What Are We Aiming At? Palliative Care in the Middle East

Michael Silbermann. MECC. The World Health Organization defines palliative as ‘‘An approach that improves the quality of life of patients and their families facing the problems 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. ’’ Today, we have arrived at the stage where one can start the evolution of quality measurement in palliative care practice both in hospital-based palliative care units and in hospices. It has become apparent, through surveys of healthcare professionals, seriously ill patients, and family members, that several domains were validated. Nearly 70% of reviewed citations agreed on the importance of the domains of symptom palliation, emotional support, promoting shared decision-making and advance care planning, meeting the needs of patients and those who care for them, addressing grief and spirituality, and coordination of care. A useful mnemonic is the 3 Cs: high-quality care is ‘‘competent,’’ ‘‘compassionate,’’ and ‘‘coordinated. ’’ A competent case involves an interdisciplinary team that provides evidence-based symptom palliation and psychological support in the key domains of physical comfort: psychological support, social support, bereavement services, and life closure, including spirituality and transcendence. Too often, seriously ill people feel as though they are lost among myriad specialists focused on body organs, with no physician specifically charged with providing critical assistance and ensuring continuity and coordination of the plan of care at the stages of the disease trajectory. Seriously ill patients and their families need to know whom they can call for help, what they should monitor, and when they should call; in short, there should be an orchestrated and clear plan of follow-up. Compassionate care treats the patient and family with respect, honors cultural traditions, and provides holistic care. Care is coordination across the setting of care and the disease trajectory. Hospital-based palliative care programs often lack the extensive use of volunteers as do hospice programs use to extend their staff services. Furthermore, hospice programs are mandated to provide 12 months of bereavement follow-up to every family they serve. A high-quality hospice program is required to have an interdisciplinary team of physicians, nurses, and volunteers; bereavement services; available rehabilitative services including speech, physical, and occupational therapies; short-term in-patient care; and home health aides. A high-quality hospice program will, at the close of life, comprehensively assess patient pain to understand its cause and both pharmacologic and nonpharmacologic approaches to its management, including the appropriate use of adjuvant medications such as gabapentin for neuropathic pain. At times, palliative sedation is the only possible means of symptom relief. Furthermore, palliative care programs must manifest understanding and respect of the unique values of the patient’s culture. In addition, supporting families and friends in their caregiving role is essential. Evidence of families frequently taking patients to and from the emergency department may highlight inadequate family education and lack of on-call staff to consult with and support at-home symptom management. Be it in a hospital environment, hospice or home care setting, palliative care at the close of life needs to be patient-focused and family-centered. This abstract is based on the excellent publication of Teno et al. The authors’ observations, judgment and analysis could serve as a basis for multiple new programs in developing countries eager to bring palliative care services to the best reachable levels. References: 1. World Health Organization—WHO definition of palliative care. Available at: http//www.who. int/cancer/palliative/definition/en. Accessed October 19, 2008. 2. Steinhauser KE, Christakis NA, Clipp EC, et al. Factors considered important at the end of life by patients, family, physicians, and other care providers. JAMA. 2000;284:2476–2482. 3. Teno JM, Casey VA, Welch LC, Edgman-Levitan S. Patientfocused, family centered end-of-life medical care: views of the guidelines and bereaved family members. J Pain Symptom Manage. 2001;22:738–751. 4. Teno JM, Connor SR. Referring a patient and family to highquality palliative care at the close of life. JAMA. 2009;301: 651–659.