This is what such a benefit should entail:

• It should include consultations with appropriately trained palliative care doctors, nurses, social workers and counsellors, and, where needed, allied health professionals, as well as appropriate medications for symptom control, limited equipment and home oxygen when appropriate.
• Importantly, palliative care should be funded separately from oncology benefits, so that patients do not have to use up benefits intended for cancer treatment in order to access palliative care.
• These benefits should be available to all patients living with serious illness, not only those with a cancer diagnosis.
• There should be no co-payments for care provided within the palliative care benefit. This means that reimbursement rates need to be sufficient for appropriately trained providers to deliver the care without passing a shortfall on to the patient.

Such a comprehensive palliative care benefit is not only in the best interests of patients and their families. Good palliative care can also help medical schemes use resources more appropriately by reducing avoidable hospital admissions and other unnecessary healthcare utilisation.

As of August 2026, this is broadly how things stand:

If you belong to a medical scheme, it is worth asking:

Do you have a formal palliative care benefit? Who qualifies for it? Does it include people with serious illnesses other than cancer? What professional services, medications and equipment are covered? And will I be expected to make a co-payment?

If your scheme does not have a comprehensive and transparent benefit, please raise the issue with them. Medical scheme members should be asking for equitable access to good palliative care, regardless of diagnosis.

I have seen patients and families struggle with poorly managed pain, and the ripple effect is significant. Pain can take up the whole day. It leaves little space for anything else, never mind basic activities like getting dressed or getting into a car, let alone something enjoyable like a short walk. It affects appetite, mood and sleep. It affects relationships. Families can feel helpless, not knowing how to make things better.

Sometimes people say, “It’s not that bad, I can deal with it.” Or they are like frogs in slowly warming water with the temperature rising so gradually that one almost forgets what a pain-free day feels like.

Pain deserves attention.

Cancer pain can have many different causes, and effective pain relief often involves a combination of approaches, including treating the underlying cause where possible, as well as physical, psychological and other supportive measures. In this article, however, we focus specifically on one of the most effective tools we have for treating cancer pain: opioids.

What are opioids?
Opioids are a group of strong pain medicines that are commonly used to treat moderate to severe cancer pain. They work by attaching to specific receptors in the brain and spinal cord, reducing the way pain signals are processed and perceived.

Morphine, the best-known opioid, is derived from the opium poppy plant. Other opioids, such as fentanyl and methadone, are made synthetically in a laboratory. Some are semi-synthetic, meaning they are created by modifying natural substances.

How are opioids given?
There are many different forms:

● Syrup, drops or tablets taken by mouth
● Long-acting tablets taken twice daily
● Patches that slowly release medicine through the skin
● In some situations, medication is given intravenously or under the skin
The choice depends on the type of pain, what is available, and what suits the patient best.

Common worries about opioids
There are many myths and misconceptions about morphine and other opioids. Let’s address some of the most common ones.

“My pain is not bad enough for morphine.”
Sometimes a low dose of an opioid gives better, cleaner pain control than a mix of weaker medications.

“If I start now, there won’t be anything stronger later.”
Starting an opioid when you have pain does not make it ineffective later. The dose can always be adjusted if needed.

“I will become addicted.”

Addiction is not a concern when opioids are used under medical supervision for cancer pain. Using medication regularly to treat real, physical pain is not the same as addiction.

“I am allergic to morphine.”
True allergic reactions to opioids are very rare. Most people who believe they are allergic
experienced side effects such as nausea or itchiness, or received a high dose after surgery and felt
unwell. When we start opioids for cancer pain, we start low and increase slowly.

“Opioids are only for the end of life.”
Not true. Many people live well for years with cancer while using opioids to stay comfortable and active.

“I can’t use opioids because they cause constipation.”
It is true that all opioids cause constipation. Rather than avoiding good pain control, we manage constipation proactively and consistently.

Did you know?
Oral morphine is also prescribed to suppress cough and help ease shortness of breath. It is often much more effective than using oxygen!

What are the common side effects?
Like all medications, opioids have side effects. The good news is that most are manageable.
● Nausea and vomiting
This often lasts only a few days after starting treatment. It can be prevented or treated effectively with anti-nausea medication.
● Drowsiness
Feeling sleepy can happen when starting opioids or increasing the dose. It usually improves within a few days. Let your healthcare provider know if you feel very sedated or if the grogginess does not settle.
● Constipation
This is the big one. Unlike nausea and drowsiness, constipation does not go away on its own. Most people need daily laxatives while taking opioids.
● Other possible effects
Itchiness, difficulty passing urine, sweating and dry mouth.

Using opioids well: practical tips
Understand the possible side effects and be prepared.

Use your laxatives. I cannot stress this enough.

Cancer pain is often constant or frequent. Taking your opioid regularly as prescribed, rather than waiting until pain becomes severe, gives much better control.

There are two main ways opioids are prescribed:
1. Short-acting opioids
For example, oral morphine syrup. These usually need to be taken every four hours because that is how long they last in the body.

2. Long-acting opioids
Such as long-acting morphine or oxycodone, taken every 12 hours.
Patches also fall into this category. Depending on the type of patch, they are usually changed either every 3 days, or every 7 days.
Ideally both are prescribed: a long-acting medication for steady background pain, and a short- acting medication for “breakthrough pain” (temporary spikes of pain despite regular treatment).

If you are using oral morphine syrup to manage steady background pain, your doctor will explain how much extra you can safely take for breakthrough pain, while continuing with your regular four-hourly doses.
If you need frequent breakthrough doses, your doctor will likely adjust your regular long-acting medication.
Keeping a simple pain diary can be very helpful. Note when you have pain, what you took, and how well it worked. And most importantly, tell your doctor or nurse if your pain is not controlled or if side effects are troublesome.

Pain control works best as a partnership. With regular, open communication and careful adjustments, most cancer pain can be managed well. When pain is well controlled, there are simply more good days. Days where you can get through the to-do list and still have space for the want-
to-do list.

For more information, download the CANSA booklet to help Manage Cancer Patient’s Pain in the Home.

There are also numerous resources on the PALPRAC website (the Association of Palliative Care Practitioners of South Africa).

This article was first published in Cancer Buddies.

I was recently fortunate enough to pack my bags and do some travelling with my family. It was so good to plan for this and know it wouldn’t be COVID-cancelled. At the same time, I have three boys and, in the midst of planning and packing, I sometimes wonder whether the chaos that this brings is actually worth it! One gets hangry, so we need enough snacks. The other usually forgets to pack something warm – he hates anything long and ‘claustrophobic’ – and then inevitably gets cold and needs to borrow a sweater. For everyone’s sake, devices need to be fully charged for the long road. Also because I like to take the smaller, winding roads and will not be forgiven if we get lost.

Going on any journey means planning ahead. Planning for what is likely, but also for the ‘what-ifs’ (which is why I tend to overpack). I have often thought this to be a much more useful serious illness metaphor, as opposed to the war one that we use more often. Wars imply winners and losers, and often leave destruction in their wake. Journeys can be gentle strolls, even if sometimes long. At other times, journeys are much more like difficult hikes: uphills with only the short relief of a plateau from time to time. It can feel as though one never quite reaches the top to appreciate the view. Sometimes there are unexpected hailstorms, sometimes a break in the clouds allowing the warmth of sunshine. Sometimes it would have been better to turn left. Either way, it helps to plan a little, knowing where you are supposed to be going and what you should pack.

In the same way, when one is on a journey with a serious illness, many people find it helpful to talk about and know what to expect along the way, so that they can do some planning. At the same time, it is also important for your medical team to know what matters most to you so that any treatment recommendations they make can be tailored accordingly. It is not the same for everyone, and as medical professionals we sometimes leave it to assumptions rather than inquiry. It requires what we call a ‘serious illness conversation’.

You will have heard the terms Advance Directives, Advance Care Planning and Living Wills. This conversation falls somewhat into that category, but it is much less genericand more personal. It is a conversation between you and your healthcare team that focuses on your goals and values when thinking about your health. We understand that these views might change as you reach different parts of your journey, so it is a conversation to have more than once. You might also want to involve those you care about and have them present. Documenting and reviewing this conversation is helpful to refer back to at times when one needs to make difficult decisions, either yourself or perhaps in cases where others need to make them on your behalf.

These are some of the questions that peoplehave found of value to discuss:

1. What would you like to know about your illness and what is likely to be ahead?
2. What kind of information would be helpful to assist you in making decisions about your future?
3. What does quality of life mean to you? Put in other words, what does a good day look like?
4. What matters most to you and what would be your most important goals if you should become sicker?
5. What are your biggest fears or worries as you think about the future and your health?
6. If you become sicker, how much are you willing to go through for the possibility of extra time? What kinds of medical care do you think you might not want?
7. Ask yourself: How do I want to involve the ones that I care about?
8. Is there someone that you trust who could make decisions on your behalf if you are unable to do so, a so-called Mandated Healthcare Decision-maker?

Contrary to what one might think, once you take the first step, talking about these things more often brings relief and does not raise anxiety levels. This has been proven through research. It gives people more control and certainly should help your medical team to make wise treatment recommendations, not just medically correct ones.

Know that it is never too soon to talk about these things. More often, we talk too late. Your healthcare team might well not bring up this topic, ever. It will be up to you to introduce the conversation: “Doctor, I want to talk to you about my goals of care and living with my serious illness.”

More information and tips can be found on this website: https://theconversationproject.org/

Palliative care improves the quality of life of the patients and their loved ones, who are facing serious illness. Doctors working in the field of palliative care in South Africa have formed a new association.

World wide there is growing recognition for this field of medicine, where in many places it is now recognised as as a (sub)speciality. It is valuable when offered offered alongside usual treatments for patients with cancer, major organ-failure and neurodegenerative diseases.

Who is Palprac?

Palprac, the Association of Palliative Care Practitioners, was first established in May 2017 and we had our first successful AGM in June 2018. To date we are 70 member strong, all doctors from various disciplines with an additional diploma or MPhil qualification in palliative medicine.

Above all however, most have a real passion for the field. I realized that my passion might border on zealousness when I asked my middle child to heat up a hot water bottle for his younger brother who had a sore tummy. “I will take the hot water bottle and Molly (our poodle) to snuggle with him. That will be a total care package,” he said with earnest. And so for my sins, I am a founding member and current secretary of Palprac.

What does Palprac do?

Palprac was borne from a need for peer-support for doctors practising in this field, many working in isolation. Peer advice is available on the management of difficult-to-treat symptoms. It has also been very valuable to have a space to sound board complex ethical questions. Medicine is lumped under the sciences, and many hope for exact answers. Often though, it is more of an art with a whole lot of philosophy and ethics thrown into the mix. Being able to discuss these situations with colleagues, where the underlying principle of patient-centredness underpins everyone’s practice, has been a great resource.

Palprac also sees itself playing a role in improving access to quality palliative care. In South Africa palliative care has been offered by the non-governmental sector, specifically hospices since the 80’s. It has only recently, and only in small pockets, been included in the formal (state) medical sector. 2017 saw the approval of the South African National Policy Framework and Strategy for Palliative Care by the National Health Council. This will hopefully create the necessary impetus to unlocking the necessary funding, political (business) will and ethical awareness for developing these valuable services.

Palprac collaborates to improve access to palliative care

One such project has been the collaboration of Palprac with Alignd, a new managed care organization in the making, www.alignd.co.za. Currently your palliative care benefit will probably be limited to 2 weeks of hospice/nursing care at the end of life. This new benefit however, will allow for a palliative care team to walk the journey with with you from early on, while facing a cancer that is unlikely to be cured. What the journey looks and feels like is the focus of the palliative care team, while the oncologists focus on managing the disease.

Care will be available in a coordinated fashion when needed. Support will be provided in managing physical symptoms, complex (albeit normal) emotions, informational and decision-making needs and existential issues. Importantly this type of care does not need to happen in a hospital. In fact, if appropriate and this is your wish, most care will be offered as an out-patient. In other words, either in an medical office or at a patient’s home.

The benefit will also be novel in that is will be paid for through a “value-based contracting” mechanism, as opposed to the usual “fee-for-service” way. For many reasons the fee-for-service model complicates offering the kind of service that is required. One of those complications that will be avoided, is the out-of-pocket expense that people have to bear.

Finding a palliative care doctor

Palprac’s website, www.palprac.org, lists all the doctors with the appropriate qualifications offering palliative care services around South Africa that we know of. There might be more. We are still on the look-out.

In conclusion

In the words of Atul Gawande (yes, I know I quote him often), “Better is possible. It does not take genius. It takes diligence. It takes moral clarity. It takes ingenuity. And above all, it takes a willingness to try.”