 Thank you. I am going to start with my thank you's because I'm likely to forget them. So just Thanks to the MSF team the healthcare workers in the local clinics in Kaili Chah and the patients in Kaili Chah Who are really trying very hard to fly the palliative flag? Hi, and so this morning we're going to talk about palliative care within the drug resistant TB program and Really the question is why would we even want to talk about palliative care? But the realities that we're facing is that Drug resistant TB remains a major source of mortality and morbidity and in South Africa Treatment is successful in only about half of our patients and the Kaili Chah Let's see if the pointer works The Kaili Chah data echoes what's happening globally and in South Africa So if you look at the purple you'll see that it is the number of our mortalities and our success rates remain low in terms of the blue and the orange It remains under 50% so Why should we bother with palliative care because in our traditional view we give everything we can at the beginning of A patient's treatment journey. So we are going to go for new drugs better regimens Shorter periods the best adherence you can find because if all doesn't work out We can just refer this patient for palliative management at the end But this is in complete contradiction to what the WHO says about what palliative care is It is actually an approach that improves the quality of life for patients and their families Facing problems associated with life-threatening illness and the method is basically prevention and relief of suffering and Really good assessment and treatment of symptoms like pain Coughing other problems and we look at the patient from a physical psychosocial and spiritual perspective And so the true pace of palliative care is right alongside our curative intervention and This is a problem for some because palliative care means end of life and people struggle So actually we don't care what you call it call it supportive care call it holistic care Call it patient-centered care is provide good assessment for all symptoms for these patients and So how do we do this? So we have a case description basically This is a journey of a 23 year old male who lives with Inkaya leecher and How how the services in Kailita works that it's completely decentralized all care happens at the local clinic And so whether you starting treatment or your treatment has failed you you will still get care at the local clinic And so no home-based care is provided So this young man is living with his family in a home. There are some issues between him and his mom and dad And then also the mom was quite concerned about the other kids in the family What was happening with this young man? He was at his foot treatment episode and The previous episode failed because of various issues But now in his fourth episode again the treatment was failing and he's only options for a better regimen or other treatment options Was going inside a hospital who really distrusted the hospital system and he when you spoke to him He basically says I refuse or care. I don't want anybody to do anything for me MSF and There's a great local doctor who really sat down with us and said what can we do? I can't reach this patient is at home his family You know got the police to take him to clinic and force him to treatment And that's how we got involved. So when we spoke to him. He was a well-spoken man He appeared weekend timid he was struggling with shortness of breath and he was adamant He understood the consequences of not taking treatment, but he did not want treatment Okay, so we did a needs assessment and really from a physical perspective He had shortness of breath coughing pain and we provided him with morphine at home from a psychosocial perspective He had financial concerns and we worked with social department to make sure he got a stipend We sat down with the family and really worked with the family to understand Patience choice versus what the family's concerns were and the family came to an agreement with the patient And we gave the patient spiritual counseling in terms of the family's concerned around infection control risk family members were up could go to the clinic for screening and the family were also provided with in three respirators and were We had a plan for the family on how they could stay safe and still be with their sign towards the end of days And so we tried to stick through with the four ethical Principles of ethics and really the patient had autonomy the patient could Choose what he wanted for his treatment Beneficence the medical team acted in the base interest of the patient but the family as well So both were listened to non-maleficence first do no harm We ensured that the environment was safe for the family that it was in and justice Despite the patient's refusal of drug-resistant TB care. He was not refused care And so conclusions and takeaway message in this case in terms of palliative care is that palliative care is an essential with drug-resistant TB treatment management and palliative care policies and implementation plans really require resources something needs to be done in the home and partnership with social and legal agencies home-based nursing and counseling services and Access to palliative care medicine. Thank you