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Received date: June 07, 2016; Accepted date: June 08, 2016; Published date: June 10, 2016
Citation:Silbermann M, Kunirova G, Kaidarova D (2016) Promoting Palliative Care to Cancer Patients in the Republic of Kazakhstan. J Palliat Care Med 6: e137. doi:10.4172/2165-7386.1000e137
Copyright: © 2016 Silberman M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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In his recent book, Palliative Care: The 400-Year Quest for a Good Death ,  Harold Vanderpool traces the emergence of medical palliation to a proclamation by Sir Francis Bacon in 1605 challenging physicians to offer and continually improve palliative medical care and treatment for dying persons. Florence Nightingale also contributed significantly to the evolution of what we call palliative care today, although the period of 1895 to 1959 – a time of great advances in medicine – unfortunately led to less appropriate care for the dying, though it contributed to discussions about the ethics of treating the dying. The following period (1960-1981) is described as a time of momentous transition. The influence of Elisabeth Kübler-Ross and Cicely Saunders emerged, solidifying palliative care concepts in the US and UK, and thereafter worldwide.
In 2015 the WHO added palliative care to its family of factsheets for the first time . To date, however, palliative care is largely absent from the global health dialogue and consequently is not practiced in most of the developing world, even though cancer is a leading cause of morbidity and mortality worldwide. Furthermore, pain control is essential but largely unavailable in developing countries even in cases of severe injury. Only 20 countries (8.5%) have integrated palliative care adequately into theirhealth-care systems .
Kazakhstan, as most of the countries in the Greater Middle East region, still faces barriers to the effective integration of palliative care in cancer care, including gaps in education, training, and the understanding that seeking palliative care does not mean “giving up” . Following up on the integration process, the Palliative Care Association of Kazakhstan, along with the Almaty OncologyCenter, jointly organized an international palliative care workshop at the Royal Tulip Hotel in Almaty (May 11-13, 2016) together with the American Society of Clinical Oncology (ASCO) and the Middle East Cancer Consortium (MECC).
Significantly, the workshop started with a session devoted to communicating bad news, along with the communication of the prognosis and care goals, led by Professor Lidia Schapira, of Harvard Medical School and the Massachusetts General Hospital in Boston, MA, USA. Thereafter, Professor Lodovico Balducci, of the Moffitt Cancer Center in Tampa, FL, USA, focused on pain assessment and management. Professor Aminah Jatoi, of the Mayo Clinic, Rochester, MN, USA, discussed the main side effects evidenced in cancerpatients (fatigue, insomnia, anorexia/cachexia, GI symptoms and dyspnea).
One of the major oncology issues in Kazakhstan, as in many countries in the region, is late presentation, which, of necessity, determines that care is no longer a realistic option, but palliation is. The reasons for late presentation are associated with cultural and psycho-social aspects. Unfortunately, a stigma is still attached to cancer, as well as to mental disorders and psychological problems linked to cancer. This phenomenon of double taboos constitutes a genuine difficulty in trying to improve the quality of cancer care .
In Kazakhstan, as in most countries in the Greater Middle East region, breast cancer is the most widespread cancer in females (Table 1). Women diagnosed with breast cancerare very hesitant regarding whom they tell, if they tell at all, as breast cancer is believed, in some local societies, to be an inherited genetic disease. Therefore, patients suffer in silence and consequently endanger their lives . Advanced breast cancer is devastating to women and to those close to them in the family and the community.
|ASR||Total number of Cases||Percentage (%) of all female diagnoses||Median age at diagnosis|
Table 1: Epidemiological Data of Breast Cancer in Middle Eastern Countries.
With cancer treatment worldwide moving increasingly into the outpatient setting and primary health care centers in the community, family members and family physicians are encouraged to take on greater responsibilities for patient care generally, and palliative care particularly. In this respect, the workshop panel, and specifically Prof. Schapira, stressed the importance of training communication skills in oncologists, family physicians and pediatricians.
Training oncology clinicians to communicate with patients and their relatives has a strong positive impact on their patients. The training should cover topics such as how to convey bad news, how to discuss the prognosis along the entire length of the illness, and how to inform about possible anti-cancer treatments. Table 2 outlines some of the barriers that thehealth system faces in promoting awareness and initial screening tests among breast cancer patients in Kazakhstan and its neighbouring countries in the region.
|Socio-demographic factors: age, education, marital status, residence in urban vs. rural areas|
|Fear of losing the traditional role of the woman as a result of cancer diagnosis|
|Embarrassment regarding breast cancer screening activities|
|Low priority of self-health care among women|
|Low perceived effectiveness of breast cancer screening|
Table 2: Barriers to Breast Cancer Screening in Middle Eastern countries: Inadequate Knowledge of Breast Cancer and Screening Activities.
The second day of the workshop, focusing on cancer pain management, was led by Prof. Lodovico Balducci of the Moffitt Cancer Center at Tampa, Florida. In Kazakhstan, as in many developing countries, healthcare personnel are reluctant to prescribe opioids to patients because of cultural, traditional and social reasons.
Table 3 exhibits the considerable difference in opioid consumption in Kazakhstan in comparison to most of the countries in the region and worldwide. Many reasons account for the lack of treatment with opioids.
Therefore, there is an urgent need for greater awareness among policymakers, healthcare professionals and the general public to dispel the fear that opioid analgesics will harm patients and society by causing dependence, and instead, increasing Kazakhstan’s quota for opioids in the International Narcotics Control Board (INCB) [7,8].
|Country||Total morphine equivalence (milligrams per capita)|
|Sultanate of Oman||3.908|
|United Arab Emirates||3.419|
|EMROa region (mean)||10.562|
Table 3: 2011 Opioid Consumption in Kazakhstan and Eastern Mediterranean Region Countries Compared to Global and United States Use.
To further elucidate the current situation as related to the availability and accessibility of opioids for the management of cancer pain, the European Society for Medical Oncology (ESMO) partnered with the European Association for Palliative Care (EAPC) in launching a global survey: The Global Opioid Policy Initiative (GOPI) project. The Middle East Cancer Consortium (MECC) joined the project as a collaborating partner organization. By and large, the Middle East still has very low medical opioid consumption .
The third and last day was devoted to the nature and management of the most common features experienced by cancer patients at the end of life, led by Prof. Aminah Jatoi, Department of Oncology, Mayo Clinic, Rochester, MN, USA. For patients nearing death, relieving distressing symptoms is perhaps the most valuable contribution one can make. Pain may predominate for cancer patients. Other common end-of-life (EOL) symptoms include agitation and delirium, anxiety, fatigue, weakness, constipation, nausea, and vomiting. Early intervention with palliative care can lead to a better quality of life, improved sleep, less fatigue, and decreased pain, which in turn enhance the patient’s sense of well-being .
When a patient nears death, the goal of care changes from cure to comfort. Managing EOL symptoms can be highly complex, as many patients have multiple comorbidities. In many EOL patients, symptoms occur together in a cluster, posing a greater management challenge. Fatigue is the most common symptom that occurs in clusters. Other symptoms that can cluster together include insomnia, pain, dyspnea, nausea, weakness, vomiting, appetite changes, and altered taste. Delirium affects cognition, attention, the sleep-wake cycle, mood and speech. Common causes of delirium are opioids, dehydration, infections, hypoxia, nutritional deficiencies, renal failure, brain metastases and endocrine abnormalities. Haloperidol is the most effective medication for treating agitation . Dyspnea is a common EOL symptom. In cancer patients with pleural effusions, dyspnea may occur as fluid amasses in the pleural cavity. The most chronic symptom associated with cancer is weakness and fatigue. Approximately 99% of cancer patients experience fatigue. Constipation can be one of the most distressing symptoms to manage and is a miserable condition for patients who can’t have regular bowel movements. If a patient is able to take oral laxatives and stool softeners, they should be provided on a regular basis. Nausea and vomiting may result from treatment such as chemotherapy. Antiemetics can control these symptoms, and may need to be given around the clock.
Most patients and their relatives don’t understand the meaning of palliative sedation. The goal of this approach is to relieve suffering, not hasten death. Medications that can be used for palliative sedation include I.V. or subcutaneous midazolam and barbiturates, alone or in combination. The Mayo Clinic also endorses the use of propofol and ketamine .
The highest proportion (78%) of adults in need of palliative care at the end of life live in low and middle-income countries, but the highest rates are found in the higher-income groups. The great majority of adults in need of palliative care die from cardiovascular diseases (38.5%) and cancer (34%), and the proportion of adults in need of palliative care for cancer is relatively important for all regions globally . The highest rates for children in need of palliative care for cancer are found in the Eastern Mediterranean, Africa, Southeast Asia and Western Pacific regions. Further, it is estimated that the total number of patients requiring palliative care at some point during life will probably double or triple if we consider the average number of caregivers involved per patient in end-of-life care, and if we include the large numbers of those needing palliative care prior to the end of life .
Working in partnership with other international organizations invested in raising the profile and awareness of palliative care may serve as an effective strategy to educate and train the public as well as health care organizations, thereby improving access to essential palliative care services. For example, the American Society of Clinical Oncology (ASCO) is collaborating with the Middle East Cancer Consortium (MECC) in an initiative to support the delivery of highquality palliative care in the Greater Middle East Region (Turkey, Sultanate of Oman, Kazakhstan), creating a joint learning collaboration. This partnership may also serve as a catalyst for finding funding methods/services or the development of research questions and projects to further advance the field .
In summary, the education and training in palliative care principles and practices that took place in Kazakhstan is an important unmet need, along with appropriate provision of pain relief. While preventive and curative approaches in oncology will remain important to people in rich and poor countries alike, the provision of effective pain relief and humane care in the palliative care setting must become more consistent .
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