|Posted by kosishthehospice on January 20, 2014 at 2:50 PM||comments (37)|
|Posted by kosishthehospice on August 13, 2013 at 3:30 PM||comments (0)|
Annual report of KOSISH
1 April 2007 to 31 March 2008
Kosish carried out the following activities in the above mentioned financial year;
1. Pamphlets in Hindi & English were distributed in the local community highlighting the importance of palliative care & the role of community participation.
2. Local helpline numbers were generated & made available to the public for access to palliative care services.
3. Donations for promotion of palliative care services were sought from the public.
4. Volunteerism in palliative care was promoted & new membership drive was encouraged.
5. Scientific activities were planned & a research project on the use of low dose ketamine in palliation of terminal dyspnea was protocolised after approval from the local ethics committee.
6. A small building was constructed using eco-friendly materials like bricks, mud & wood at Satanpur village. This acts as a satellite center of Kosish in providing palliative care services. The funding was made available by personal contribution by the members.
7. Dr.A.K.Dam successfully completed his Fellowship in Palliative Medicine.
8. On World Hospice Day, a programme entitled “Role of Music Therapy in Palliative Care” was organized followed by a lecture on Introduction to Palliative Care at Sec. 8 C, Bokaro Steel City. This was attended by 150 delegates. Funding was organized by local contribution.
9. Kosish organized a programme entitled “light a life” in which the community was invited to participate & light a lamp in memory of their departed relatives on the eve of Christmas.
10. Dr.A.K.Dam & Mr. Sanjay Kumar attended the International Conference on Palliative care at Cochin, Kerala on Feb.2008.
11. Dr.A.K.Dam was elected as a member of the executive council of IAPC.
12. With the involvement of local leaders of the community, a water mattress was donated to a terminally ill & bedridden patient living in the slums on 26 Feb.2008. This event was also utilized to highlight the importance of community participation.
Annual report of KOSISH
1 April 2008 to 31 March 2009
Kosish carried out the following activities in the above mentioned financial year;
1. Propagation of palliative care awareness in the community
2. Home care activities were given special emphasis in which many terminally ill patients were cared for at home with regular home visits being given by our team. Focus was laid upon empowering the family in the care process. Use of locally available resources were promoted.
3. Active feedback on the satisfaction with the care process was obtained from the relatives of the patients to have a means of internal audit of the quality of care being provided & also to find avenues for rectification & improvement.
4. On 16 June, 2008, a special awareness camp was organized at Vill. Satanpur, Dist. Bokaro.
5. Dr.Dam & Mr.Sanjay Kumar were invited by the Dept. of Oncology, Indira Gandhi Institute of Medical Sciences, Patna, on 8 Aug.2008 to deliver a lecture on palliative care. A major outcome of this process was to convince the authorities to start a Pain & Palliative care unit in the hospital, which was officially declared by the Medical Director.
6. Dr.A.K.Dam was invited by Mahavir Cancer Sansthan, Patna on 16-17 August, 2008 to deliver a lecture on palliative care. During this period it was formally announced by the Medical Director, Dr.J.K.Singh, to start a large palliative care center & Hospice at Hajipur, Patna.
7. A local press conference was organized on 14 Sept.2008 at Bokaro Club as a part of advocacy campaign for palliative care. The conference was addressed by Dr.A.K.Dam, Mr. Sanjay Kumar & Usha Rani Mohanty.
8. The First Eastern Zonal Palliative Care Update was organized on 25-26 Oct.2008 at Bokaro Club. 150 delegates attended the conference which included doctors, nurses, paramedics, social workers & general public. The international faculty included Ms.Gilly Burn of CRI, U.K. & the national invited faculty included Prof.S.Sarkar from Kolkata Medical College & Dr.Arpita Bhattacharya from Apollo Hospitals, Kolkata. A souvenir was released on the occasion.
9. 100 NCC cadets were given an introduction to the concept of palliative care on the occasion. The theme was ‘catch them young’.
10. The website of Kosish, www.kosish.org was inaugurated by Ms.Gilly Burn & Dr. Mahapatra, Director, Bokaro General Hospital on 25 Oct 2008.
11. Dr.Nivedita Datta & Mrs.Usha Rani Mohanty undertook the Certificate programme in palliative care & successfully passed the exams.
12. Dr.A.K.Dam was invited by the Dept. of Radiotherapy, Kolkata Medical College to conduct exams for certification in palliative care.
13. Dr.A.K.Dam & Mr.Sanjay Kumar underwent a one month training in Pediatric palliative care at a Childrens hospice in Warsaw, Poland in Nov.2009.
14. As a part of our ongoing advocacy to procure oral morphine for the terminally ill, a meeting with the Drug Controller of Jharkhand was undertaken at Ranchi.
15. As a part of continuing advocacy, articles were published in the Hindustan Times dated 23 Jan 2009 & 16 Feb. 2009.
16. Kosish was visited by Ms.Gilly Burn, Founder Director, CRI, UK & Dr.Lindsay Crack, Consultant in Palliative Medicine, NHS, UK in Feb.2009. During their visit, a small refresher course on advances in palliative care was organized at Bokaro Club which was attended by 50 delegates. They also visited the remotely located villages in Kantadih, Dist. Purulia & Vill. Obra at Pindrajhora.
17. The international annual conference on Palliative care at AIIMS, New Delhi was attended by Dr.Dam, Mr.R.K.Karan, Mrs.U.R.Mohanty & Mr.Sanjay Kumar. It provided a valuable platform for interaction with national & international counterparts & growth of knowledge.
Annual report of KOSISH
1 April 2009 to 31 March 2010
Kosish carried out the following activities in the above mentioned financial year;
1. Receipt of a grant from Help the hospices, U.K. in the form of study material called the Palliative care Toolkit programme. A financial grant of 2000 GBP (pounds) was also included but the same could not be availed as we did not have FCRA status. As we did not have access to the grants, I personally conducted lecture sessions on various aspects of palliative care, following the guidelines of the toolkit & adapting the knowledge to the local conditions. I am a national faculty & examiner of the IAPC. The training was held in batches of 10-11 students, consisting of doctors & nurses. We even invited paramedics(O.T.technicians & pharmacists) for the sessions. The language used was English & Hindi.
2. Local awareness programme in palliative care with thrust on community participation was carried out at Jodadih More in which 15 young men & women were given lectures on palliative care with the intention of promoting community participation
3. A workshop organized by Indian Association of Palliative Care at Karunashraya hospice at Bangalore was attended by Dr.A.K.Dam. The topic was “Involving the media”.
4. A glucometer was purchased to assess the blood glucose status in the rural elderly for early detection & treatment of diabetes mellitus.
5. Dr.Nivedita Datta, Consultant Gynaecologist was requested to hold regular gynaecological check-up for the rural elderly women at Vill. Obra, Thana Pindrajhora. This service is currently available on the first & third Saturday of every month, free of cost.
6. A decision was taken by the executive committee to lay more thrust on care of the rural elderly & hence twice a month camps for the rural elderly was started at Vill.Obra, Thana: Pindrajhora.
7. Funding was sought from pharmaceutical companies & local donors.
8. The “once a month nutritious meal programme” for the rural elderly was started at Vill. Obra with the aim of early detection & rectification of nutritional deficiencies in the rural elderly. Utensils & cooking stove for large scale cooking were procured. Partial funding was made available for the same from local donors & a small grant from the IAPC.
9. Local patients suffering from cancer as well as other terminal diseases were provided palliative care regularly by our home visit team.
10. Dr.Chandreyi Bandopadhyay was motivated to undertake the certificate course in palliative medicine, which she passed with flying colours.
11. Dr.A.K.Dam traveled to Kolkata & Cuttack to conduct the exams for the certificate course in palliative care at Kolkata Medical College & Regional Cancer Center respectively.
12. Dr.Dam’s scientific paper entitled “Use of low dose ketamine & midazolam in palliation of terminal dyspnea” was accepted for presentation at Together2009 at Perth, Australia.
13. Dr.Dam also received a travel grant from Together2009 to present his paper at Perth, Australia.
14. On World Hospice Day, Dr.Dam & Mr.Surjit Sigh undertook “Hospice Tour India” in which they drove through seven states promoting the message of palliative care. The veichle was provided by Hindustan Auto Agency, Bokaro Steel City & funding was partially through local contributions & the rest self-funded.
15. An initiation grant of Rs.75,000 was provided by Indian Association of Palliative care through which a local guard cum co-ordinator was stationed at Vill.Obra. In addition the grant money was also used in conducting visits to Kantadih & Adra for promoting palliative care & home care visits.
16. Two scientific papers were published in the Indian Journal of Palliative care.
17. Dr.A.K.Dam was invited to deliver a guest lecture on “palliative care in Gynaecological malignancies” at Conference of Gynaecological malignancies held at Kolkata on Sept. 2009
18. Dr.A.K.Dam delivered guest lecture & chaired session at “Excellence in Oncology 2009” at Cancer Welfare home & Research Center, Thakurpukur, Kolkata in Dec.
19. Kosish was shortlisted for the Spirit of Humanity Awards by Americare India.
20. A lecture on “Care of the terminally ill in the last days of life” was given at Bokaro General Hospital to the doctors.
21. The annual conference of IAPC was attended by Dr.Dam & Mr.R.K.Karan at Trichi, Tamilnadu in Feb.
22. Dr.A.K.Dam was re-elected as a member of the Executive council of IAPC at Trichi in Feb.2010.
23. Dr.A.K.Dam received a scholarship to participate in Palliative Care Education & Practice programme to be held at Dana-Fraber Cancer Institute, Harvard University, Boston, USA in April 2011.
24. A seminar on Palliative care for the elderly was organized on 20 March, 2010 at Bokaro Club. 50 delegates attended the programme which included dignitaries. The programme highlighted the role of palliative care in the elderly. The speakers included Dr.Dam, Dr.Nivedita Datta, Dr.Sanjay Choudhary, Dr.T.Sudhir & Dr.P.Pandey.
Annual report of KOSISH 2011-2012
1. Health camp for elderly conducted at Pindrajhora in April. The elderly were given free medicines and food at the camp.
2. Screening camp for breast & cervical cancer & its awareness organized at Chandra, Chandankiyari block.
3. Tree plantation programme organized at Pindrajhora on “Van Mahotsav Day” with the help of local volunteers.
4. A screening camp for dementia was organized at Pindrajhora.
5. An information, education & counseling programme on palliative care was organized at Jain Hospital, Bokaro Steel City for ANM’s.
6. Maternal, child & elderly care started on a regular basis at Pindrajhora on every Saturdays.
7. Dr.A.K.Dam passed the Diploma in Palliative Medicine from Cardiff, UK.
8. Dr.A.K.Dam got selected for MSc in Palliative Medicine at the University of Cardiff after being awarded a Commonwealth scholarship. He also attended the contact session at Cardiff, UK for 6 days.
9. Dr.A.K.Dam visited Regional Cancer Centre, Cuttack, to conduct certificate course in palliative care.
10. Dr.A.K.Dam & Dr.Nivedita Datta invited as guest speakers on an Update in Palliative care at Thakurpukur Cancer hospital, Kolkata.
11. On World Hospice Day, 09 Oct 2011 a workshop on Volunteerism in Palliative Care was organized at Jodadih More, Chas involving paramedics & volunteers.
12. The training manual for volunteers published by the Pain & Palliative Care Society was translated into Hindi by Mr.R.K.Karan.
13. An annual general body meeting was organized at Sec 4, Bokaro Steel City.
14. Dr.Anil Agarwal appeared for the certification exams in palliative Care in Jan. in Medical College Kolkata.
15. A small hut made of eco-friendly materials was constructed at Pindrajhora.
16. Prof.Jaeck Luczack from Poland visited KOSISH in Feb. 2012
17. A MOU was signed between Kosish & University of Poznan, Dept of Palliative Medicine, Poland.
18. A conference on “Volunteerism, Spirituality & Palliative Care” was organized in the “Institution of Engineers”, Bokaro Steel City on 04 Feb 2012.
19. Dr.A.K.Dam delivered a lecture on “Working without morphine” at the pre-conference workshop at IAPC Annual conference at Kolkata.
20. Dr.Dam, Mrs. U.Mohanty, Dr.S.Dey & Mr.Sanjay Kumar participated in the IAPC annual conference at Kolkata in Feb 2012.
|Posted by kosishthehospice on June 3, 2013 at 9:45 PM||comments (0)|
At Kosish-the hospice, we are planning to undertake an intervention-based survey of the rural-based elderly widows with the following aims & objectives:
1. To have an insight into the quality-of-life and problems faced by the rural elderly widows
2. To quantify their physical problems
3. To provide measures to help solve these problems as far as feasible with an overall motive to help improve their quality of life.
Study design: Prospective, cohort based
Methodology: This would be a survey-based method in which two female health care workers would conduct door-to-door surveys of the elderly widows in rural settings. A focused questionnaire which has been designed keeping in mind the local & cultural appropriateness (having questions directed at physical, social, psychological & spiritual issues), would be asked and appropriate interventions where possible would be undertaken, like administration of analgesics, anti-hypertensives, calcium and vitamin supplementation, etc.
Requirements: Funding for the two health care workers (approx. INR 5000/month x 6 months) and funding directed towards cost of medications & appliances (approx INR 2500/month x 12 months). Donors can donate partially or completely. The names of the donors would be featured in our website www.kosishthehospice.webs.com .Donation details are featured in our website.
|Posted by kosishthehospice on May 26, 2013 at 11:40 AM||comments (0)|
Photography competition was held on 18 th May 2003 in the Institute of engineer , Bokaro Steel city . About 150 photographs from school students were displayed . Best entries got various prizes. The occasion was attended by parents and teachers also .
|Posted by kosishthehospice on April 22, 2013 at 11:50 AM||comments (0)|
. PHOTOGRAPHY COMPETITION will help them talk about their
The power of visual imagery cannot ever be overstated and KOSISH – the hospice is looking for photographs that tell the stories of the lonely elderly, people living with terminal illness and in their last days of life and also that of the people who care for them and live with them.
• Event 1 - A photography competition, around the concept of healthcare. School students are invited to submit entries, which will be judged by an expert panel. The three best entries from each age category will be awarded a prize each. The 50 best entries will receive a certificate of appreciation, and also be exhibited.
• Event 2 – "On the spot slogan writing" competition on the exhibits. Students will be required to choose any of the photographs (except their own entry) in the exhibition and write down a slogan based on the theme and judged by an expert panel. The best slogan in each three categories will be awarded a prize.
• Event 3 – A half day interactive session on "how to cope with the illness of a loved one". This will be facilitated by experts .The programme will be structured in a way that will help young people to express their innermost hopes and fears and learn to deal with them in a sensitive manner.
• Individual Themes:
Class 6, 7 – Good Habits for Good health/ care of elderly
Class 8, 9 – Being healthy or sick/care of elderly
Class 10, 11, 12 – Caring for the sick/care of elderly
• Adult category: Palliative care & care of the elderly
Rules, Regulations and Guidelines for Photography competition
1. Registration: All students wishing to participate will have to submit postcard size color/black & white photographs to the undersigned with their name, age and contact details, including phone number. Last date for submitting entries is 10 May 2013.
2. Eligibility: Students of Classes 6 to 12 are eligible to participate. Adults can also send in their photographs.
• Each participant will send in three entries out of which the best one will be selected as the final entry for competition.
• A maximum of 200 entries will be taken. The best 50 entries will be selected for final competition and information will be displayed.
4. Event date: 18th of May, Saturday, 2013.
5. Event venue: Will be notified soon
6. Contact Person:
• Mrs. Usha Mohanty : 9234478506
• Mrs. Ratna Biswas : 8603378337
|Posted by kosishthehospice on April 14, 2013 at 10:45 AM||comments (0)|
Dr.Abhijit Dam, MD, FCCP, FPM, Dip Pall Med(Cardiff)
Kosish – the hospice
Email: [email protected]
Jyotsna, 9 years, was detected to have Retinoblastoma 1 year back for which she received radiotherapy & chemotherapy . Since the last six months, she was declared ‘palliative’ and referred to our hospice, the parents residing in a rural area of Jharkand. They had to travel for 4 hours by Jeep to reach our hospice.
She had gone blind in both eyes since last 3 months and was very distressed about it as she could no longer play with her brother & sister. She however enjoyed their company & this filled her with happiness.
She frequently complained of headache, which often used to be unbearable. She was already on Step 2 of the WHO analgesic ladder & also getting oral dexamethasone and Amitryptiline. Her VAS score however remained around 7/10. At that point of time, our hospice had no access to oral morphine. We made the maximum use of locally available resources (oral codeine, tramadol, NSAIDS with proper use of adjuvants).
Figure 1. In severe pain
After discussing with her parents, we decided to start her on ‘Kosish Cocktail’(which we have developed & is a mixture of pentazocine lactate 5mg/ml, ketamine 2.5 mg/ml, midazolam 0.25 mg/ml, ondansetron 0.5 mg/ml & lignocaine 3mg/ml. 1 ml of this mixture given S/C 5 hrly) by the subcutaneous route using Intermittent subcutaneous injections given by the family members through an indwelling SC cannulae. Thus, we made adequate use of locally available resources which were accessible, appropriate, acceptable to the patient & family. We thus empowered the family members to participate in the care process.
Figure 2. Jyotsna happy with the pain relief afforded by 'Kosish cocktail'
She lived on for another 2 months with a good quality of life (pain free, living with her parents & siblings & with good symptom control).
We at our hospice, thought out of the box, when morphine was not available & made good use of locally available resources for symptom control. Just because you do not have access to morphine is NOT synonymous with no palliation.
|Posted by kosishthehospice on July 6, 2012 at 7:55 AM||comments (8)|
Hospice Tour India: a report on palliative care awareness in our country Dr.A.K.Dam, MD, FCCP, FPM Kosish-the hospice ?Discovering your voice? was the theme chose for the World Hospice & Palliative care day this year?this gave us the inspiration to undertake a Herculean task; to assess the peoples awareness of palliative care & its importance in our society on the basis of random interviews taken from a broad cross section of people from various castes, creeds, socio-economic backgrounds, cultural backgrounds; in short representing the true India. This was not planned as a formal ?study? with statistical analysis of data, etc. but rather based on a casual tour involving less traveled parts of India, in fact involving parts of India which even most Indians have not traveled to. Our desperate pleas of funding for the program fell on deaf ears from all possible sources including large palliative care organizations. In fact we were discouraged from many areas. However my morale was boosted by a small group of well wishers & thus I got the psychological support to undertake the tour. My nominated partner had to drop out at the last moment & my volunteer Mr.Surjit Singh pitched in & agreed to accompany me for the tour. I had to pool in my personal savings for the tour. It was a blessing in disguise when our local Maruti Suzuki dealer, Mr.Gopal Lodha, agreed to sponsor the vehicle, a Maruti A-Star. The cost of the fuel was however borne by us. Being financially constrained, we could not afford a driver & so I decided to drive. Also, our original plan to cover most parts of India had to be pruned due to lack of funding & so we decided to travel to those parts of India where palliative care had yet to lay its footprints. We covered Jharkhand, Orissa, Chattisgarh, Maharashtra, Madhya Pradesh, Uttar Pradesh & Bihar. We were flagged off at 9.30 am on 9 Oct.2009. The first lap began from Bokaro to Ranchi traveling through a less traveled road. From Ranchi we proceeded to Gumla where we stopped for lunch & chatted with truck drivers explaining the concept of palliative care & distributing leaflets on palliative care. From thereon, the road conditions progressively worsened as the roads meandered through hilly terrain & forests. At most places it was not possible to drive at more than 25 kmph . At around 7 pm after 8 hours of teeth rattling drive we reached the sleepy town of Pathalgaon where we stayed at a local Gurudwara (cost control strategy). We interviewed the priest (Gyanii ji) & got his feed back on palliative care. We then interviewed a dhaba owner. People had no concept of palliative care but were very enthusiastic to have it as a part of the health care system. They also voiced their agreement on the importance of community participation. We then drove on taking small tracks passing through villages to reach Raigarh (there is a Steel plant there-Jindal steel) & then onto Raipur, the capital of Chattisgarh. The lesser that we speak of the road conditions on that stretch, the better it is. We crossed Bhilai, Durg and decided to halt at Rajnandgaon. We got a cheap motel at Rs.350 per night. We interacted with a few people there & distributed pamphlets. The A-Star gave us great mileage & comfort. In spite of the poor road conditions, we averaged around 20 km to a liter of petrol with the A.C. running for most of the day. The large tyres gave us an added advantage in negotiating the ruts & craters on the roads. The next day we traveled to Nagpur passing through a reserve forest. The road in this stretch was pretty good & we managed an average speed of 60 kmph. At Nagpur we put up at one of my friend?s place. We visited the local Maruti workshop for a free check-up & proceeded to visit a local hospice called Snehaanchal. What amazed us was its fantastic infrastructure. We later got to learn that it was built on the lines of Karunashreya at Bangalore. We were greeted by Sister Mary who showed us around. There were 17 beds & all of them were occupied! They also had a waiting list! But alas, they did not have a qualified palliative care specialist to guide them. I felt helpless! After saying our goodbyes & some suggestions, we climbed back into our car. But then just before I would start it, providence struck as I felt an overwhelming desire to stay back & help them out. I got out & went back to an amazed sister & told her that we were willing to stay back for a couple of days to help the hospice if it was OK with her. The look of delight in her eyes were answer enough & I suspect that she would have clapped her hands in glee if she could do it. However she said that she would have to contact the Managing trustee, Mr.Jimmy Rana. She got back to us by late evening & said that we could come the next morning. We learnt that Mr.Rana is an industrialist & was held in awe. The next morning we were greeted by a gentle & very unassuming person who introduced himself as Mr.Rana. He was accompanied by a charming lady, Dinnaz, who was his wife. Jimmy & Dinnaz are excellent examples of a successful business house who have also striven to help mankind in its most pure manner. They form an ideal couple with a common goal to help mankind. They have been running the hospice since 3 years. Jimmy has visited almost all hospices in India which speaks of his zeal to advance palliative care. What is most important that being a non-medical person, he still realized the importance of palliative care & struggled hard to establish Snehaanchal. I wish that I could be like them?.. During the two days that we spent at Snehaanchal I conducted lectures on symptom control, conducted ward rounds, tapped a malignant ascites, learnt how to be humble from Jimmy & to be cheerful & enthusiastic from the staff. Dinnaz would quietly slip away for a few moments during our discussions to oversee lunch preparations ? how much more considerate & caring could a person be! I strongly recommended that they start their network of volunteers & Mr.Devnath, my schoolmate, pitched in to help. We parted with a heavy heart after 2 very fruitful days at Snehaanchal & I choose to think that the Grand Master somewhere out there had planned it all in advance?. We drove the next day for Bhopal. The road took us through ghats & hills. It was a picturesque drive. We stopped at a dhaba for brunch & interviewed the locals & distributed pamphlets We drove on through Bhopal & proceeded to Sanchi. On the way, we crossed the Tropic of Cancer. We also took a small detour through hilly terrain to reach a lake situated on the hill. We stopped for the night at a hotel which was expensive at Rs.1000 per night. We met Mr.U.K.Singh, the propretier, & talked about palliative care. He was very enthusiastic about it. The next morning our journey took us through forests & hilly terrain, including the Panna Tiger reserve & we reached the sleepy hamlet of Satna. We visited the local Maruti workshop. We stayed at a motel & the next morning took a less traveled road to Chitrakoot. This area is not taken by many as it is infested with dacoits. But the scenic beauty is worth the risk. There was some big mela going on at Chitrakoot & we saw hundreds of villagers thronging to the area. Most of them were carrying small bundles on their heads containing their personal belongings & some were carrying their little children on their shoulders. We even saw the old & infirmed walking by. An excellent example of the importance of spirituality in our culture. In India, in all religions, particularly in Hinduism, spirituality place a major role in our outlook at health & disease. But then unfortunately, poverty, illiteracy & brief beliefs modify the spirituality in a major way so that the whole framework becomes askew. We proceeded on to the holy city of Allahabad which is the sangam of 3 rivers, Ganga, Yamuna & Saraswati. We met an Anesthetist, Dr.Roopam Sinha & his wife Dr.Smita, with whom we discussed about palliative care. They too were not exactly sure about the concept of palliative care initially. But they did promise to take up the initiative in their city. From Allahabad we started off after a 2 hour halt & then bypassing Varanasi we stopped overnight on the highway near Gaya from where we started the next morning to reach Bokaro Steel City. In all, we traveled 3000 km traveling through areas of India which is less known to the intrepid traveler. We could observe the diversity of landscapes, people, religions, cultural backgrounds & ways of life. It became immediately clear that no uniform policy of health care including palliative care could fit in. What would work in a particular community would perhaps be worthless in another. Each state needs its own local initiatives that are best blended to suit the local conditions. Lack of availability of morphine REMAINS A PROBLEM & WILL CONTINUE TO DO SO FOR SOMETIME?. Let us all wake up to the fact. But then good palliative care can still be provided without morphine using locally available resources (e.g. the ?Kosish cocktail?). It seems useless to talk about quality & standards when the basic service does not exist in most parts of the country. But then drops of water make an ocean & we definitely shall strive forwards towards perfection soon.