Operational Handbooks

There are at least three important considerations in suspending anti-TB therapy:

Palliative care for people affected by TB should be monitored and evaluated to help assure its accessibility and quality (104, 120, 121). The following two outcome indicators are recommended:

• Number of patients with TB in the previous reporting period/year for whom all attempts at curative treatment were deemed to have failed.
• Number of patients with TB in the previous reporting period who received morphine (oral fastacting or injectable) for symptom relief.

The following process indicators are optional but also suggested:

People affected by TB are often also affected by other medical conditions such as HIV/AIDS, diabetes, hepatitis, chronic lung disease, neurological disease, substance use disorders and other mental health problems. Some of these illnesses and disabilities may by themselves contribute to an increased risk of death among people with TB while on treatment and afterwards. When creating TB palliative care services, the prevalence of serious comorbidities in the target population and the associated types of suffering should be estimated and preparations should be made to address them.

Palliative care is best provided by a multidisciplinary team whenever possible (104). The ideal palliative care team includes a physician, nurse and psychologist or social worker. TB treatment supporters, community health workers or volunteers can be trained and supervised to visit patients at home, to provide emotional support, to recognize and report inadequately controlled suffering or inappropriate use of opioids, and to practise and teach strict infection control (91).

Strong opioids such as morphine have been proven to relieve safely and effectively not only pain but also dyspnoea that is refractory to oxygen therapy and treatment of the underlying cause (106–112). Morphine is the most studied and least expensive strong opioid and is widely available on the world market. Consequently, morphine, in both oral fast-acting and injectable preparations, is the most essential of the essential palliative medicines for people with TB (106, 107).

Oxygen therapy may provide relief from mild dyspnoea and sometimes at least partial relief from moderate dyspnoea. It should be accessible at least in TB hospitals and wards. Whenever possible, it also should be accessible in the home.

The essential package of palliative care for people affected by TB consists of a set of medicines, simple equipment, social supports and human resources (Table 6). Adapted from the WHO essential package of palliative care for primary care (95), it is designed to be safe and effective for preventing and relieving all types of suffering associated with TB (Box 6). The package includes only inexpensive and readily available medicines and equipment, and its use requires only basic palliative care training (30–40 hours).

Most palliative care can and should be provided by TB and lung disease specialists, primary care doctors and nurses with at least basic palliative care training (30–40 hours of training), TB treatment supporters and community health workers trained to recognize and report uncontrolled suffering, and by social workers and psychologists (91, 92, 94–96). Ideally, specialist palliative care doctors should be available to treat patients with refractory or complex suffering and also as supervisors, consultants and teachers.

An initial assessment for suffering related to TB should be done at the time of diagnosis. Palliative care should be initiated immediately as needed and should be combined with TB treatment to relieve any suffering due to the disease, to the adverse effects of treatment, to comorbidities, or to social problems. It is especially important for people with DR-TB (98). Tailored to the patient’s needs, palliative care should continue regardless of whether the cure is expected or whether treatment fails.

WHO’s End TB Strategy has a vision of zero suffering (13).