|
NEWSLETTER
IAPC SECRETARIAT
Official Newsletter of the Indian Association of Palliative Care |
|
|
MESSAGE
FROM THE SECRETARY |
|
|
Dear Friends,
Greetings!
National organisations in palliative care around the world are coming together to form World Palliative Care Alliance (WPCA), an international body which aims to promote scaling up of services and sharing of good practices across the world. IAPC is a member of the steering group of WPCA which will soon become a legal entity. Among other things WPCA has facilitated World Hospice and Palliative Care Day for last four years. This year the World Hospice and Palliative Care Day will be on 11th October and the theme for the occasion is “Palliative Care as Human Right”. Palliative Care is being considered as a basic human right. We have always maintained that it not only about pain relief but about human dignity in total. For the first time a joint statement on palliative care has been signed by various international, regional and national organisations for the care of chronically ill. |
|
This was announced on 1st August 2008. This is going to be a major advocacy tool for taking palliative care activities forward worldwide. IAPC, as a member of the World Palliative Care Alliance (WPCA) is a signatory of the declaration. The declaration is now set for reading and signing at
http://www.hospicecare.com/resources
/pain_pallcare_hr/
The Palliative Care policy of the Government of Kerala, which was long expected, was announced on 15th April 2008. It is for the first time that any government in Asia coming up with a palliative care policy and what is more important is that the policy has an action plan linked to financial means to achieve the goals. The policy, I hope, will inspire palliative care developments else were in the country. |
|
The secretariat is now fully set up at the Institute of Palliative Medicine, Kozhikode. The web site is updated. Now we have a discussion forum in the website where we can discuss issues related to palliative care.
You will find in this news letter the details on how you can access and use the forum.
IAPC is in the process of updating the information on the members and palliative care activities in India. This issue of the newsletter has a data collection form which you can fill and return using the postage paid envelope.
I request all the members of the organisations to return the forms and you can use them also for other members whose contact details were not updated.
Warm regards
Dr. Anil Kumar Paleri
Hon. Secretary |
|
|
|
|
IAPC Conference 2009 |
16th International Conference of Indian Association of Palliative Care 2009 will be held in New Delhi from 13th to 15th February at Jawaharlal Nehru Auditorium , AIIMS, New Delhi.For registration and other details contact
Dr. Sushma Bhatnagar
Organizing Secretary, Room No. 242,
Unit of Anesthesiology , Dr.BRA institute of Medical Sciences
New Delhi-110029, India, Tele fax No. +91 11 26588227
Email: iapcon2009@gmail.com
Website: http://www.iapcon2009.org |
Dr. Sushma Bhatnagar, Organising Secretary, Room No.
242, Unit of Anesthesiology , Dr.BRA Institute Rotary Cancer
Hospital, AIIMS, New Delhi-110029, India, Tele fax No.
+91 11 26588227. Email: iapcon2009@gmail.com
Website: http://www.iapcon2009.org |
| International Conference on Public Health and Palliative Care |
1st International Conference on Public Heath and Palliative will be held in Kozhikode, Kerala on 16th and 17th 2009.
For registration and other details visit
www.pubhealthpallcare.in |
| CURRENT IAPC EC MEMBERS |
President: / Prof. Sukdev Nayak /suk_dev@rediffmail.com/ 9338904400
Secretary: / Dr.Anil Kumar Paleri/anilpaleri@gmail.com/ 9447853340
Treasurer: / E. Abdul Majeed/ abdulmajeed.e@gmail.com/ 9745146090 |
|
Vice Presi.: /Dr.T. Mohanasundaram/ drmohs.trichy@hotmail.com/ 9345116599
Editor: / Dr. Jacob Alexander/ dralexander_in@yahoo.com
Executive Members
Dr. Aarti Kaul Patel/ aartikaul7@gmail.com / 9752547731
Dr. Mathew Numpeli/ painclinic@sify.com/ 9446444667
Ms. Saroja G/ sarojasen@yahoo.co.in
Ms. Kumari Thankam/ kumarithankam@hotmail.com
Dr. Shyamal Sarkar/ drsarkarsmay@rediffmail.com/
9831097315
Dr. Anjum Joad/ anjumjoad@hotmail.com/ 9828915257
Dr. Nandini. V/ nandiniv@aims.amrita.edu/ 9446033050
Mr. Gafoor Thaneri/ 9447304316
Dr. Kabindra Bhagabati/ kbhagabati@yahoo.co.uk/ 9864093687
Dr. Abijith K Dam/ ratuldam@yahoo.com/ 9431915282
Past President/ Dr. Firuza D. Patel/patelfd@glide.net.in
Past Secretary/ Dr.Dinesh Chandra Goswam/goswamidcg@yahoo. |
|
|
| g |
|
| Leading Organizations Call for Recognition of Palliative Care and Pain Treatment as Human Rights |
The Seven Goals in the Declaration are:
|
1 . Identify, develop and implement strategies for the recognition of palliative care and pain treatment as fundamental human rights.
2 . Work with governments and policy makers to adopt the necessary changes in legislation to ensure appropriate care of patients with life-limiting conditions.
3 . Work with policy makers and regulators to identify and eliminate regulatory and legal barriers that interfere with the rational use of controlled medications.
4 . Advocate for improvements in access to and availability of opioids and other medications required for the effective treatment of pain and other symptoms common in palliative care, including special formulations and appropriate medications for children.
5 .Advocate for adequate resources to be made available to support the implementation of palliative care and pain treatment services and providers where needed.
6 . Advocate for academic institutions, teaching hospital and universities to adopt the necessary practices and changes needed to ensure that palliative care and pain positions, resources, personnel, infrastructures, review boards and systems are created and sustained.
7 . Encourage and enlist other international and national palliative care, pain treatment, related organizations, associations, federations and interested parties to join this global campaign for the recognition of palliative care and pain treatment as human rights. |
|
The International Association for Hospice and Palliative Care (IAHPC), the Worldwide Palliative Care Alliance (WPCA) and different organizations from around the world have issued a Joint Declaration and Statement of Commitment calling for the recognition of Palliative Care and Pain Treatment as Human Rights. The Declaration and Statement have been jointly developed and signed by representatives of several international and regional organizations from Africa, Latin America, Eastern Europe, Western Europe, Asia and North America. The Declaration was presented on August 4th at the XVII International AIDS Conference in Mexico City. |
The Joint Declaration and Statement of Commitment are also scheduled to be presented in meetings sponsored by cancer, palliative care and pain management organizations throughout the rest of the year. The IAHPC and WPCA invite other interested organizations and individuals to sign the Declaration using the online signature page at http://www.hospicecare.com/resources/pain_pallcare_hr/ Signatures will be collected until October 11th, the date of World Hospice and Palliative Care Day, at which point list of individuals and organizations singing on the Declaration will be published. |
This is the first time that a Joint Declaration has been developed and signed by a collection of leading international organizations in the field of palliative care, hospice, pain, cancer, HIV/AIDS and others. |
|
|
|
| Pain & Palliative Care Policy; Another First From Kerala. |
 |
Another major aspect of the policy is government’s commitment to work together with community based organisations and other palliative care providers for improving the quality and access to palliative care. The relevance of this lies in the fact that Kerala has a system of decentralised governance and health is one of the many areas delegated to Local Self Governments Institutions (LSGI). This gives the local governments the power and means to take decisions |
on health issues as relevant locally and implement them.
The policy has an action plan for achieving targets mentioned. It include training more volunteers and professionals, ensuring availability of essential drugs including oral morphine, starting inpatient units in government hospitals where appropriate, developing new community based palliative care programmes with home care services with support from Community Based Organisations (CBOs), LSGIs and local government and other health care institutions, developing common bodies in LSGIs
|
|
The government of Kerala announced a pain and palliative care policy to become the first government in Asia to have a declared policy on palliative care.
. The Kerala chapter of the Indian Association of Palliative Care has taken a lead role in pooling the opinions and suggestions from the palliative care programmes to develop the policy. The government had convened a series of meetings of the representatives from palliative care services in the state and also consulted the officials concerned
The policy takes a lot from the current palliative activities in Kerala. It identifies home based care as the “corner stone” of palliative care services and community based approach the way to reach all persons needing such care. It also recognises the need for integrating palliative care with primary health care and disease specific treatment programmes for effective coverage. |
|
|
|
to coordinate palliative care activities of CBOs, LSGIs and local health care programmes, developing more training centres in palliative care, incorporating palliative care modules in various medical and paramedical courses and also in to the training programmes of the officials and administrators, quality check and documenting. It is encouraging to note that the National Rural Health Mission (Kerala) has come out with a 45 million Rupee project this year to facilitate these initiatives. |
This policy is a great step forward by the government and also a major boost to the palliative care activities in the state. The copy of “Pain and Palliative Care Policy” of the Government of Kerala can be downloaded from www.kerala.gov.in/annualprofile/, the official website of the Government of Kerala. It is also available at www.palliativecare.in, the website of Indian Association of Palliative Care and www.arogyakeralam.gov.in |
| PROJECT KIRAN - AN UPDATE |
| Project kiran living with dignity is a project that proposes to integrate the care of the elderly together with palliative care. This five year project began on November 1st, 2007 |
An update of the responsibilities of Indian Association of Palliative Care for the project |
| Upgrading Palliative Care Centres toTraining Centres |
In this activity , select centres offering palliative care treatment are to be upgraded into palliative care Training centres of Excellence. Existing palliative care centres will be offered support.
The three centres upgraded by IAPC in the first year are:
- Jeevodaya Institute of Palliative Care , Chennai
- Palliative Care Unit, PGIMER, Chandigarh
- Guwahati pain and palliative care society , Guwahati
The centres have each been sanctioned Rupees one lakh.
All these centres have carried out certificate course in essentials of palliative care introduced by IAPC. Jeevodaya has conducted two courses in the first year and one course each by P.G.I.M.E.R and GPPCS. In the first quarter of the second year one course each was conducted by the three upgraded centres. This year three more centres will be upgraded
|
| Training of Health Care Professionals in Palliative Care |
The certificate course in Essentials of Palliative Care is a basic course that has been developed by IAPC for doctors and nurses to train in palliative care. In the first year 148 Doctors and 64 Nurses have been trained through the 15 courses run across the various 12 centres. IAPC is conducting two courses in the second year. 392 candidates were registered through 20 centres in the first batch which started on 1st June. Evaluation has been completed . The next batch will begin from 1st November 2008.
|
|
|
A team of 44 trainers has also been established at the national level. Consisting of Palliative care physicians, nurses, community volunteers and social workers, all who have had some experience in training , members of this team have regular updates, reviews and train the trainers sessions.In addition, they are also expected to spend a total of 10 days every year on IAPC training assignments and take part in the train the trainer programs.
A workshop for the national faculty has been fixed on October 31st and November 1st at Kochi, Kerala |
| Organising and Operating a PC Information service |
The National Information office located at the institute of palliative medicine (IPM) began to develop a hub for information access, awareness generation and management of information. A website(www.palliativecare.in)has been launched and the first newsletter has already been circulated among members of IAPC. |
| Project Kiran-Living with Dignity |
 |
| Home visit a Cuddalore |
| Project Kiran-Living with Dignity is a joint venture of IAPC, IPM (Institute of Palliative Medicine) and HelpAge India. This project is a first step of HelpAge India towards providing Palliative Care services to the elderly and also advocating for its cause at various levels. The project was launched in February’08 at Manjeri, Mallapuram district. HelpAge India’s main activities involve incorporating components of training received on Palliative Care to the field level and |
|
|
|
| |
|
developing a Demonstration Project (which could later on based on its success be replicated elsewhere) in Cuddalore district, Tamil Nadu.
HelpAge India is also responsible for overall co-ordination of all the other meetings, workshops and conferences.
In Demonstration Project the intention is to replicate the Network Neighbourhood in Palliative Care model (Manjeri, Malppuram District).
Training was organised for 50 volunteers in Mancheri and in cuddalore where three people from IPM/NNPC were resource persons |
At the moment There are more than 50 patients receiving palliative care in 12 villages of Cuddalore district, under the Demonstration Project. The project aims at making direct intervention in the community, sensitise them about the need of palliative care, mobilise community to come forward and volunteer for providing home care to people around them, sensitise community and local government leaders to co-operate in all possible ways to reach out to as many needy people as possible, and establish linkages with medical institutions for providing tertiary care to patients referred by the medical team of the project.
The Demonstration Project team has 8 members (4 medical, 4 social). Besides these, a force of nearly 20 volunteers is also working actively and in very close coordination with the project team. The Project currently is being implemented by HelpAge India in 12 villages, in close association with IPM and IAPC, and the objective is to expand to 25 villages.The project is being implemented in India with assistance from Help the Aged and Help the Hospices (UK).
|
| Media Campaign |
The Institute of Palliative Medicine, Calicut has joined hands with Malayala Manorama,
the largest circulating regional language newspaper in India to run a one year campaign to develop community owned palliative care services in Kerala. The ultimate aim of the campaign is to set up the neighborhood network in palliative care (NNPC) and thus to provide palliative care to all those in need. IAPC kerala has a major role in coordinating the programme.
The media campaign was launched on April 29th and in the first phase of the program the daily newspaper Malayala Manorama published serialized features and supportive news stories to highlight the achievements of current palliative care services. Vanitha Magazine, a co-publication of Malayala Manorama and MM TV, a news channel owned by the same group also supported the campaign. |
 |
| Inagural Function of palliative care Compaigan |
The response to the publicity campaign from the public was overwhelming. Through the helpline, Institute of Palliative Medicine received more than 500 telephone calls from individuals and groups offering their service. |
|
| Workshop for Social Workers |
 |
Workshop at Jeevodaya |
Jeevodaya Institute of Palliative Care Chennai, Succefully conducted the first programme of the project for the year 2008-2009 after upgradation of Jeevodaya into a training centre under project kiran.
The programme was a one day workshop for the MSW students of Mar Gregorious College of Chennai. Twenty five students attended the workshop.
Dr. Manjula Krishnaswamy, Medical Director Jeevodaya , Dr. Udaya Mahadevan Professor and HOD , Dept of Social Work, Loyola College , Chennai and Mr. Antony lead the classes.
The students were allowed to interact with a patient and with the spouse of a terminally ill patient.
The programme ended with the distribution of certificates of participation which they received from Sr. Libretta, Executive Director of Jeevodaya. |
|
|
|
District level awareness seminars and training classes for the volunteers have been conducted throughout Kerala in the first phase of the campaign. The first seminar in this series was held at Kottayam on May 17th .
Two hour sensitization courses were offered through the district level seminars. More than 3000 volunteers sensitized in the first phase of the project. A certificate has been issued for those volunteers who have successfully completed the foundation course conducted by Malayala Manorama and Institute of Palliative Medicine, Kozhikode. |
The event culminated in Delhi where over 2000 people gathered together on February 10th 2008.Us ambassador Mr.Mulfordand his wife participated.
The fund raised by “walk for life” will be used to provide home care to cancer patients.
Can support have decided to conduct the program as an annual event. |
| BRUCE DAVIS GOLD MEDAL |
Examination Announced |
Institute of Palliative Medicine, Calicut, Kerala, India, is conducting an examination atthe National Level in December 2008 for Bruce Davis Gold Medal in Palliative Medicine for young doctors. Doctors who appear(ed) for their final MBBS examination between 31st December 2005 and 31 December 2008 from any Medical College in India can apply for the examination.
There is no registration fee for this examination
The application form and other details are available at www.painandpalliativecare.org
|
The completed questionnaires along with the application forms should reach the Instituteof Palliative Medicine, Pain and Palliative Care Society, WHO Demonstration Project, Medical College, Calicut 673008, Kerala, India before 20th November 2008
|
| The winner of the final examination will be awarded the Bruce Davis Gold Medal in Palliative Medicine, a citation and cash award. |
| Drawing Attention to Chronic Pain in Women |
The international Association for the study of Pain has launched a campaign to draw attention into the global issue “Chronic pain in women” as a first step towards reducing pain and suffering for women around the world. Studies conducted by IASP reveal that, chronic pain affects a higher proportion of women than men around the world, but unfortunately women are also less likely to receive treatment compared to men. This is due to various factors, including societal and cultural norms and economic and governmental barriers. |
Throughout the year, IASP members and chapters will be organizing various programs and events to raise awareness of pain conditions affecting women |
|
| Useful Links and Resources |
|
This is a useful site for health professionals. The site provides essential, comprehensive and independent information about the use of drugs in Palliative Care. |
|
|
| “Walk For Life” by can support New Delh |
 |
| “Walk For Life” by can support |
|
A Campaign‘The Walk for Life’ was held on 10th February 2008, to raise awareness about the growing threat of breast cancer in urban areas, and as a fundraiser for CanSupport, Delhi. It was jointly organized by the CanSupport family of volunteers and staff, and the international community in New Delhi. The Programme was sponsored by six corporates, and supported by 28 other companies and hundreds of volunteers who lent their services, time and effort to this event. |
A free breast cancer awareness and screening campaign was held across Delhi, preceding the walk. Mrs. Gurcharen Singh, wife of the prime Minister of India, flagged of the walk. Ms Meira Kumar, Union Minister for social justice and empowerment and fashion designer, Ms.RItu Kumar were also present at the venue seven ambassadors of Latin American nation also participated in the walk. |
|
|
| IAPC Certificate Course in Essentials of Palliative Care |
Last year, when the IAPC Certificate Course in Essentials of Palliative Care was introduced, the response was overwhelming. …………. doctors and …………nurses underwent the course at 11 centres. This year the response so far is even greater! We are planning to have two intakes in 2008 and in the first batch which started on 1st June ,387 candidates have registered for the course through 20 centres in different parts of India.
At the moment the evaluations are taking place at different centres and the results will be available at our website, www.palliativecare.in, by late August..
The next batch for 2008 will begin from 1st November 2008. Those doctors and nurses who are interested in the course may apply soon. Last date for submitting applications is 1st October 2008. The evaluation will be in January 2009 |
16. MNJ Institute of Oncology and Regional Cancer centre, Hyderabad
Dr. Gayathri Palat
17. Tata Memorial Centre, Mumbai
Contact :Dr. M A Muckaden: 098203 47802
18. Institute Rotary Cancer Hospital, AIIMS, Newdelhi
Contact :Dr. Sushma Bhatnagar: 098113 26453
19. St. Johns Medical College Hospital, Bangalore
Contact :Dr. Bharathi: 9845891979
20. Amrita Institute of Medical Sciences and Research Centre, Kochi
Dr. Nandini: 0484 4003012
21: Cipla Palliative Care and Training Centre , Pune
Contact :Dr. Priyadarshini Kulkarni , Mob: 09822455288
22: Palliative Care Unit , CMC Vellore
Contact :Dr. Reena George, Tel: 041- 62283159
23: Choitram Hospital and research Centre , Indore, MP
Contact :Dr. Aarti Kaul Patel, Mob: 09752547731 |
| |
| Apply now for upgradation |
Apply now for upgrading your centre in to a Recognised Training Centre |
Last year IAPC (thorough Project Kiran) has supported three centres for upgrading themselves in to training centres. In the year 2008-2009 IAPC proposes to upgrade three more palliative care units as Recognised Training Centres. Applications are invited from interested centres. Centres should send the application to the National Information Officer, IAPC Secretariat, Institute of Palliative Medicine, Medical College PO, Calicut, Kerala with details of the existing facilities. Selected centres will be awarded Rs. One lakh for improving their infrastructure and human resources for organising training. |
| Recognised Training Centres are required to |
|
| 1 |
Conduct a regional workshop for training the trainers in palliative care |
| 2 |
Conduct a minimum of two IAPC run Certificate Course in Essentials of Palliative Care on a regular basis. |
| 3 |
Establish basic infrastructure/human resource for running regular training programmes at these centres |
|
| The centre applying for the grant should have |
• Out patient service
• Home care service
• Inpatient Unit or access to inpatient care facilities
• A minimum of 100 patient contacts every week
• The center should have atleast one full time doctor and one full time nurse working in palliative care as trainer |
|
How to apply
The completed application form with a Demand Draft of Rs.1000 and proof of professional qualifications is to be submitted to the centre closest to you. |
The Centres are : |
1. Palliative care clinic, PGIMER, Chandigarh
Contact : Dr. Firuza Patel: 0 977 9124440
2. Institute of Palliative Medicine, Calicut
Contact : Dr. Rajasree: 098952 60192
3. Community resource centre in Palliative care , Manjeri
Contact : Dr. Mathews Numpeli: 094464 44667
4. Institute of Palliative Care, Thrissur
Contact : Dr. RamlaBeebi: 098479 37767
5. Sudharshana Palliative Care Hospital Trichirappalli
Contact : Dr. T. Mohanasundaram 093451 16599
6. Jeevodaya Hospice, Chennai
Contact : Dr.Manjula Krishnaswamy: 044 2641 1879
7. Lakshmi Pain and Palliative Care Clinic, Chennai
Contact : Dr. Mallika Tiruvadanan: 044- 2641 1879
8. Total Care Charitable Trust, Chennai
Contact : Dr. Azhar Hussain: 098410 23540
9. Bangalore Baptist Hospital , Bangalore
Contact : Dr. Stanley C Macaden: 094484 96612
10. Kidwai Memorial Institute of Oncology, Bangalore
Contact : Dr. P. SaraswathiDevi: 094480 70055
11. Pain and Palliative Care Centre, Kasturba Medical college, Mangalore
Contact :Dr. Ambareesha: 093435 70062
12. Guwahati Pain and Palliative Care Society, Guwahathi
Contact :Dr. Dinesh Chandra Goswami: 098640 64070
13. Acharya Harihar RCC Pain Clinic, Cuttak
Contact :Prof. Sukdev Nayak: 093389 04400
14. Medical College Calcutta
Contact :Dr. Shyamal Kumar Sarkar: 098310 97315
15. Bhagavan Mahaveeer Cancer hospital and Research Centre, Rajasthan
Contact : Dr. Anjum Joad: 098289 15257
|
|
|
|
• A minimum of 20% of the working time of the doctors and nurses identified as trainers should be kept protected for training activities
• The trainer doctor should be a qualified doctor with Indian Medical Council registration. She/He should have the experience of at least one year as a full time palliative care physician at a centre described as above or she/he should have six months experience as a full time Palliative Care physician at a centre described above after successful completion of a minimum six weeks hands on training in Palliative Care at a recognised training centre.
• The trainer Nurse should be a qualified nurse with nursing council Registration. She/He should have the experience of at least one year as a full time Palliative Care nurse at a centre described above.
• The trainers should be IAPC members.
|
| C4CCI Launched |
|
| AWARD |
 |
| Sr.Merlin receiving award from Indian president Prathiba patil |
Sister Merlin who has worked with Pain and Palliative Care Society Calicut since 1994, has won the national Florence Nightingale award for Nursing Personnel, 2008. Indian President Prathiba Patil, Presented the award to Sister Merlin in a function held at Rastrapathi Bhavan in New Delhi on 11th May. This is the first time in India a professional in palliative care has been hounoured with high honour. |
Amrita Institute Implements Pain Policy |
Pain policy and end of life care policy are undergoing the process of implementation for the relevant patient population at AIMS first time in the country. The hospital shall do all that is necessary to facilitate a dignified dying process for the registered in-patients, who are at their end of life. AIMS Hospital takes a stand that all attempts will be made to make the registered patients in the premises of the hospital PAIN FREE.
The generic ‘Indian Terminal Care Pathway’ is also being modified to adapt it for the wide range of situations seen within a multi speciality Hospital at AIMS. |
|
| Online Directory for Palliative Care
|
The Indian Association of Palliative care is collecting information on all existing palliative care services in India with a view to create an online directory of palliative care services in India. Mr. Joseph Clark, a research fellow from UK is helping IAPC with developing the format and collecting the information.
The questionnaire developed has been pilot tested in Tamil Nadu by distributing it to the 15 known palliative care services in the state. The Information Office is assessing the responses for checking possible modifications and will be soon sending the modified questionnaire to all known palliative care services in India.
We request you to remember this and return your responses as soon as you can . Let us hope for a 100/ response to the questionnaire ! Once established the directory will serve as a useful information tool for professionals and the public. |
|
 |
| Inaguration of C4CCI Launched |
Caring for Child hood Cancer and Chronic Illness (C4CCI), a project to take care of children suffering from lukaemia and other chronic diseases has started functioning in Kozhikode.
The project , a joint venture of the department of paediatrics, kozhikode Medical College Hospital and Institute of Palliative Medicine, Kozhikode was inaugurated on wenesday May 21st by Nandu, a leukemaemia survivor and sarika who is undergoing treatement for the disease.
Malayalam film actor Bharath Mammootty attended the function.
In its first phase the c4cci will mainly support over 100 children registered with the leukemia ward of the Institute of Maternal and child Health (IMCH) in the Kozhikode Medical College Hospital.
For more Details Visit:www.Caring4ccci.com |
|
|
| g |
| Printed and published by Dr.Anilkumar Paleri for Indian Association of Palliative Care. For Private Circulation Only. |
| |