Carlo Leget, Vice-president, EAPC, (and Associate Professor Ethics of Care, Tilburg University, the Netherlands)
One of the things I have been racking my brain with last week is the following question. According to the World Health Organization (WHO), non-communicable diseases (NCDs) are currently the leading global cause of death worldwide. So it is a great idea to have a global monitoring framework set up to prevent and monitor NCDs. It is an even greater idea that a palliative care indicator is proposed in order to measure how nations respond to NCDs. But now the ‘brain racking’ starts. In order to have a feasible monitoring framework, the number of indicators is limited, and then the question is: is there one single palliative care indicator that makes sense?
The question arises because there is a proposed indicator:
“Access to palliative care assessed by morphine-equivalent consumption of strong opioid analgesics (excluding methadone) per death from cancer.” 1.
The problem is that this indicator will tell only the correlation between the registered administration of strong opioids and the registered number of cancer patients. It will not tell anything about care and as an indicator for palliative care it will be misleading in a number of ways:
1. It wrongly suggests that palliative care is meant only for cancer patients, whereas palliative care is the active, total care of the patients whose disease is not responsive to curative treatment.
2. It wrongly suggests that palliative care is about physical pain control, whereas next to control of pain, control of other symptoms, and of social, psychological and spiritual problems is paramount.
3. It will give a false picture about what goes on in reality. In many so-called ‘developed countries’ most of the legal opioid consumption is generated by individuals with non-malignant pain conditions (>50% musculoskeletal pain).
4. It may endorse the false idea that an increase of opioids is equal to (or sufficient for) the provision of good palliative care.
These are serious problems associated with the proposed indicator, sufficient to reject it altogether. But what if this means a complete exclusion of palliative care among the indicators? Is it better to have a poor indicator than no indicator at all?
It is likely that in cases such as this, no single indicator will be sufficient and a combination of indicators is needed. Which combination is the best to do the job is still an open question. But an important question, high on the EAPC agenda. All brains are invited!
1. World Health Organization (WHO), 2012: Second WHO Discussion Paper (version dated 22 March 2012). A Comprehensive Global Monitoring Framework including Indicators and a Set of Voluntary Global Targets for the Prevention and Control of Non-communicable Diseases. http://www.who.int/nmh/events/2012/discussion_paper2_20120322.pdf (accessed 12 April 2012).
(Photo by Karigee on Flickr).