Memorandum by Marie Curie Cancer Care
(PC35)
1. INTRODUCTION
1.1 Marie Curie Cancer Care welcomes the
opportunity to contribute to the House of Commons Health Select
Committee Inquiry into Palliative Care.
1.2 The Charity is delighted that the committee
has chosen to look at an area of healthcare where inequity, lack
of real choice, too little sharing of best practice and difficulties
around funding need close examination.
1.3 We believe this inquiry is timely following
the Government's pledge as part of its "choice" agenda
". . . to offer all adult patients nearing the end of life,
regardless of their diagnosis, the same access to high quality
palliative care so that they can choose if they wish to die at
home"1.
1.4 It is now crucial that Government and
Non-Governmental Organisations (NGOs) work together to ensure
the right structures, mechanisms and funding are in place to make
the commitment to choice a reality for cancer patients and their
families.
1.5 This year, Marie Curie Cancer Care will
provide general and specialist palliative care to more than 23,000
cancer patients and around 1,000 patients with other life-limiting
illnesses such as Motor Neurone Disease, HIV/Aids and Multiple
Sclerosis.
1.6 Marie Curie Cancer Care is the largest
single provider of hospice beds and specialist palliative care
outside the NHS. For this memorandum we intend to confine our
response mainly to the delivery of palliative care in the home.
We believe all relevant points regarding hospice care will be
covered in submissions from the National Council for Hospice and
Specialist Palliative Care Services and Help the Hospices.
2. ABOUT MARIE
CURIE CANCER
CARE
2.1 Established in the same year as the
NHS (1948), the Charity provides palliative care services to patients
in both community and hospice settings. The Charity also conducts
scientific research, palliative care research and provides palliative
care education to healthcare professionals.
2.2 Charitable expenditure on nursing, hospice
and education services in the last financial year was £41
million. The charity received £14 million of statutory funding.2
2.3 Working in communities across the UK
are 2,500 Marie Curie Nurses caring for cancer patients in their
own homes. In general, care will be provided in the last three
or four weeks of life, with Marie Curie Nurses mainly working
eight or nine hour shifts overnight on a one-to-one basis with
the patient. On average, patients in the community will have six
shifts of Marie Curie Nursing, although this can vary considerably.
2.4 The Charity has contracts with 96% of
Primary Care Trusts (PCTs) to provide a nursing service. Care
is always free of charge to patients and their families, with
costs split 68% Marie Curie Cancer Care and 32% PCT.
2.5 Marie Curie Cancer Care also funds and
operates 10 hospices around the UK with a total of 220 beds. The
hospices are in London, Cardiff, Caterham, Solihull, Bradford,
Liverpool, Newcastle, Edinburgh, Glasgow and Belfast. There is
also a Day Therapy Centre in Devon.
2.6 In addition to providing specialist
palliative care for in-patients, all Marie Curie hospices offer
a range of additional services, such as day therapy, outpatient
clinics and home care teams aimed at helping patients to remain
in the community. In 2003, community support through Marie Curie
Hospices involved 15,669 day therapy attendances, 11,071 outpatient
attendances, 12,847 home care visits and 18,178 other home care
contacts (eg telephone support).
2.7 The Marie Curie Palliative Care Research
and Development Unit aims to foster high quality research which
will lead to improvements in care for those affected by cancer
and other life threatening illnesses through the implementation
of evidence-based practice.
2.8 Our education department provides a
wide range of courses up to Degree and Masters level to enable
nurses and other healthcare professionals drawn mainly from the
NHS to learn the latest techniques for caring for cancer patients.
In 2003 the charity invested £2.3million in education and
delivered 9,600 face-to-face training days.
3. ISSUES OF
CHOICE
3.1 A number of research projects have looked
at people's preferences regarding choice of place of death. In
the most recent survey, commissioned by Marie Curie Cancer Care,
64% of those asked "where would you like to be cared for
if you were dying?" said they would like to be cared for
at home, with 23% choosing a hospice and 4% opting for hospital.
(See Appendix 1 for full results). This is in marked contrast
to actual place of death. Around 47% of patients die in hospital,
with 17% dying in hospices, 25% dying at home and 12% in nursing
homes.3
3.2 Probable reasons why cancer patients
end up being admitted to hospital when they wish to remain at
home will include:
3.2.1 Family/Carer Fatigue: Many families
will struggle to support someone through a terminal illness at
home. However, modern lifestyles mean that families may be scattered,
with the women working full time as well as caring for children.
Sympathetic employers can make a considerable difference to a
carer's ability to cope. In Canada, there is mandatory six weeks'
compassionate leave for those caring for the terminally ill.
3.2.2 Lack of Information/Advice/Support:
Easily accessible sources of information and practical support
can often make a considerable difference to the family/carer's
confidence. Widely distributed, balanced and easily understood
information on the issue of care at home must be provided in print
and over the internet. Carers need reassurance that what they
are doing is right.
3.2.3 Health Professional Lack of Knowledge/Training:
The average GP will only have a few terminally ill cancer patients
per year on his/her list. Very few feel entirely competent to
manage the death of a symptomatic patient at home. Many hospices
run education programmes for GPs, but up-take is patchy. Guidance
for the management of common symptoms is now available within
most cancer networks, but their use is not uniform. This problem
can be addressed by ensuring palliative care is seen as a mainstream
part of GP work and is an integral part of their training and
on-going practise development. It should also feature in audit
and clinical governance.
3.2.4 Health Professional Guidance:
The recently announced funding to enable wider implementation
of structural programmes such as the Marie Curie Liverpool Care
Pathway for the Dying Patient and the Macmillan Cancer Relief
Gold Standards Framework will improve knowledge and general standards
of care among all healthcare professionals.
3.2.5 Uncoordinated Care: The changes
in out-of-hours cover for GPs highlight the need for robust communication
between many teams of professionals. Lack of information about
the management plan and the patient's wishes results in many inappropriate
out-of-hours admissions to hospital. The forthcoming introduction
of Electronic Patient Records (EPR) could go a long way to solving
this problem. However, healthcare professionals employed by voluntary
organisations such as Marie Curie Cancer Care will need to have
free access to this service to ensure the benefits of EPR are
maximised.
3.2.6 Difficulties in Co-ordinating
the Home Care Package: This is often a combination of services
provided by the GP, clinical nurse specialist in palliative care,
District Nurse, Marie Curie Nurse, Social Services and voluntary
services (eg Crossroads—a charity providing practical support
for carers).
3.2.7 Patients Unaware of How the System
Works: Surveys also clearly show that patients dislike having
to repeat their problem to different on-call services. Although
the continuing development of NHS Direct is welcome, there will
need to be careful consideration of its role in supporting the
delivery of out-of-hours palliative care.
3.2.8 Patients' wishes may change as
their health deteriorates.
3.2.9 Patients may develop symptoms
which are unmanageable in the home.
3.2.10 Patients' Lack of Knowledge and
Confidence: The patient's choice of place of death may be influenced
by the attitude of professional carers if they sense that the
professionals are reluctant for them to be at home. Primary Health
Care Teams (PHCT) require access to sources of information about
all aspects of managing a cancer death at home and education in
the management of the common symptoms of end stage cancer. Most
of the Marie Curie Cancer Care hospices run regular programmes
of education for GPs.
3.2.11 All these factors mean that, while
the choice of place of care is in theory available to a patient,
in practice the choice may already have been made for them by
healthcare professionals
3.3 To set this issue in context, it is
worth noting that the early development of palliative care services
across the country was driven by local enthusiasm rather than
by strategic health service planning. Fundraising committees were
set up and buildings completed before any scientific consideration
of the needs of the local population was made. The `choice' of
the services available was driven by the founders of each hospice
rather than the patients who would use the service.
3.4 The more recent introduction of Cancer
Networks has led to a mapping of the available services and an
attempt to ensure that all types of palliative care provision
are available appropriately for all patients. In reality, because
of limited funding and, more particularly, limited numbers of
specialist staff, the access of patients to services is often
determined by the professionals' assessment of need rather than
the patient's choice. The guidance from the National Institute
for Clinical Excellence, which will be published in March, will
require a network-wide view of services to be taken, and will
focus attention on areas of under provision.
3.5 The allocation of statutory funds to
all types of general and specialist palliative care services varies
widely, often across PCTs which have similar demographic distributions
of population. This variation is often based on historical allocations
and on the advocacy of individuals lobbying for funding for the
specialty.
4. EQUITY OF
PROVISION: BY
GEOGRAPHY
4.1 The Marie Curie Nursing Service covers
96% of the UK population. Local coverage is variable mainly because
of funding. Each PCT may adopt a different set of criteria to
determine the priority of its commitment to palliative care and
to expenditure on the Marie Curie Nursing Service and other allied/alternate
healthcare providers.
4.2 It is our belief that funding of services
such as Marie Curie Nursing is driven by budget constraints and
historical precedent, rather than careful analysis of patient
need.
4.3 Hospice beds are available to the whole
population, but numbers of beds per 1,000,000 population differ.
Per region, only 18-34% of patients with malignant disease will
gain access to palliative care beds.
4.4 Development and location of hospices
was "ad hoc" and usually in more affluent areas
where fund-raising would be easier.
4.5.It would appear that there is a correlation
between social deprivation, the number of cancer deaths per 100,000
population and the need for palliative care. Up to twice the resource
may be required to support patients at home in areas of acute
deprivation compared with the most affluent areas.
4.6.The Primary Health Care Team should be the
provider of palliative care support to the majority of people.
Its members should be trained to assess the needs of patients
and refer those with complex problems to a specialist service.
5. EQUITY OF
PROVISION: BY
AGE
5.1 Cancer is mainly a disease of old age;
therefore hospices are geared to providing care to older people.
Surveys suggest that younger people would prefer a "menu"
of services, for example day therapy models offered by Marie Curie
hospices and other providers which they can access on demand.
5.2 Older people have multiple problems
of "co-morbidity" which may result in a gradual, general
decline not easily attributed to cancer. Therefore they may not
"qualify" for the input of a specialist team.
5.3 Older people often are not referred
for oncology opinion by their GP and thus miss out on the usual
route into palliative care services.
5.4 Older people, living alone or with a
single elderly carer, may find it difficult to access the support—both
in terms of information and physical support—needed to allow
them to stay at home.
5.5 Older people get admitted to hospital
to die because they often seek help late when the work required
to deal with the crisis at home may be more than that needed to
arrange an admission to hospital. Elderly people are also less
inclined to question the advice of a healthcare professional.
5.6 Around 20% of deaths occur in nursing
or residential homes. For many people, these places will have
been their home prior to the diagnosis of cancer and they may
choose to die in their "home". Others may move to a
care home because of frailty caused by the illness. In both situations
these people have the right to expect appropriate, good quality
palliative care. At present, only some nursing homes are registered
for terminal care. In order to prevent people having to move as
their disease progresses, and avoid an emergency admission to
hospital, education for all nursing and attendant medical staff
in nursing and residential homes has been recognised as a priority.
The Liverpool Care Pathway for the Dying is targeted to be in
use in 30% of all nursing homes in England and Wales by 2006.
6. EQUITY OF
PROVISION: BY
DIAGNOSIS
6.1 Palliative care services were traditionally
confined to cancer and Motor Neurone Disease. (HIV/AIDS was added
later. There is currently a decline in numbers of people with
palliative care needs and AIDS.)
6.2 Health Service Circular 1998/115(7)
recommended the integration of palliative care principles and
practice into the NHS for all those facing life-threatening illness.
6.3 There is a long-standing recognition
of the inequity of provision for those with other major causes
of death eg cardiovascular and respiratory disease. New National
Service Frameworks contain specific reference to palliative care
for several of these groups of patients.
6.4 Approximately 20% of all Health Improvement
Programmes explicitly include non-cancer palliative care needs
6.5 Many specialist palliative care providers
fear being overwhelmed by demand from non-cancer patients if they
indicate a willingness to accept them, partly because of the numbers
involved and partly because of the unpredictable nature of the
disease trajectory. Researchers at Manchester University are reviewing
the evidence on predicting the appropriate time for palliative
care in older, non-cancer patients (report due late 2004).
6.6 The larger national, and some smaller,
charities have `cancer' in their title or founding statements
and judge that this excludes other groups of patients from accessing
services.
6.7 Under the terms of its constitution,
Marie Curie Cancer Care is able to care for up to 10% of patients
with non-cancer diagnoses.
6.8 Most specialist palliative care clinicians
believe that the most appropriate way to extend care to all patients
who would benefit from their expertise is by education and training
of other specialist groups, with a small increase in the care
capacity to cope with those patients who have complex, intractable
problems.
6.9 Marie Curie Cancer Care's doctors are
leading the way by working closely with other medical specialists
such as cardiologists and nephrologists to develop models for
providing palliative care to their patients.
7. COMMUNICATION
BETWEEN CLINICIANS
AND PATIENTS
7.1 The "cancer journey" involves
interaction with many organisations/agencies. In theory these
should be linked by the Cancer Network umbrella; in practice the
experience of the individual patient remains that of failure of
communication and on the movement of clinical records with the
patient through the system. Groups within the Network are working
to improve this problem.
7.2 A recent survey at the Marie Curie Hospice
in Edinburgh found that the average cancer patient coming to a
palliative care service had met 32 doctors in the course of a
2.5 year illness. At the top end of the scale in this survey,
one patient had met with 97 doctors. The possibility for miscommunication
at many levels is enormous.
7.3 A lack of understanding of Data Protection
law may damage communication between professionals and services.
7.4 There are often difficulties in maintaining
patient confidentiality in a large team of healthcare professionals
and within a complex family setting.
7.5 The need for teaching of communication
skills is recognised in the NHS Plan. Marie Curie Cancer Care
is involved with the National Health Service University and Cancer
Research UK in developing cascade models for communications skills
training.
8. BALANCING
WISHES OF
PATIENT AND
CARERS
8.1 One of the most common reasons for a
hospital admission at the end of life is carer fatigue, either
real or perceived by the patient who fears they are becoming a
burden.
8.2 Hospital staff's lack of knowledge of
services available in the community may result in the professionals
inappropriately discouraging a patient's discharge.
8.3 Some services provide support, advice
and training for family/carers of a dying person. For example,
at the Marie Curie Hospice in Caterham, informal drop-in sessions
are organised for carers where they can speak with palliative
care experts or simply spend time and share concerns with other
carers. There are also more formalised training sessions, where
carers are shown a variety of skills, such as how to move patients
safely, and are given advice on subjects such as patient nutrition.
8.4 The biggest benefit of support and training
for carers is that it can relieve their anxiety about whether
or not they are doing things "right". This level of
support is available at many hospices around the UK, but is more
difficult to provide for carers not in contact with their local
hospice.
9. MEETING NEEDS
OF DIFFERENT
CULTURES AND
BELIEFS
9.1 The hospice movement was developed on
Christian foundations. People of other faiths may feel unable
to consider involvement with such a service.
9.2 Healthcare professionals in the large
majority are white and female.
9.3 Efforts are made to provide the appropriate
religious support in hospitals and hospices. An understanding
of cultural differences in health related beliefs is not routinely
included in training.
9.4 The practice of palliative care is very
dependent on direct communication. This way of working is often
restricted by the need to use interpreters. This is particularly
difficult when caring for people in their own homes as the use
of family members as interpreters may not be practical or appropriate.
9.5 Research in the Marie Curie Hospice,
Bradford, showed that the specific wants and needs of each individual
override the needs attributed by culture or racial background.4
10. SUPPORT SERVICES
INCLUDING DOMICILIARY
SUPPORT AND
PERSONAL CARE
10.1 The introduction of Continuing Care
for Terminally Ill Patients is intended to improve the coordination
of care. In practice, different interpretation of the criteria
and assessment protocols by neighbouring Continuing Care teams
result in confusion and delaying bureaucracy for individual patients
and healthcare workers.
11. QUALITY OF
SERVICES AND
QUALITY ASSURANCE
11.1 Quality of service provision is monitored
by the components of clinical governance such as audit, risk management
and user involvement in service development.
11.2 Marie Curie Cancer Care manages an
extensive programme of education to develop the effectiveness
of its staff and of other healthcare workers.
11.3 Palliative care research in the UK
is a very small proportion of all cancer-based research. Marie
Curie Cancer Care is actively involved in developments which will
support the growth of a critical mass of researchers and also
encourage the translation of research findings into clinical practice.
11.4 External regulation also provides a
mechanism for monitoring quality. There are, however, inherent
problems;
11.4.1 Lack of integration for UK wide
providers such as Marie Curie Cancer Care. Our services are the
same in all parts of the UK. We are subject to four different
inspection regimes, three different sets of national minimum standards
and three different sets of statutory legislation.
11.4.2 There is a cost to service providers
in time and money complying with these regimes and other regulations,
such as the Criminal Records Bureau checks.
12. SERVICES
MEETING NEEDS
OF DIFFERENT
USERS
12.1. Our hospices exhibit good practice
in the provision of multi-faith "chapels," facilities
for young visitors, complimentary therapies for patients, community
liaison workers and the provision of information in other languages.
13. GOVERNANCE
OF CHARITABLE
PROVIDERS, STANDARDS
OF ORGANISATION,
LINKS TO
THE NHS AND
SPECIALIST SERVICES
13.1 Marie Curie is a registered charity
and a company limited by guarantee. The Charity is governed by
its trustee body comprising of 18 part time volunteers who include
senior individuals from the NHS, commercial and other public organisations.
Responding to the Trustee Board is a full time paid Executive
Board which includes Medical and Nursing Advisers, both with significant
experience of working in specialist palliative care and the NHS.
13.2 The Charity is regulated by the Charity
Commission and also subject to all legislation affecting UK based
limited companies. The Charity's hospices are regulated under
the Care Standards Act 2000 and internal policies and procedures
have been developed to with Care Standards and also to establish
broad equivalence to those NHS standards which are relevant to
the Charity's activities.
13.3 The Charity has strong links to the
NHS at every level:
13.3.1 The NHS partially funds the
hospices and the community nursing service through commissioning
arrangements and service level agreements.
13.3.2 Patients are referred to the
Charity's services through GPs, District Nurses and occasionally
hospital doctors. Patients of the Nursing Service remain under
the GP's care plan.
13.3.3 Members of the Charity's staff
work in partnership with the NHS through membership of Cancer
and Palliative Care Networks, and working with commissioners of
palliative care.
13.4 In each location the Charity's services
have usually developed to complement the services provided by
other cancer or palliative care providers, for example local hospices
the NHS and Macmillan Cancer Relief.
14. WORKFORCE
ISSUES AND
TRAINING
14.1 In common with the NHS and other healthcare
providers, Marie Curie Cancer Care faces the challenge of a maturing
nurse workforce—particularly in the community setting. Although
working as a Marie Curie Nurse has many attractions, including
a wide degree of flexibility, the Charity can never compete with
agencies on rates of pay
14.2 The Charity is committed to Agenda
for Change, which will impact in two main ways:
14.2.1 Costs in the nursing service
will rise and the Charity needs to obtain full cost recovery from
the PCTs.
14.2.2 Agenda for Change also contains
the Knowledge and Skills Framework, which involves assessment
of competency. This will be relatively straightforward in the
hospice setting, but presents challenges in the community.
14.3 The Charity's nursing service is a
mix of registered nurses (61%) and health care assistants (39%).
This means nursing skills can be matched with patient needs. However,
there is a lack of consistency among PCTs in their requirements
of the Marie Curie Nursing Service. The majority ask for a mix
of registered nurses and health care assistants (HCAs). However,
an increasing number are moving towards HCAs only, which may—in
some cases—be driven purely by budgetary considerations.
14.4 Looking to the future, it is likely
the balance of the Charity's community workforce may move towards
a greater proportion of HCAs. It is, therefore, essential the
training infrastructure for HCAs looking to work at a higher level
and acquire an NVQ is in place as soon as possible.
15. FINANCING
INCLUDING THE
ADEQUACY OF
NHS AND CHARITABLE
FUNDING AND
THE RESPECTIVE
CONTRIBUTIONS AND
BOUNDARIES
15.1 NHS funding represents approximately
45% of the total cost of Marie Curie Cancer Care's hospice services
and 38% of the total cost of the managed Nursing Service. Where
the Nursing Service cares for non-cancer patients, charges to
the NHS are doubled as the Charity was founded to principally
care for cancer patients. The remaining costs are funded from
a wide range of sources of voluntary income and profits from the
Charity's shops. Certain projects for development of services
may be funded 100% by commissioning bodies or other government
funders, such as New Opportunities Fund, but these projects comprise
a relatively small proportion of the Charity's activities.
15.2 In general, funding from the NHS has
to be renegotiated annually and in the past increases in funding
have not mirrored the increases in the Charity's cost base necessitated
by progressive above-inflation increases in clinical salaries,
essential quality improvements (particularly additional medical
resources) and compliance with regulations. This has only been
partly addressed by recent increases in funding for English hospices
from the Cancer Plan. Only revenue expenditure is funded and therefore
any investment in facilities, including renewal of buildings,
is funded entirely from voluntary funding.
15.3 The Charity has approximately 330 contracts
for services with NHS organisations throughout the UK. Contracts
vary significantly in size. Our smallest community nursing contract
with a PCT is for £5,000—and the largest is for £130,000.
There are a number of PCTs serving similar size populations with
similar perceived service needs, but the budget for Marie Curie
Nursing in one of them may be two or three times that of the other.
Sizes of contract for the nursing service vary as a result of
history and individual commissioning preferences and there are
no clear links to local levels of need or demand for home based
care. As all funding agreements are renewed annually the contracting
process is extremely labour intensive and therefore costly.
15.4 This method of funding creates significant
difficulties in terms of the long-term sustainability of services;
responding to changes in demand for services; making commitments
to service growth and other service developments. Even project
funding may take a long time to secure due to cumbersome application
and compliance processes.
15.5 At several times in the Charity's history,
services have had to be temporarily cut back due to a significant
downturn in voluntary funding. The Charity has worked hard to
develop a wider range of voluntary income streams to reduce risk
to services. However, any significant downturn in legacies, for
instance, which make up around 30% of voluntary income, could
threaten services in both hospices and the community. A £1
million shortfall, for instance, is the equivalent of 50,000 nursing
hours.
15.6 There is no doubt that the Charity
could care for more patients, particularly patients wishing to
be cared for at home, if more funding was available in conjunction
with a commitment to full cost recovery on services delivered
in partnership with the NHS. If it were decided to target a doubling
of the number of terminally ill patients cared for at home as
opposed to in the hospital, the Charity would not be able to grow
its voluntary income sources sufficiently to fund this without
a significantly greater proportion of funding from Government
sources.
15.7 Marie Curie Cancer Care has commissioned
an economic model to look at the case for the equitable provision
of high quality support for people who wish to die at home, including
the economic issues. A key conclusion is that in the medium to
long term, every £1 extra invested in the appropriate provision
of nursing care at home will release £2 within hospital services.
(See appendix II for the full report).
16. IMPACT OF
GOVERNMENT POLICY
16.1 Government has identified the right
of every adult to have access to high quality palliative so that
they can choose if they wish to die at home. This commitment was
made in the Secretary of State for Health's December 2003 paper
Building on the Best: Choice Responsiveness and Equity in the
NHS. The pledge is welcome, but will clearly raise expectations
among the terminally ill and their carers and sets tough challenges
for health and social care providers working in palliative care.
Increased funding is not the only answer to improving palliative
care provision, but it is a key component.
16.2 The NICE guidance on Supportive and
Palliative Care, which is due to be published in March 2004, contains
20 key recommendations, the majority of which will put considerable
demands on Marie Curie Cancer Care in terms of clinician and management
time, education and training and developing links with new partners.
17. RECOMMENDATIONS
FOR IMPROVING
PALLIATIVE CARE
SERVICES
17.1 Provision and funding of palliative
care services should be based entirely on patient and carer needs
and preferences. In the event that demand for palliative care
services increases dramatically, it may be necessary for Government
to increase the proportion of funding contribution to services
such as Marie Curie Nursing. There is obviously a limit to the
amount of funding that can be raised by voluntary organisations.
17.2 Government and voluntary organisations
must investigate and help to eradicate any barriers to service
provision.
17.3 More information about palliative care—particularly
in the terminal phase—needs to be made available to patients
and carers and healthcare professionals.
18. SUMMARY
18.1 Marie Curie Cancer Care has more than
50 years' experience working with the terminally ill. The Charity
is committed to working with Government and other NGOs to ensure
patients and their families have equality of access to services
and can exercise real choice around place of care
18.2 The Charity would welcome the opportunity
to meet with the Health Select Committee to discuss the issues
further—in particular the need to make choice of place of
death a reality for all palliative care patients.
REFERENCES
1. Building on the Best: Choice Responsiveness
and Equity in the NHS. Department of Health, December 2003.
2. Marie Curie Cancer Care Annual Report
and Accounts, September 2003.
3. Priorities and Preferences for End of
Life Care in England, Wales and Scotland. Irene Higginson, July
2003.
4. Planning Culturally Competent Palliative
Care Services for Patients of South Asian Origin. R Lennard, S
Chattoo,M Haworth, W Ahmad, November 2003.
February 2004
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