Barriers to, and opportunities for, palliative care development in the Eastern Mediterranean Region

What helps or hinders effective end-of-life care in adult intensive care units in Middle Eastern countries? A systematic review

BACKGROUND

As many patients are spending their last days in critical care units, it is essential that they receive appropriate end-of -life care. However, cultural differences, ethical dilemmas and preference practices can arise in the intensive care settings during the end of life. Limiting therapy for dying patients in intensive care is a new concept with no legal definition and therefore there may be confusion in interpreting the terms 'no resuscitation' and 'comfort care' among physicians in Middle East. Therefore, the research question is 'What helps or hinders effective end-of-life care in adult intensive care units in Middle Eastern countries?'

METHODS

The authors conducted a comprehensive systematic literature review using five electronic databases. We identified primary studies from Medline, Embase, CINAHL, Psycinfo and Scopus. The team assessed the full-text papers included in the review for quality using the Joanna Briggs Institute checklist (JBI). We completed the literature search on the first of April 2022 and was not limited to a specific period.

RESULTS

We identified and included nine relevant studies in the review. We identified five main themes as end-of-life care challenges and/or facilitators: organisational structure and management, (mis)understanding of end-of-life care, spirituality and religious practices for the dying, communication about end-of-life care, and the impact of the ICU environment.

CONCLUSIONS

This review has reported challenges and facilitators to providing end-of-life care in ICU and made initial recommendations for improving practice. These are certainly not unique to the Middle East but can be found throughout the international literature. However, the cultural context of Middle East and North Africa countries gives these areas of practice special challenges and opportunities. Further observational research is recommended to confirm or modify the results of this review, and with a view to developing and evaluating comprehensive interventions to promote end-of-life care in ICUs in the Middle East.

Ensuring quality of life in palliative care physiotherapy in developing countries

Palliative care (PC) focuses on the body, mind, and spirit and can also provide pain and symptom relief, clarifying and focusing the provision of care on the patient's desires and goals, and helping them understand their disease and its treatment plans. Although PC is widely recognized for its applicability near the end of life or during terminal illness, it is also applicable and beneficial for patients with diseases in their earlier stages. Near the end of life, palliative care often focuses on providing continual symptom management and supportive care. Although palliative care has been noted to improve some life expectancy, its primary aim is to improve quality of life via focusing on the comfort of the patient, maintaining dignity, reducing intensive care utilization, and avoidance of expensive hospitalizations. One major challenge to quality of life for patients in PC is the physical and functional decline that occurs with disease progression. These issues can be addressed by specialized PC physiotherapy. Uniform provision of high-quality PC services (and physiotherapy in palliative care) faces substantial challenges in resource-challenged settings, including low- and middle-income countries. When properly integrated into PC teams and adequately supported, physiotherapy within PC can address common symptoms (pain, breathlessness, weakness) and assist patients to remain in an adapted home setting to optimize their quality of life, safety, and dignity.

Barriers Faced by Healthcare Providers during Home Visits of Palliative Care Patients - A Qualitative Study

Objectives

We, the Department of Community Medicine, have been training healthcare providers for palliative care in the hospital and community setting. There were many difficulties in providing proper palliative care. The objective is to explore the various difficulties faced by Junior Residents, auxiliary nurse and midwife (ANM) and medical social workers (MSWs) during the home visits of palliative care patients and to address those difficulties in future visits.

Materials and Methods

The study was conducted in our peripheral institutions such as the Rural Health Training Centre and the Urban Health Training Centre among Junior Residents, ANMs and MSWs who had provided palliative care for the patients. Qualitative study design includes participatory research action techniques such as force field analysis, cobweb diagram, and pairwise ranking, and Systematic techniques include the Delphi technique.

Results

Indicators for difficulties faced by Junior Residents were derived and plotted based on priorities and joined to form a cobweb diagram. Difficulties were time constraints, lack of resources such as medications and transport facilities, need for specialist care, and non-adherence to the advice. Driving force and restraining force for palliative care were derived and plotted on the force field analysis. The favourable factors in providing palliative care services of the healthcare providers are self-satisfaction with treating the patient, satisfaction due to treatment at the doorstep, understanding the patient's psychological or social factors affecting their health, skill development and counselling of the patient. The restraining factors in providing palliative care services of the healthcare providers are time constraints, lack of resources, patient not following the advice properly, improper care by caregivers and unable to fulfill certain needs of the patient. Pairwise scoring/ranking was done for MSWs by plotting the issues faced in palliative care visits in rows and columns. The difficulties were time constraints, lack of resources, lack of proper knowledge of staff and need for specialist care. The possible potential solutions derived from the Delphi technique were proper planning to reduce time constraints and intense counseling of patients on adherence to treatment.

Conclusion

It helped to identify the difficulties faced by healthcare providers and to plan for solutions in future palliative home care visits.

Enhancing Global Development of Palliative Care: Insights from Country Experts on ATLANTES Observatory's Role

Background: Despite a steady increase in palliative care (PC)-oriented research, authentic engagement of stakeholders with findings needs to be more used. Objective: This study aimed to explore how ATLANTES Observatory can effectively promote the global development of PC by engaging with stakeholders and addressing their specific needs and priorities. Design: An international e-survey among Observatory collaborators explored key audiences, best ways to reach them, and priority activities. Answers were evaluated according to respondents' roles (Academics, Policymakers, and clinicians) and toward impact on diverse key stakeholders. Correlation between respondents' roles with select products was studied. Results: One hundred fifty-five collaborators participated. The collaborators suggested addressing ATLANTES Global Observatory's activities to policymakers (5,6/7), professional associations (5,2/7), and health care practitioners (4,4/7). Preferred activity to reach all stakeholders is the use of websites and social networks, while particularly for policymakers, academics, and general practitioners, the conduction of atlases and articles stand out. Conclusions: Our study emphasizes prioritizing policymakers and all health care practitioners as key stakeholders in promoting PC and driving global development and integration into health care systems. By leveraging innovative web tools and social networks for dissemination, our aim is to extend the reach of our efforts beyond the PC community.

Burden of breast cancer and attributable risk factors in the North Africa and Middle East region, 1990-2019: a systematic analysis for the Global Burden of Disease Study 2019

Background

Breast cancer (BC) is the most common cancer in women globally. The North Africa and Middle East (NAME) region is coping hard with the burden of BC. We aimed to present the latest epidemiology of BC and its risk factors in this region.

Methods

We retrieved the data on BC burden and risk factors from the Global Burden of Disease Study 2019 to describe BC status in the 21 countries of the NAME region from 1990 to 2019. We explored BC incidence, prevalence, deaths, disability-adjusted life years (DALYs), and attributable burden to seven risk factors of female BC, namely, alcohol use, diet high in red meat, low physical activity, smoking, secondhand smoke, high body mass index, and high fasting plasma glucose. Decomposition analysis on BC incidence trend was done to find out the contributing factors to this cancer's growth.

Results

In 2019, there were 835,576 (95% uncertainty interval: 741,968 to 944,851) female and 10,938 (9,030 to 13,256) male prevalent cases of BC in the NAME region. This number leads to 35,405 (30,676 to 40,571) deaths among female patients and 809 (654 to 1,002) deaths in male patients this year. BC was responsible for 1,222,835 (1,053,073 to 1,411,009) DALYs among female patients in 2019, with a greater proportion (94.9%) of burden in years of life lost (YLLs). The major contributor to female BC incidence increase in the past three decades was found to be increase in age-specific incidence rates of BC (227.5%), compared to population growth (73.8%) and aging (81.8%). The behavioral risk factors were responsible for majority of attributable female BC burden (DALYs: 106,026 [66,614 to 144,247]). High fasting plasma glucose was found to be the risk factor with the largest effect (DALYs: 84,912 [17,377 to 192,838]) on female BC burden.

Conclusion

The increasing incidence and burden of BC in the NAME region is remarkable, especially when considering limited resources in the developing countries of this region. Proper policies like expanding screening programs and careful resource management are needed to effectively manage BC burden.

Towards the Provision of Palliative Care Services in the Intensive Coronary Care Units: Nurses' Knowledge, Training Needs, and Related-Barriers

Despite the notable benefits of palliative care (PC) for patients with chronic diseases, its delivery to people with cardiac problems, particularly in the Middle East region (EMR), remains a critical issue. There is a scarcity of research assessing nursing staff's needs and knowledge in providing PC to cardiac patients in the EMR. This study aimed to assess the level of knowledge and needs of PC among nurses towards the provision of PC in intensive coronary care units (ICCUs) in the Gaza Strip, Palestine. It also identified the barriers to the provision of PC services in ICCUs in the Gaza Strip. A hospital-based descriptive quantitative cross-sectional design was adopted to collect data from 85 nurses working in ICCUs at four main hospitals in the Gaza Strip. Knowledge about PC was collected using a developed questionnaire based on the Palliative Care Quiz Nursing Scale (PCQN) and Palliative Care Knowledge Test (PCKT). PC training needs and barriers were assessed using the PC Needs Assessment instrument. Approximately two-thirds of nurses did not receive any PC educational or training programs, which contributed to their lack of PC knowledge. Most nurses would like to enroll in PC training programs, such as family support and communications skills courses. Nurses reported that there was a high demand for PC guidelines and discharge planning for patients with chronic illnesses. Insufficient healthcare professionals' knowledge about PC and a staff shortage were the main barriers to integrating PC into the Gaza healthcare system. This study suggests incorporating PC into nursing curricula and in-service training, and it covers both basic and advanced PC principles. Intensive coronary care unit nurses need knowledge and training about PC, guidance, and support to provide appropriate care to patients with cardiovascular issues.

Death, dying and caring: exploring the student nurse experience of palliative and end-of-life education

BACKGROUND

Undergraduate education and training are fundamental in preparing student nurses for working in palliative and end-of-life care.

AIM

This article explores the experiences of student nurses in their palliative and end-of-life undergraduate nurse education.

METHODOLOGY

Sandelowski and Barroso's (2007) framework for undertaking a metasynthesis was used. Initial database searches returned 60 articles of interest. Re-reading the articles in the context of the research question identified 10 studies that met the inclusion criteria. Four key themes emerged.

FINDINGS

Student nurses voiced concerns regarding their feelings of unpreparedness, and lack of confidence and knowledge when dealing with the complexities of palliative and end-of-life care. Student nurses called for more training and education in palliative and end-of-life care.

CONCLUSION

Flexible nursing curricula responsive to the needs of student nurses and the changing landscape of healthcare provision, including care to ensure a good death experience, should be prioritised at undergraduate level.

A Countrywide Assessment of Omani Undergraduate Nursing Students' Palliative Care Knowledge and Attitudes Towards End-of-Life Care

Palliative care (PC) is a vital part of the responses needed to address the outcomes of cancer and other non-communicable diseases such as chronic pain, terminal illnesses, and end-of-life situations. Until today, there is a significant lack of access to PC in most developing countries, where the majority of the global population lives. Deficiencies in nurses' knowledge and attitudes exacerbate the lack of access to PC and end-of-life care (EOLC) in these countries. This study was conducted in Oman to assess undergraduate nursing students' (NS) PC knowledge and attitudes towards EOLC. A cross-sectional design was used to collect data from 276 NS in all undergraduate programs in Oman. The PC knowledge and attitude towards EOLC were measured using the PEACE-Q and FATCOD-B. The NS had a borderline level of PC knowledge but favorable attitudes towards EOLC. The NS were least knowledgeable about the philosophy of PC, delirium, side effects of opioids, cancer pain, and dyspnea. There were differences in PC knowledge and attitudes across programs. The findings highlight potential deficiencies and opportunities that can be utilized to augment future nursing human resources for PC and EOLC in Oman. We recommend a national interdisciplinary PC education and training consortium (NIPCET-C) to dialogue, develop, promote, monitor, and evaluate PC and EOLC education in Oman.

A Multi-country Comparative Study on Palliative Care Knowledge and Attitudes Toward End-of-Life Care Among Undergraduate Nursing Students

The global burden of human death after experiencing serious health-related suffering (SHRS) requiring palliative care (PC) and end-of-life care (EOLC) is increasing. The largest increase in SHRS, death situations, PC, and EOLC needs continues to be in developing countries with limited access to PC. It is critical that nursing human resources in countries with limited access to PC are well trained and have adequate knowledge, attitudes, and skills to provide PC and EOLC. This study aimed to compare the PC knowledge and attitudes toward EOLC of future nursing human resources in Oman, India, and the Philippines. A comparative, cross-sectional design and two standardized questionnaires (the PEACE-Q and FATCOD-B) were used to collect data from 547 undergraduate nursing students (NSs). Overall, the NSs had positive attitudes toward EOLC (102.5 ± 15.39), but moderate PC knowledge (20.99 ± 3.59). The NSs were least knowledgeable about dyspnea, cancer pain, delirium, and side effects of opioids. Most of the NSs reported that their program did not include specific content about PC (56.1%) and hospice care (54.1%). The differences between countries and the predictors of PC knowledge and attitude toward EOLC were identified. The findings reveal gaps that need to be addressed in order to enhance access to PC and EOLC through well-trained nursing human resources.

Palliative care in the Eastern Mediterranean: comparative analysis using specific indicators

Background

Monitoring the development of palliative care (PC) illustrates the capacity of health systems to respond to the needs of people experiencing serious health-related suffering.

Aim

To analyse comparatively the situation of PC in the countries of the Easter Mediterranean region using context-specific indicators.

Method

An online questionnaire with 15 context-specific PC indicators investigating service provision, use of medicines, policy, education, and vitality was designed. Authors Institution 1 nominated in-country experts to complete the survey. Data were analysed using a comparative description of indicators per domain and a multivariate analysis.

Results

In-country experts were identified in 17/22 countries. 12/17 contributed to the survey. In total, 117 specialized PC services were identified. Specialized services per population ranges from 0.09 per 100,000 inhabitants in Lebanon and Saudi Arabia, Qatar and Kuwait; to zero services in the Occupied Palestinian Territories. On average, opioid consumption was 2.40 mg/capita/year. National PC strategies were reported in nine countries. In six countries, PC is officially accredited either as a specialty or sub-specialty, and PC mandatory courses are implemented in 36% of medical schools and 46% of nursing schools. National PC associations were documented in six countries. A higher pattern of development was identified in Jordan, Kuwait, Saudi Arabia, Oman, Lebanon, Qatar.

Conclusions

Despite a higher development in the Arabian Peninsula, the region is characterised by a very low provision of specialized PC services and opioid consumption. Policy improvements represent an opportunity to improve access to PC.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-022-01047-7.

Assessment of the Educational and Health Care System-Related Issues From Physicians' and Nurses' Perspectives Before Developing a Palliative Care Program Within the Palestinian Health Care System: A Cross-sectional Study

A scarcity in research assessing the palliative care (PC) educational and health care system-related issues has been reported in the Middle East region; the region comprises a wide range of economically diverse countries. Discrepancies across countries have created difficulties in adopting other countries' experiences. This study aimed to assess PC knowledge, attitude, educational needs, and health care system-related issues from physicians' and nurses' perspectives before developing PC services within the Palestinian health care system. One hundred sixty-nine professionals participated in this cross-sectional survey. Data were collected by validated instruments. Professionals had insufficient knowledge about PC, but they had positive attitudes toward end-of-life care and care of the dying. Patients'/families' avoidance of talking about issues around dying and lack of training for staff related to PC were the most 2 significant barriers to providing PC. Educational level and previous training were found to be associated significantly with knowledge and attitudes toward PC. Study conclusions support the recommendation for integration of education about PC within the health curricula and in-service training and should cover the basic and advanced principles of PC and symptom management.

Psychosocial determinants of intention to seek palliative care among the public in lebanon: A cross-sectional study

Objectives: This study aimed to assess the psychosocial determinants of intention to seek palliative care for the client themselves, or intention to enroll a family member in palliative care among the public in Lebanon. Methods: A cross-sectional study was initiated in 2020 on a convenience sample of adults permanently living in the Greater Beirut (GB) area; people with no current or previous experience with palliative care either for themselves or for someone dear to them were included. Verbal consent was obtained before data collection, and participants received a questionnaire to be self-completed, statistical analysis was performed using SPSS statistics version 23.0. Results: A total of 875 participants with a mean age of 42 years were interviewed, of whom 24 participants (2.7%) had had a previous experience with PC, either personally or with someone very close to them. The best-fit multivariate predictive model for intention to use PC included older age, positive attitude, and higher perceived control on one's health. The multivariate model for intention to recommend use was significantly associated with a positive attitude, higher perceived control, and lower perceived barriers. Conclusions: Promotional activities should be conducted to provide the Lebanese public with accurate, detailed, and direct information about the benefits of PC, involving essentially physicians. Future research should explore the decision-making process in "real-time" situations, and within our specific psychosocial, cultural, and organizational context.

Barriers to Access to Palliative Care in Colombia: A Social Mapping Approach Involving Stakeholder Participation

This study aimed to identify barriers to access to palliative care through a social mapping approach. In Colombia, the barriers to access to palliative care denote an enormous geographic disparity of resources and health needs, making it necessary to conduct community-based participatory research using an approach such as social mapping. A qualitative research design was used. Stakeholders from health insurance companies, regulatory authorities, regional health secretariats, health care professionals, patient and caregiver organizations, scientific societies, and medical journalists from 7 Colombian regions participated. It involved 3 stages. Stage 1: Semi-structured, audio-recorded interviews were conducted with 36 stakeholders and were subsequently transcribed and analyzed. Stage 2: An electronic survey was conducted to obtain feedback on the first outline of the map and the categories that emerged from stage 1. Stage 3: The nominal group technique was used to analyze and validate the barriers to access to palliative care included in the final map. The COREQ checklist was used. Twenty-seven barriers to access to palliative care related to limited availability of medications, stakeholders' poor knowledge of regulations, limited formal education in palliative care, few patients' support networks, patient care fragmentation, few specialized programs of palliative care, and mistaken beliefs about palliative care were identified. Stakeholders' diverse perspectives and opinions were crucial to understanding the development of palliative care in Colombia and its challenges. Better knowledge about palliative care can open opportunities to overcome the barriers identified in this study, directly impacting access to palliative care.

Oncology palliative care: access barriers: bibliometric study

OBJECTIVE

To perform a bibliometric analysis of studies that evaluated the barriers to access to cancer palliative care (PC).

METHODS

This was a bibliometric review using MEDLINE; EMBASE; Web Of Science; LILACS and the Cochrane Library. A search was conducted with the terms Barriers, Palliative Care and Cancer. Articles whose objectives targeted barriers to access to PC were considered, regardless of the year of publication. The setting is articles published from 1987 to 2020.

RESULTS

A total of 6158 articles were identified, of which 217 were eligible for analysis. The USA and UK being the countries with the largest number of articles on the subject (n=101, n=18, respectively). After expert analysis, the barriers were grouped into nine categories.

CONCLUSIONS

Barriers related to symptom control were identified in 19% of the eligible articles, along with barriers related to health, which with 24% of occurrence in the articles, were the most frequently cited barriers. Countries which have implemented PC for some time were those with the greatest number of publications and in journals with the highest impact factors. Cross-sectional study design continues to be the most frequently used in publications.

National cancer control plans across the Eastern Mediterranean region: challenges and opportunities to scale-up

National cancer control planning is crucial for countries in the WHO Eastern Mediterranean region. This region is challenged with an increase in cancer incidence leading to substantial disease burden, premature deaths, and increasing health-care costs in most countries. Huge inequity in cancer control planning and implementation exists between and within the countries. Over half of the countries (12 [55%] of 22) have standalone comprehensive National Cancer Control Plans and six (27%) have non-communicable disease plans that include cancer. The implementation of cancer plans has common challenges related to weak governance structure, few coordination mechanisms within countries, and inadequate human and financial resources. In most countries, the plan is not costed. Yet, the majority of countries (20 [91%]) reported having fully or partially funded plans. Additionally, political instability and conflicts affecting over half of the countries in the Eastern Mediterranean region have enormously affected cancer planning and implementation, both among the affected countries and those that host large numbers of refugees. In this Policy Review, we used the WHO regional framework for action on cancer to systematically analyse the status of cancer control planning and implementation across the six domains of cancer control, from prevention to palliation. We highlight the gaps, and the opportunities for bridging these gaps, to achieve scale-up on implementation of cancer control programmes in the Eastern Mediterranean region.

Dignity of patients with palliative needs in the Middle East: an integrative review

Background

Patients with palliative needs experience high psychological and symptom distress that may lead to hopelessness and impaired sense of dignity. Maintaining patient dignity or the quality of being valued is a core aim in palliative care. The notion of dignity is often explained by functionality, symptom relief and autonomy in decision making. However, this understanding and its implications in Middle Eastern countries is not clear.

The aim of this review is to 1) explore the understanding of dignity and how dignity is preserved in adult patients with palliative care needs in the Middle East 2) critically assess the findings against the Dignity Model dominant in western literature.

Method

Using an integrative review we searched four databases EMBASE, Psych-Info, CINAHL, and PubMed. These databases retrieve a broad literature on palliative care and are often chosen in other palliative care reviews. To enhance the search strategy, three online journals were hand searched, reference lists of review papers scanned, and forward citations sought. No time limits were applied. The retrieved papers were assessed independently by two authors including quality assessment using the Hawker’s appraisal tool.

Results

Out of the 5113 studies retrieved, 294 full texts were assessed. Sixteen studies were included for synthesis of which fourteen were published in Iran. Seven themes were developed after data analysis: Maintaining Privacy and Secrecy; Gentle communication with a dialogue that preserves hope instead of blunt truth-telling; Abundance characterised by accessibility to medical supplies and financial stability; Family Support where relatives deliver major assistance in care; Physical Fitness; Reliable health care, and Social justice that endorses equal care to all.

Conclusion

The results are compatible with the existing evidence from the Dignity Model ascertaining that dignity is socially mediated and influenced by interactions and physical fitness. Nevertheless, the findings highlight that patient dignity is also shaped by the socio-political, cultural, and economic conditions of the country, where family support, gentle communication and accessible health care are essential elements.

Palliative and end-of-life care in Egypt: overview and recommendations for improvement

BACKGROUND

The literature on the situation of palliative and end-of-life care in the Arab and Islamic world, including Egypt, is limited and does not present a clear picture of the cultural context. This report aims to portray the palliative and end-of-life care situation in Egypt, focusing on the nursing viewpoint. First, we describe health- and illness-related cultural, religious, and ethical issues. Second, we present an overview of the healthcare and nursing system in Egypt. Third, we discuss the situation of palliative and end-of-life care, highlighting the shortcomings of existing literature. Finally, we delineate country-specific recommendations to improve the palliative and end-of-life care situation at the level of policy, education, and research. Countries with similar healthcare, cultural, legal, religious, economic, or ethical contexts may benefit from the recommendations made in this study.

Health Care Providers' Attitudes and Beliefs on Providing Palliative Care to Patients in Bahrain: Findings From a Qualitative Study

CONTEXT

Present studies suggested that cultural and religious factors, as well as law and policy, may have impeded the advancement of palliative care in the Middle East. Little is known about health care providers' perceptions of palliative care and the barriers to its development in the Gulf Cooperation Council.

OBJECTIVES

To understand health care professionals' attitudes and beliefs regarding palliative care and highlight current practice barriers in Bahrain.

METHODS

Semistructured interviews with 16 health care providers (physicians and nurses) were conducted. Thematic analysis was then performed after interviews were transcribed verbatim.

RESULTS

Health care professionals perceived palliative care as a service only delivered to patients at the end of life. Palliative care was only offered to patients who have been diagnosed with cancer and had exhausted all curative treatments. Do-not-resuscitate orders and code status discussions are not currently practiced. Palliative care decisions are usually decided by patients' families. Middle Eastern culture, health care law and policy, conservative interpretations of Islam, and a lack of professional expertise were identified as barriers.

CONCLUSION

This study unveiled the perceptions of palliative care among health care professionals in a Gulf Cooperation Council country. Six major barriers that hindered palliative care practice were identified. Future health care policy in the region needs to address these barriers within the current health care system while taking culture, religion, and social factors into consideration.

System transformation in palliative and end of life care: developing a model for excellence

PURPOSE

The purpose of this study is to report how the palliative and end of life care community in one region of England worked together to create a new model for integrated palliative and end of life care to respond to the challenges of changing demography, the need to reduce unnecessary hospital admissions of people nearing the end of life and to improve the quality of provision in line with current policy.

DESIGN/METHODOLOGY/APPROACH

A co-production approach to system transformation was adopted involving 73 members of the palliative and end of life care community in one region of England.

FINDINGS

A new model for the delivery of integrated palliative and end of life care services was produced. The breadth of membership of the co-production working party and constructive/collaborative working helped ensure a viable model was produced.

PRACTICAL IMPLICATIONS

Although systems' thinking perspectives can help address the challenges of large-scale transformation because they focus on promoting the value of relationships, recognise the nuances of context and the need to understand system behaviour over time, the potential for systems to benefit from this approach is limited by the complexity of the processes involved and the sheer number of issues to be addressed in practical terms by policy makers and change leaders.

ORIGINALITY/VALUE

The paper explores the contribution that theories of large-scale transformation can make to the design of palliative and end of life care services in health and social care.

Lessons Learned from Countries That Have Introduced Palliative Care Services into Their National Health System: A Narrative Review

OBJECTIVE

This review aims at gaining a broad overview of national approaches about Palliative care (PC) implementation into health care systems in countries that have PC identified within their national policies and strategies.

METHODS

Paper searching was conducted using both peer-reviewed databases and gray literature sources covering governmental reports with PC strategies from 2000 onward. Articles published in English that cited at least 1 category of the WHO's public health PC model were included. Qualitative content analysis was used for data analysis and synthesis of findings.

RESULTS

Thirteen reports met the inclusion criteria. Education and appropriate policies were the most frequent strategies covered by all countries included. Under education; information about training health care providers was needed for the effective introduction of a PC program. Reviewing standards of care required to deliver PC effectively, and financial support for PC service development were considered the central policies needed. Furthermore, partnerships and collaborations across the health systems as well as providing care based on patients' needs were required for the provision of a PC program.

CONCLUSION

It is of the essence to learn from countries demonstrating enhanced PC practices before the implementation of a new PC program in a given country. Such practices could be used as a guide and to address barriers that may hinder the development of PC at a national level. Best practices can be achieved by focusing on educational and policy-based strategies through identifying patients' needs, assessing general public awareness, health care providers' knowledge and training as well as incorporating stakeholders' perspectives.

What Is the Preparedness and Capacity of Palliative Care Services in Middle-Eastern and North African Countries to Respond to COVID-19? A Rapid Survey

CONTEXT

Evidence from prior public health emergencies demonstrates palliative care's importance to manage symptoms, make advance care plans, and improve end-of-life outcomes.

OBJECTIVE

To evaluate the preparedness and capacity of palliative care services in the Middle-East and North Africa region to respond to the COVID-19 pandemic.

METHODS

A cross-sectional online survey was undertaken, with items addressing the WHO International Health Regulations. Nonprobabilistic sampling was used, and descriptive analyses were conducted.

RESULTS

Responses from 43 services in 12 countries were analyzed. Half of respondents were doctors (53%), and services were predominantly hospital based (84%). All but one services had modified at least one procedure to respond to COVID-19. Do Not Resuscitate policies were modified by a third (30%) and unavailable for a fifth (23%). While handwashing facilities at points of entry were available (98%), a third had concerns over accessing disinfectant products (37%), soap (35%), or running water (33%). The majority had capacity to use technology to provide remote care (86%) and contact lists of patients and staff (93%), though only two-fifths had relatives' details (37%). Respondents reported high staff anxiety about becoming infected themselves (median score 8 on 1-10 scale), but only half of services had a stress management procedure (53%). Three-fifths had plans to support triaging COVID-19 patients (60%) and protocols to share (58%).

CONCLUSION

Participating services have prepared to respond to COVID-19, but their capacity to respond may be limited by lack of staff support and resources. We propose recommendations to improve service preparedness and relieve unnecessary suffering.

Use of cancer data for cancer control in the Eastern Mediterranean Region: Results of a survey among population-based cancer registries

Data from population-based cancer registries (PBCR) are critical for planning, monitoring and evaluation of cancer control programs, but are frequently underutilized by key stakeholders. As part of the ongoing partnership of the International Agency for Research on Cancer (IARC) and the WHO Eastern Mediterranean Regional Office (EMRO) in cancer surveillance, we designed a cancer registry survey to assess the level of involvement of PBCR in national cancer control planning across the region. A questionnaire on registry characteristics, their contribution to cancer control and perceived barriers, was sent to 14 countries with operational PBCR. We obtained replies from Bahrain, Egypt, Iraq, Iran, Jordan, Kuwait, Lebanon, Morocco, Oman, Qatar, Saudi Arabia, Tunisia and the United Arab Emirates. We found a high participation of PBCR in cancer control planning (all registries involved, 46% routinely) and the evaluation of screening (92% registries involved, 46% routinely), but a much lower level of participation in palliative care and rehabilitation activities. Specified barriers included poor governance, a lack of awareness by policy makers, insufficient resources and a limited availability of data electronically, including mortality data. Appropriate planning to ensure the sustainability of PBCR (including the employment of permanent staff), increasing training, building research capacity and ensuring an efficient provision of high-quality data to policymakers, were among the proposed solutions. The results of our study reinforce the need for further tailoring of activities in support of cancer registration and enhanced networking among stakeholders, toward improving quality and use of cancer registry data for cancer control in the EMR.

Strategies used to establish palliative care in rural low- and middle-income countries: an integrative review

Globally, 40 million people need palliative care; about 69% are people over 60 years of age. The highest proportion (78%) of adults are from low- and middle-income countries (LMICs), where palliative care still developing and is primarily limited to urban areas. This integrative review describes strategies used by LMICs to establish palliative care in rural areas. A rigorous integrative review methodology was utilized using four electronic databases (Ovid MEDLINE, Ovid Emcare, Embase classic+Embase and CINAHL). The search terms were: ‘palliative care’, ‘hospice care’, ‘end of life care’, ‘home-based care’, ‘volunteer’, ‘rural’, ‘regional’, ‘remote’ and ‘developing countries’ identified by the United Nations (UN) as ‘Africa’, ‘Sub-Saharan Africa’, ‘low-income’ and ‘middle- income countries’. Thirty papers published in English from 1990 to 2019 were included. Papers were appraised for quality and extracted data subjected to analysis using a public health model (policy, drug availability, education and implementation) as a framework to describe strategies for establishing palliative care in rural areas. The methodological quality of the reviewed papers was low, with 7 of the 30 being simple programme descriptions. Despite the inclusion of palliative care in national health policy in some countries, implementation in the community was often reliant on advocacy and financial support from non-government organizations. Networking to coordinate care and medication availability near-patient homes were essential features of implementation. Training, role play, education and mentorship were strategies used to support health providers and volunteers. Home- and community-based palliative care services for rural LMICs communities may best be delivered using a networked service among health professionals, community volunteers, religious leaders and technology.

Challenges on the provision of palliative care for patients with cancer in low- and middle-income countries: a systematic review of reviews

BACKGROUND

Despite the significant benefits of palliative care (PC) services for cancer patients, multiple challenges hinder the provision of PC services for these patients. Low- and middle-income countries (LMICs) are witnessing a sharp growth in the burden of non-communicable diseases. There is a significant gap between demand and supply of PC in LMICs in current health services. This review aims to synthesise evidence from previous reviews and deliver a more comprehensive mapping of the existing literature about personal, system, policy, and organisational challenges and possible facilitators on the provision of PC services for cancer patients in LMICs.

METHODS

A systematic review of reviews was performed following PRISMA guidelines. PubMed, EMBASE, SCOPUS, PsycINFO, Web of Sciences, CINAHL, and Cochrane Library databases were searched to identify review papers published between 2000 and 2018 that considered challenges and possible facilitators to PC provision. A modified socioecological model was used as a framework for analysing and summarising findings.

RESULTS

Fourteen reviews were included. The reviews varied in terms of aim, settings, and detail of the challenges and possible facilitators. The main challenges of personal and health care systems included knowledge deficits and misunderstandings from patients, families, the general public, and health care providers about PC; and inadequate number of trained workforce. Besides, limited physical infrastructure, insufficient drugs for symptom relief and lack of a comprehensive national plan for implementing PC were the core organisational and policy level challenges that were recognised. Furthermore, the main possible facilitators that were identified included provision of adequate training for health care providers and health education for patients, families and the general public to enhance their knowledge, beliefs, and attitudes to PC. Finally, involvement of policymakers and making drugs available for symptom relief should also be in place to improve the health care systems.

CONCLUSIONS

Understanding challenges to the provision of PC for people with cancer could help in the development of a PC pathway in LMICs. This knowledge could be used as a guide to develop an intervention programme to improve PC. Political influence and support are also required to ensure the sustainability and the provision of high-quality PC.

Barriers to ideal palliative care in multiple care settings: the nurses' point of view

Background:

Nurses and certified nursing assistants (CNA) have a crucial role in 24/7 continuity of palliative care for many vulnerable patients and families, however, their perspective has been largely omitted in reported barriers to palliative care.

Aim:

To describe barriers to ideal palliative care that are specific to nurses and CNAs working in all care settings.

Methods:

A cross-sectional, online survey was distributed to members of the Dutch Nurses' Association.

Findings:

Almost 50% of the participating 2377 nurses and CNAs experienced more than five barriers to ideal palliative care in their work situation; nurses and CNAs employed in regional hospitals, mental healthcare and nursing home settings encountered more barriers than those working in other settings.

Conclusion:

The three most common barriers were: lack of proactive care planning, lack of internal consultation possibilities and lack of assessment of care recipients' preferences and needs for a seamless transition to another setting.

[The role of the family doctor in the palliative care of chronic and terminally ill patients]

The objective of this work was to identify the role of family physicians in the care of patients and their families in the approach to the end of life. Nowadays, with the increase in the demand for care of patients with terminal illnesses, there is also evidence on the lack of physicians with the profile and skills to fulfil this coverage deficit. A review of the literature was carried out in five databases from January 2015 to May 2018, and concluded that family doctors, based on their professional skills, ability to engage with the patients, their families, and their performance in the coordination of medical resources, are in an ideal position to attend and solve complex problems of patients at the end of life. In the present review, the specific roles of family physicians in clinical and psychosocial areas, and also the difficulties in facing the challenges in the care of patients and families undergoing the end of life process are described.

Preferred Place of Death for Patients With Incurable Cancer and Their Family Caregivers in Egypt

BACKGROUND:

Little is known about the place of death of patients with cancer in Eastern Mediterranean countries including Egypt, where palliative care is underdeveloped. Identifying the preferred place of death (PPoD) is important for the development of appropriate palliative care models in these countries.

OBJECTIVES:

To know the PPoD of Egyptian patients with incurable cancer and their family caregivers (FCGs) and to determine the factors that may impact their preferences.

METHODS:

An observational cross-sectional study that included 301 dyads of patients with incurable cancer and one of their FCGs. A questionnaire was designed to collect data about the characteristics of patients and FCGs as well as their preferences.

RESULTS:

The majority of dyads (272/301, 90.4%) answered the PPoD question. Home was the PPoD in 93% of patients and 90.1% of FCGs ( P = .218). The congruence between patients' and FCGs' PPoD was 92.7% (κ = 0.526). In multivariate analysis, poorer performance status (Eastern Cooperative Oncology Group 3 or 4) and full employment of FCGs associated significantly with patients' preference to die in hospital (odds ratio [OR] = 3.015 [95% confidence interval [CI]: 1.004-9.054], P = .049 and OR = 4.402 [95% CI: 1.561-12.417], P = .005, respectively), while poorer performance status and nonreferral to the palliative medicine unit were associated with FCGs' preference of hospital death (OR = 2.705 [95% CI: 1.105-6.626], P = .029 and OR = 2.537 [95% CI: 1.082-5.948], P = .032, respectively).

CONCLUSIONS:

The results of the current study suggest that home is the PPoD for the vast majority of Egyptian patients with incurable cancer and their FCGs. Palliative care interventions that promote home death of patients with incurable cancer are needed in Egypt.

Palliative Care: Opportunities for Nursing

Ayda G. Nambayan, PhD, RN is the Training Consultant for The Ruth Foundation for Palliative and Hospice Care. Prior to this, she held various positions as a Consultant for Advanced Education and Training at Makati Medical Center, Philippines; a curriculum and distance learning developer for www.Cure4Kids.org, the educational website of the International Outreach Program of St. Jude Children's Research Hospital in Memphis, TN. In 2002, she retired from a faculty position from the University of Alabama at Birmingham, where she taught Adult Health Nursing for 25 years. Her nursing degrees were from the University of Santo Tomas, Manila, Philippines, Teacher's College, Columbia University in New York, NY and The University of Alabama at Birmingham, Birmingham, AL. Among her many professional awards include the Oncology Nursing Society's Pearl Moore Making a Difference Award in Oncology Nursing, International Award for Contributions in Cancer Care and the End of Life Nursing Education Consortium award for Pediatric Education.