. The importance of the role of the general practitioner in delivering palliative care is widely accepted. The greatest majority of general practitioners in South Africa have never received official palliative care training. The question to be answered then is how well are they equipped to meet this increasing demand for end-of-life care. The study was designed as a descriptive cross-sectional KABP study. The study population was defined as all practising GPs working in a particular area in the northern suburbs of Cape Town and a number of Boland towns. The data collection tool used was a self-administered questionnaire that was developed through a process of review and through a pilot process. The questionnaire was then posted to all identified GPs with a return envelope with follow-up of non-respondents to ensure a better response rate. The response rate was 34,7%. Overall 69,45% of the questions were answered correctly and 30,55% incorrectly. The respondents showed good knowledge on morphine use and respiratory depression, the dangers of addiction to morphine, emergencies in palliative care and spinal cord compression. The greatest majority of respondents do not understand the holistic approach to pain management and also do not have knowledge about the use of syringe drivers. A high percentage of participants have a positive attitude towards palliative care in general, feel comfortable with their own emotions in end-of-life care and acknowledge their need for further training. On the questions on belief, respondents believe that the family must be involved in decision-making and that the GP must be doing bereavement care. Unfortunately most participants believe the management of physical symptoms ensures quality of life and seem not to grasp the holistic approach followed in palliative care. In practice only a few respondents understand the routine use of anti-emetics with initial opioid prescriptions. There is a significant number of GPs uncertain about the use of combinations of analgesics, the use of intravenous fluids in end-of-life care and the use of the subcutaneous route to administer drugs and fluids. The importance of the role of the GP in palliative care has to be recognized and acknowledged by all involved in such care. Programmes have to be initiated to train and educate practising GPs in palliative care to empower them and also to spread the end-of-life care message.

Includes bibliographical details. / In Tanzania, palliative care is relatively new, and faces the common challenges of access to services, crucial medications, and education. Since 2004, an initiative within the health system of the Evangelical Lutheran Church in Tanzania (ELCT) began to promote and develop palliative care, using as a model the Selian Hospice and Palliative Care Programme. The hospitals which are the sites for team development and service delivery are widely scattered throughout rural Tanzania. Access to oral morphine was only a dream, as it is for much of the rural population of the world. In 2007, a program called CHAT (Continuum of care for people living with HIV/AIDS in Tanzania), funded by the U.S. government, allowed the up-scaling of these palliative care programs, resulting in 13 strong and mature teams by 2011, though still lacking oral morphine. Part of the monitoring and quality assurance of the program has been use of a tool developed by APCA: the APCA African Palliative Outcome Scale (POS). Hundreds of people living with cancer and HIV were subjected to the questions of the tool, which was always sent on to the core supervising team for assessment and feedback. Tramadol was the strongest analgesic available to the teams throughout the study time. 145 APCA African POS results on cancer patients were assessed, looking at differences in pain scores (0 to 5 scale) over time as well as assessing the other domains of care (psychological, spiritual, social, and family). 11 Palliative care nurses were also interviewed, asked to reflect on specific cases from their experience with both good and bad pain control. 5 of the nurses came from Selian, with access to oral morphine, while 6 of them came from the CHAT hospitals. Significant improvement in pain scores over 4 weeks was noted (3.83 to 2.31, p < 0.0001). All other domains assessed in the POS also improved significantly. Nurse interviews revealed an emphasis on the holistic approach and a strong preference for having access to oral morphine. In this rural Tanzanian environment, effective palliative care services – including pain control - were delivered even in the absence of oral morphine. Such services can become a strong advocacy at the government level for achieving breakthroughs in palliative care, including access to oral morphine.

Includes abstract. / Includes bibliographical references (leaves 138-149). / A survey was done in the City of Cape Town Health District to identify possible barriers and other factors that influence the referral of patients to hospice by oncologists. Factors that influenced referral of patients to hospice included lack of training of oncologists in palliative care, the view of the oncologist's individual role in the care of his patients as well as the ability to communicate comfortably with patients regarding end-of-life care. Reasons for non-referral included hospice not being available in the area or not accessible to patients, the perception of the doctor that he/she is giving up on the patient, previous dissatisfaction with service by hospice and not wanting to lose control of the treatment of the patient.

Includes bibliographical references (leaves 100-105). / Includes abstract. / The aim of the research was to determine changes in quality of life over the first six months of anti-retroviral therapy.

Includes bibliographical references. / This is an evaluation of the holistic care of Tuberculosis patients with palliative care needs in the Western Cape, South Africa.

There are currently more people living with cancer than ever before. The management of the heavy symptom burden carried by these patients remain a critical subject. Of these symptoms, depression is one of the most frequently reported and debilitating symptoms in advanced cancer. The negative impact of untreated depression on both the patient and the healthcare system is well documented. The aim of this study was to explore how South African radiation oncologists manage depression in their late-stage cancer patients. The study focussed specifically on the use of screening tools, their choice of drugs and the mental health resources available to them. A convenience sample of 34 South African radiation oncologists that included participants from both the private and government sector completed an online questionnaire. The results from this study showed that these oncologists do encounter depression in their late stage cancer patients confirming the importance of the subject. While the lack of a universally agreed screening tool remains a problem, at least fifty percent of the respondents were already using some form of screening tool and thirty-five percent of the rest indicated their interest in implementing depression screening in their practice. When faced with a depressed patient, Seventy-four percent of these oncologists felt confident in starting antidepressants and all of them had some sort of mental health resources available to them. Unfortunately, the small study sample and self-reporting lead to concerns regarding the generalizability and validity of the study. However, the study remains valuable in its role of raising awareness for depression in our cancer population, identifying the shortcomings in our current management as well as identifying education needs in our health-care personnel.

Includes bibliographical references. / The 2 Military Hospital Palliative Care unit seeks to provide high quality, holistic palliative care to all patients suffering from life-threatening diseases. This care should be initiated early after diagnosis, to prevent unnecessary suffering and allowing the patient and the family to be part of the decision making process. However, the majority of the cancer patients are either referred very late in the disease process or are not referred at all. The purpose of this study was to enumerate the percentage of patients who were not referred to the palliative care unit; to identify possible barriers to referral within referring doctors and to promote the role of the palliative care unit.

Includes bibliographical references. / Burnout is a syndrome of emotional exhaustion, depersonalisation and reduced personal accomplishment that may occur amongst individuals who work primarily with people. Nurses and doctors working in oncology must care for many critically ill and dying patients. Pretoria is a city with a high concentration of oncology institutions. The aim of this research is to evaluate the incidence of burnout amongst health care professionals in Pretoria oncology centres, to assess whether certain variables have an influence on the levels of burnout and to compare the situation in Pretoria to the rest of the world. A questionnaire was distributed to all health care professionals working in oncology centres in Pretoria. The questionnaire consisted of an informed consent, demographic data and the Maslach Burnout Inventory. The participants included doctors, nursing staff, radiographers and social workers in both state and private health care institutes, involving radiotherapy, chemotherapy and palliative care units. 240 questionnaires were distributed and 156 were returned. Results show that 24.65% - 32 .87% of participants experienced a high degree of burnout, which is average compared to the rest of the world. Burnout in cancer care workers has been reported to be 22.1 - 53.3% in the rest of the world. Young, single participants appeared to experience a greater incidence of burnout, which is consistent with the literature. The incidence of burnout amongst healthcare professionals, in Pretoria oncology centres appear to be average when compared to the rest of the world. However, language problems, cultural differences and other limitations of the burnout scale may have played a role and warrants further research.

Includes bibliographical references. / The control of pain is an important aspect of patient care for physicians who deal with cancer and has significant impact on the quality of life of patients. With appropriate care, pain can be controlled in 90% of patients who have advanced malignant conditions.

Patients with terminal illness may benefit greatly from hospice and palliative care. Studies of patients with chronic terminal illness revealed that those who did not received palliative or hospice care experienced poor quality medical care characterized by untreated symptoms, unmet spiritual and personal care needs, increased burden for the caregiver, and low patient and family satisfaction (Meier, 2011). According to the World Health Organization (2011), palliative care is offered at the time of diagnosis alongside potentially curative treatment and can be utilized during the trajectory of illness until death. Hospice is a Medicare benefit considered the model for quality, compassionate care during the last 6 months of life and is available to all patients regardless of age, religion, race, or illness (Medicare Hospice, 2011). This study examined why patients with non-cancerous terminal illness were not receiving timely palliative or hospice care by interviewing primary care providers. A systemic literature review suggested possible barriers including confusion between palliative and hospice care, lack of understanding about the scope and intent of hospice care (McAteer & Wellberry, 2013), prognostic uncertainty, timing, and no clear point to originate a referral (LeMond & Allen, 2011). Insufficient training for primary care providers, including the lack of familiarity with various prognostic tools that aid in determining eligibility for the patient with a non-cancerous, terminal diagnosis might also be a barrier to referral (McAteer & Wellberry, 2013). Lastly, primary care providers lacked confidence in communicating the need for advanced care planning in non-cancerous terminal illnesses according to a survey done by Karlekar, Collier, Paish, Olson, & Elsay (2014). The findings of this study confirmed the available literature. Much work is needed to educate providers and incorporate palliative care and hospice guidelines in academic institutions and in practice. Regulatory issues need continuous attention as the landscape of coverage, payment, and reimbursement changes rapidly. Further research is needed so that this vulnerable population will benefit from early interventions and a better understanding and acceptance of their non-cancerous terminal illness.