Palliative care: death with dignity

Dr. Wrishi Raphael
World Palliative Care Day was observed on 10th October 10, 2015 in Bangabandhu Sheikh Mujib Medical University. Palliation deals with looking after the physical, emotional and spiritual needs of people who are suffering from severely debilitating and incurable diseases. In 2014 World Health Organization (WHO) has passed a directive to all member states to incorporate palliative care into the national health infrastructure. Palliation services were started in Bangladesh in 2005 and a department in BSSMU became operational in 2011. The seminar to commemorate World Palliative Care Day was inaugurated by Vice Chancellor of BSMMU Prof Dr Ruhul Amin Miah. Among the several panelists who deliberated, was Prof Dr Nizamuddin Ahmed Head of Department Centre for Palliative Care, BSMMU.
The need for hospice care in Bangladesh is severe. The number of institutions capable of providing hospice care in Bangladesh is very few but the number of patients who are suffering from hopelessly incurable conditions like end stage cancer, is overwhelming to say the least.
The National Institute of Population Research and Training (NIPORT) in association with BSMMU Centre for Palliative Care recently published the dossier; ‘Assessment of Palliative Care in Bangladesh’ which speaks of the dire need for palliation around the country. Research shows that, at least 265,556 people in Bangladesh require palliative care at the end of life, but only 1070 patients receive palliation.
According to oncologists and referral hospitals, approximately 75% of cancer patients attending for treatment are incurable, and they get treatment in palliative settings. 30%-40% of these patients are in the last days of their lives, with a lot of them suffering, and their admissions refused by hospital as most of them are overloaded with patients of acute illness. The Society of Neurologists of Bangladesh stated that the incidence of stroke patients is 5-12 per 1,000 per year, and among them 35% become permanently disabled or dependent on care-givers. There is no hospital to support them on a regular basis.
Recently, the 2015 Quality of Death Index was released by the Economist Intelligence Unit (EIU). Bangladesh’s position is 79 out of 80. For a population of 160 million, there are just a handful of foreign–trained specialists in Dhaka. Our health infrastructure lags behind when it comes to basic needs. A large percentage of patients who need palliative care are cancer patients in extreme pain; some of them are in the terminal stage. Only 5-6 organizations are providing palliative care in Bangladesh. ASHIC Palliative Care Unit is the first such unit in Bangladesh for children.

A total of 30-40 in-patient beds are available for palliative patients, which are government and private resources combined, such as BSMMU, Ahmed Medical Centre, Delta Medical Centre, Bangladesh Medical College Hospital, etc. Only 4-5 doctors are fully devoted, trained from abroad, and give full-time service. Some oncologists and anaesthetists also offer palliative care services on the side. Recently, health personnel at Hospice Bangladesh have started offering home care services. They have already served 60 patients, and 45 of them are cancer patients. But Hospice Bangladesh is suffering from lack of manpower and other resources. It is the only centre in Bangladesh which provides 24-hour support for end-of-life care at homes for patients.
Bangladeshi researchers raised concern for inadequate medical use of opioids in Bangladesh 12 years back.
 The study reported that the barriers of opioid use in Bangladesh are; inadequate dose, interrupted drug supply, legal restrictions and the unavailability of immediate release morphine. Doctors across Bangladesh are apprehensive about the use of morphine for patient care.
The amount of analgesics required for pain management is inadequate and requires major reforms in terms of national legislation, number of manufacturing units around the country and dissemination of knowledge among health professionals about the administration of opioid analgesics.
Bangladesh is in the 160th position according to Morphine consumption. In 2013, Morphine consumption in Bangladesh was 0.05 mg/capita whereas the global consumption of morphine is 6mg/capita. These numbers reflect the miserable condition of pain management for the multitude of patients with end stage disease.
Teaching medical graduates about adequate pain management is just as important. Due to lack of current training many physicians choose the wrong opioid to treat cancer pain. In our country physicians often choose pethidine over morphine for cancer pain. Often doctors have very little choice to do otherwise due to the lack of availability of morphine. Because pethidine is a short acting opioid and capable of producing toxic metabolites; WHO has restricted the use of pethidine while simultaneously advocating the use of morphine for chronic pain relief.  
The evolution and growth of palliative care services and hospices should come from the combined effort of both the public and private sectors. Without community involvement, establishment of this sector will not be possible. The lack of adequate pain medication both in terms of manufacture and supply is one of the prime impediments of effective palliation in Bangladesh.  
The fact that should not be overlooked is that if specialists and facilities dealing in palliative care become more prevalent in the future, a big proportion of the total number of patients with incurable, progressive diseases will benefit from this care.
The writer can be reached at: w.t.raphael@gmail.com