Editorial
Palliative Care Unit in an Oncology Hospital in Turkey
Gonca Tuncel Oğuz1, Gülçin Özalp Şenel1 and Michael Silbermann2*
1AY Ankara Oncology Education and Research Hospital, Pain and Palliative Care Unit, Turkey
2Department of Palliative Care, Middle East Cancer Consortium, Israel
*Corresponding author: Michael Silbermann, Department of Palliative Care, Middle East Cancer Consortium, Haifa, Israel
Published: 05 Dec, 2016
Cite this article as: Oğuz GT, Şenel GÖ, Silbermann M.
Palliative Care Unit in an Oncology
Hospital in Turkey. Clin Oncol. 2016; 1:
1157.
Editorial
Palliative care is defined by the World Health Organization as 'an approach that improves the
quality of life of patients and their families facing the problem associated with life-threatening
illness, through the prevention and relief of suffering by means of early identification and impeccable
assessment and treatment of pain and other problems, physical, psychosocial, and spiritual' [1]. For
cancer patients, combined standard oncology care and palliative care should be considered early in
the course of illness for any patient with metastatic cancer and/or high symptom burden [2].
The A.Y. Ankara Oncology Education and Research Hospital was founded in 1956 throughout
the efforts of Turkish Cancer Research Society. Today, it serves as atertiary training hospital with
many modern facilities in cancer treatment such as robotic-assisted chemotherapies, new radiation
technologies, surgical procedures and bone morrow transplantation. Experienced health care
personnel from all disciplines care for oncological patients who come from all parts ofthe country.
The initiative or palliative care approach began in the hospital's pain unit which was established
in 1991 as a division of anesthesiology department. It was organizedprimarily for pain management
of patients with a diagnosis of cancer. Medicaltreatment for pain was administered with/without
necessary invasive procedures such as nerve blocks, neurolytic blocks or neuraxial drug infusions
when needed. Although some interventions were applied to provide symptom relief other than pain
control, there was no established palliative service designed to routinely meet the needs of these
patients. They were frequently given care in medical oncology unit, radiation oncology unit or surgical
wards. Majority of the clinicians in these departments were unfamiliar with appropriatealgorithms
for pain management and had little experience with the use of morphine and manage its side effects.
Opioids were regarded as 'heavy' drugs to be saved for the very end-stage. With the establishment
of pain unit, the approach to pain management and opioid use began to change and the number of
patients referred to our unit for pain control gradually increased by year. During that period, opioid
formulations were very limited in the country.
By 2006, the growing cancer population along with growing suffering due to pain and other
symptoms, and the unmet needs of patients prompted the decision to establish a new inpatient
unit. The hospital chief physician and the pain unitteam worked together on a report regarding
the necessity and design of a palliative care unit. The Palliative Care Unit was finally implemented
in July 2007 with 18 inpatient beds. The standards of the clinic were not optimal and the healthcare
personnel were not completely trained in palliative care. The training mostly relied on the
experience of the team about pain management and reading materials.
The concept of palliative care has improved and disseminated slowly in Turkey. There was no
legislation regarding palliative care.The Turkish Ministry of Health launched a 5-year national cancer
control program in 2009 and the Pallia-Turk project, a unique population - based program focusing
on the primary-care level followed in 2011 [3]. Close collaborationwith several national organizations
and involvement in the workshops and education programs of international societies [MECC-Middle
East Cancer Consortium] improved knowledge and awareness about palliative care. The palliative
care team in the hospital has participated as trainers in nationwideeducationsymposiumsfor nurses,
physicians and other professionals. The Palliative Care Unit also served as an advisory model for
oncologic palliative care and was awardedseveral appreciative commemorative admiration plaques
by the Cancer Control Department. In 2014, a directive entitled 'Directives for Palliative Care
Services Implementation Procedures and Principles' was published by The Turkish Ministry of
Health to regularize the standards of palliative care units established in hospitals. The directive
highlighted the importance of teamwork, psychological, social, and spiritual support, integration
of palliative care for both the patient and the family and close contact with family physicians
and home care teams. However, the doctor responsible for the unit was defined as 'preferably an anesthesiologist' whichledto heated discussions over the role of the
anesthesiologist and concern about his/her relation with intensive
care.Palliative care units weredisregardedas a kind ofintensive care
units by several clinicians and decision makers in health care. Certain
ethical and reimbursement issues also arose. Although the distinctive
philosophy of palliative care is well emphasized in the educational
programs, residual misunderstanding of the underlying concepts and
terms of palliative care remain.General palliative care can be provided
by primary care professionals and specialists treating patients with
life-threatening diseases with good basic palliative care skills and
knowledge [4]. We hope that the ministry will amend the regulations
and provide the involvement of physicians from various specialties
with necessary education, willingness and permanency. A palliative
care specialty is needed and should be made available in the country
inthe future.
Our palliative care unit is the first registered service with 13
inpatient beds in 2015, following the announcement of the official
regulations by the Turkish Ministry of Health.We aim to improve
quality of life of patients and their families by controlling pain and
other symptoms, while also addressing psychological, social, and
spiritual problems. The unit mainly serves cancer patients at all stages
of the illness. The palliative care team consists of 4 physicians (3 pain
specialist, 1 anesthesiologist), 12 nurses, 1 medical secretary and 2
cleaning staff. Patients are accepted in the palliative care service from
pain unit, other services in the hospital, emergency department and
other hospitals (university, government or private). Palliative care is
also provided in pain unit for outpatients and in other services by
consultationto manage pain and other symptoms. The number of
cancer patients given palliative care in the last 5 years (2011-2015) are
presented in Table 1..
The palliative care unit is supported by the anesthesiology
clinic after working hours during the day. A psychiatrist and
psychologist accompany daily visits to patients once a week and also
work in liason. Social workers, physiotherapists and spiritual-care
specialists give support to the unit on the appointed days. Regular
family meetings are organized on Thursdays with input bynurses /
doctors and psychologist. The families meet each other, share their
feelings and experiences and sometimes cry together. All patients
and caregivers are informed about the concept of palliative care
upon admission to the clinic and their expectations are addressed.
Written informed consent is obtained. During their stay, necessary
reports for medications and devices are prepared for the continuation
of palliative care at home.Insufficient organization of palliative care
settings other than hospitals (hospice, nursing home) prolongs the
length of stay in the units. A detailed epicrisis is prepared at discharge
to serve a reference for family physicians and home-care teams.
Contact telephone numbers of the unit are also given.
Cancer treatment is a long journey for the patient and the family.
Palliative care is essential throughout this journey and can be started at
any time in the disease trajectory in conjunction with active treatment.
Unfortunately, we still face barriers to the effective integration of
palliative care in cancer care. It is usually considered as an end stage,
or terminal care, and referral to a palliative care organization often
occurs late in the course of disease. InTurkey, thereis great difficulty
in informing a diagnosis of cancer to the patients.Often, family
members do not want the patient to be fully informed about the
cancer diagnosis or incurable nature of the disease. Therefore, bad
news and poor prognosis are frequently withheld from the patient
and the truth is shared only with the family.Sometimes, this may lead
to self despair in patients waiting for curative therapies, and increase
their depressive mood. Notably, the right of dying patients to issue
advance directive and do-not-resuscitate [DNR] order is not legal in
Turkey.
Despite these unfavorable circumstances, we try to alleviate
patients' suffering by providing symptom control and psychosocial
and spiritual support. Pain is one of the important symptoms in
palliative care and has a major impact on quality of life of cancer
patients [5,6]. Difficult access to opioids and the lack of wellestablished
palliative care facilities results in under-treatment of
pain.Turkey is one of the countries with statistical evidence of
inadequate morphine consumption per capita. In 2010, the adequacy
of opioid analgesic consumption was only 7% - based on a per capita
consumption of 14.31 mg morphine equivalents [7]. Many cancer
patients are treated by health-care professionals lacking the essential
skills for pain management. Opiophobia is still common not only on
the part of health-care practitioners, but also in families and patients.
Modern principles of cancer pain treatment, opioid doses and side
effects are not fully recognized by physicians and nurses. Misguided
concerns about dependency, tolerance and side effects limit the
optimal use of opioids in medical practice.
Many types of opioids are lacking in the market in Turkey.
We have only tramadol, transdermal fentanyl, hidromorphone,
oxycodone and morphine in the country. Immediate release oral
morphine is very new, therefore we have used parenteral forms for
many years. Oxycodone came into the markets a few years ago. All
forms and doses of opioids are not also available. Moreover, Turkey
has a complicated, restrictive, and burdensome regulatory system
for prescribing opioids. A color coded prescription system is used -
namely, red prescription sheets for strong opioids and green sheets
for sedatives and weak opioids.The total doses that can be prescribed
in one prescription are also limited.
In a recent study, we examined the patterns of opioid use among
cancer patients in our palliative care unit [8] and found that the daily
oral morphine equivalent dosage per patient is 172±58 mg (40-328).
Indications for opioid use were pain (61%), dyspnea (19%), and both
dyspnea and pain (20%). The results show the importance of opioid
use to alleviate pain and dyspnea in palliative care settings. Despite
the limited variety of opioids in our country, a more adequate and
effective level of pain management can be obtained byimproving
the education of health practitioners. The confident and safe use of
opioids in palliative care is essential.
The Cancer Control Department, together with other
organizations, is working hard to disseminate the modern philosophy
of palliative care and opioid use throughout the country. Several
meetings have been held for health-care professionals who wish
work in a palliative care team. In our hospital, we have organized
'Palliative Care Nursing Symposium' in 2014 and 'Spring Symposium
in Oncologic Palliative Care'in 2016 with the contribution of speakers
from several disciplines.
In Turkey, there is no formal comprehensive palliativecare
curriculum and palliative care specialty. Training is usually obtained
from symposiums, workshops, literature, whereas it should be
included in the curricula for medical faculties, nursing and related
professional’s education. Some certification programs for nurses are
being planned by the ministry.Yet, not all health care team are aware of the palliative care strategies, and a significant proportion of the
population does not have access to palliative care at all. It isessential
that an improved palliative care program should be integrated in the
national health care systems to control suffering.Manyterminally ill
patients are admitted to emergency departments because of inadequate
support in the community, difficulty in controlling symptoms at
home or inability to further care for the dying patient. Although the
concept of palliative care is more pronounced in our hospital, still, a
large number of those patients are referred to intensive care unit for
further care. An absence of legislative regulations, coordinated referral
systems, and an insufficient number of palliative care services result in
futile hospitalization in intensive care units.Palliative care needs to be
integrated and balanced with other care services to address the needs
of patients and their families [9]. A comprehensive system of services,
including inpatient units working in close collaboration with homecare
teams and family physicians, should be available to cover all care
needs and treatment options.Although the number of palliative care
services has increased in the past few years in Turkey, integration
with family physicians and home-care teams has not been sufficiently
established to cover the increasing palliative care demand. Similarly,
organizations that provide visits to patient's homes are insufficient,
andbereavement services and follow-up support for the family after
the death of the patient also need to be improved. In our unit, we give
bereavement support by telephone calls and the families usually visit
the service and the staff afterwards to express their gratitude.
The Turkish Ministry of Health is working to improve the national
health strategies and deliver palliative care educationin a culturally
sensitive manner accessible to all segments of the population.
Legislative regulations about end of life care, advance directives
and DNR orders are still under discussion. Awareness in public and
health professionals and coordination of palliative care services with
home-care teams areneeded to be improved.
Palliative care is a fundamental human right. All patients should
have accesses to such care at any stage of the illness. Our aim must be
to provide the best possible quality of life for patients keeping in mind
the words of Dame Cicely Saunders, the founder of modern hospice
and palliative care, ‘we will do all we can, not only to help you die
peacefully, but also live until you die’.
References
- Definition of palliative care. World Health Organization. 2002.
- Smith TJ, Temin S, Alesi ER, Abernethy AP, Balboni TA, Basch EM, et al. American Society of Clinical Oncology provisional clinical opinion: The integration of palliative care into standard oncology care. J Clin Oncol 2012; 30: 880-887.
- Ozgul N, Gultekin M, Koc O, Goksel F, Bayraktar G, Ekinci H, et al. Turkish community -based palliative care model: a unique design. Ann Oncol 2012; 23: 76-78.
- Radbruch L, Payne S and the Board of Directors of the EAPC. White paper on standards and norms for hospice and palliative care in europe: Part 1 Recommendations from the European Association for Palliative Care. Eur J Palliative Care. 2009; 16: 278-289.
- Black B, Herr K, Fine P, Sanders S, Tang X, Bergen-Jackson K, et al. The relationships among pain, nonpain symptoms, and quality of life measures in older adults with cancer receiving hospice care. Pain Med 2011; 12: 880-889.
- Hwang SS, Chang VT, Kasimis B. Dynamic cancer pain management outcomes: the relationship between pain severity, pain relief, functional interference, satisfaction and global quality of life over time. J Pain Symptom Manage. 2002; 23: 190-200.
- Duthey B, Scholten W. Adequacy of opioid analgesic consumption at country, global, and regional levels in 2010,its relationship with development level, and changes compared with 2006. J Pain Symptom Manage 2014; 47: 283-297.
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