In the western health-care system, palliative care is provided in the form of hospice care. However, there is a shortage of available hospices. Inability to fulfill enrollment requirements for hospice admission and lack of integration of palliative care in most heath-care systems are challenges that face those who care for terminally ill patients in developed countries. The main discipline involved in the palliative circle of care in developed countries is shown in Figure 1.
COMMUNICATION AND COLLABORATION ARE KEY ASPECTS OF THE INTERDISCIPLINARY TEAM
Developing countries face different spectrum of obstacles. Lack of resources directed to palliative care, administrators' unawareness of the role of hospice care in health-care system, poor physician understanding and training of medical care in the final stages of diseases, and the unreasonable expectations of patient and families are some additional challenges (Fig. 2).
Al Salama hospital is a nonprofit, nongovernmental hospital, located in Tanta city, the Capital of Gharbia governorate in the middle of Nile Delta. The sole financial support is provided through individual donations. The hospital provides acute care to patients with cancer including surgery, chemotherapy, and radiation. We believe that this setting was suitable for establishing hospice care program in the hospital.
Egypt is a country where religion plays a pivotal role in daily life. Charity “Al-Zakah” is 1 of the 5 pillars of Islam. During the entire month of Ramadan when donations are at their peak, we run a campaign to collect money for expensive equipments. We purchase linear accelerators, imaging machines, and lab equipment depending on the amount of donations received annually. We believe that hospice care can only be financed using the same approach. It is unrealistic to request financing for hospice care in countries struggling to provide the basic services of infectious disease control, sanitation, and food.
Proper staffing of a specialized unit, that will provide care to a wide variety of medical problems, is another challenge. We started a nursing education program with emphasis on communication skills, pain recognition and control, and comfort care.
We sought physicians willing to care for terminally ill patients. Doctors treating patients with cancer are aware of the medical problems that their patients face. Most of the physicians do not get formal training in hospice care in developing countries. We believe that training of doctors working in the field of cancer will be more beneficial to the patients. Through formal lecture series and in-service training of our staff, we provide the staff to start the hospice unit rather than hiring a new crew.
Pain management is an integral part of cancer care. Proving opioid medicine is difficult most of the time. Extensive paper work is needed to receive pain control medicines. To solve this problem, we plan to dedicate a separate pharmacy with proper staffing and secretarial personnel to dispense pain medication. The nursing and physician training will include pain management, among different options.
Awareness among physicians about the exact role of hospice care is lacking in developing countries. Transferring patients who need acute care may have a chance of disease remission. It is difficult to provide accurate information to families. In societies in which issues such as informed consent, do not resuscitate, living will, or health-care proxy are unknown, the same rules governing the western medicine cannot be applied. We plan to implement a cultural-sensitive and religion-sensitive approach. Family members will be included in the decision making by arranging family meetings rather than private patient-physician discussion.
Illiteracy remains a major problem hindering development in many countries around the world. Spreading the word about our mission of relieving suffering rather than cure requires extra effort; therefore, we make sure to educate patients and families about our role in helping patients. Paying attention to the unique structure and limitations of our society will help establish a successful relationship with the patients and their families. We plan to integrate ancillary services to our hospice unit including nurse educators and psychology therapists.
There are some advantages in Egyptian culture. Family ties are strong, and most patients are surrounded by their loved ones during the difficult phases of their illnesses. Family members usually request their involvement in the daily care of the patients. Their presence assures the patient and raises his morale. Our unit is structured around this principle.
The experience of other investigators in this field is invaluable. We believe that each culture should tailor its program based on its cultural, religious, and spiritual beliefs. Establishing an international forum for exchange of thoughts, ideas, and experience can help in formulating a basic universal standard of care for terminally ill patients.