**10. Conclusion**

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

worse in current pandemic situations of Covid.

running the programme are raised locally by volunteers [21].

**9. Best practice – example from Kerala, India**

financially, in countries like India.

**8. Limitations**

viii.Considering the increasing cost of treatment of chronic illnesses, it's sometimes hard on the part of the family to continue treatment in a hospital or hospice. It's especially true in scenarios where population are not protected

i.One of the limitations is to convince the patients and their families to call the care team when they experience a health crisis, for which, the Home PAL team need to build trust and rapport with the patients and their families [20].

ii.Family members may not be prepared to bring the patient to hospital in times of urgency. So, Home PAL team needs to develop preparedness among the family members to shift the patient to health care facility whenever required, which calls for advanced arrangement of money, transportation and people who will be accompanying them to hospital. Scenarios can get

iii.The providers of the home PAL needs to be very sincere in paying the home visits in order to avoid care fragmentation and should never fail in their routine.

Kerala is pioneer in community-based palliative care through a socially innovative approach called the Neighborhood Network in Palliative Care in an attempt to develop a free of charge, sustainable, community led service capable of offering comprehensive long-term care and palliative care. The network aims to empower local communities to look after their chronically ill and dying patients. Funds for

The programme was first pilot studied in 1996 in Malappuram, located in the northern district of Kerala, the state with the highest literacy rate in India. It was run by community based organizations. It was first started for cancer patients. The program was gradually expanded to include other patients who required long-term care and support such as stroke, alzheimer's disease, paraplegia and psychiatric conditions. Volunteers from the community were selected and were trained to identify the psycho-social needs of people with chronic disease in their area in order to intervene effectively with active support from a team of trained health care personnel [21, 22]. The nurses who were trained in palliative care played a vital role in this. They regularly visited the home of the patients who were enrolled in the program and provide nursing care and support at home, which included wound dressing, catheterisation, nasogastric tube insertion, and counseling. The doctors were called only for selected patients where the patient needed a physician's consultation, which was chartered by the palliative care nurse. The community volunteers also played an important role. Trained by the palliative team with the first-hand knowledge of basic nursing and palliative care, they helped patients and their families financially and emotionally. The model was a successful one. It inspired the state of Kerala to implement a palliative care policy to ensure universal coverage of palliative care services in all its local administrative units, making it the first state in Asia to develop such a policy. Home based care was considered as the corner stone of palliative care services in the policy implemented [23]. The Neighborhood Network in Palliative Care in Kerala is the best example of a community-based palliative care for low-resource countries in the world.

**38**

Considering the increasing number of critically ill patients who are in need of palliative care for long, it is high time to focus towards implementing home based palliative care measures that will help patient maintain their quality of life. It should be emphasized to include palliative care, especially home based palliative care in the primary care, community and home based health care services. Gradually, it is necessary to create and implement National health policies that integrate Home PAL services into regular home health care services.
