The Oman Specialized Nursing Institute, Sultanate of OmanOman
The Middle East Cancer Consortium, P.O. Box 7495, Haifa 31074, IsraelIsrael
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Cancer is considered to be one of the leading causes of death globally. With the increasing prevalence of cancer, the World Health Organization (WHO) expects cancer cases to surge in the next two decades from 14 million in 2012 to 22 million in 2022. Tremendous efforts are exerted world-wide to fight this “human disaster”.
Opinion The Fight against the “Human Disaster” of * *Corresponding author Cancer in the Middle Eastern Countries Michael Silbermann, PhD Executive Director The Middle East Cancer Consortium P.O. Box 7495, Haifa 31074, Israel 1 2* Manal Al-Zadjali and Michael Silbermann E-mail: cancer@mecc-research.com 1The Oman Specialized Nursing Institute, Sultanate of Oman Volume 1 : Issue 1 Article Ref. #: 1000PMHCOJ1102 2The Middle East Cancer Consortium, P.O. Box 7495, Haifa 31074, Israel Article History th Received: April 24th, 2014 Cancer is considered to be one of the leading causes of death globally. With the th Accepted: May 15th, 2014 increasing prevalence of cancer, the World Health Organization (WHO) expects cancer cases th Published: May 17th, 2014 to surge in the next two decades from 14 million in 2012 to 22 million in 2022.1 Tremendous efforts are exerted world-wide to fight this “human disaster”.
Citation An important example of such efforts is the International Palliative Care Conference Al-Zadjali M, Silbermann M. The sponsored by Turkey’s Health Ministry in Ankara during April 2-4, 2014, highlighting the Fight against the “Human Disas- th Turkey’s 13 National Cancer Awareness Week. Organizing bodies were the Middle East ter” of Cancer in the Middle East- ern Countries. Palliat Med Hosp Cancer Consortium (MECC), in collaboration with the Oncology Nursing Society (ONS), the Care Open J. 2014; 1(1): 4-7. National Cancer Institute (NCI), and the American Society of Clinical Oncology (ASCO).More doi: 10.17140/PMHCOJ-1-102 than 70 participants from the following countries attended the conference: United States of America, Egypt, Iran, Iraq, Israel, Jordan, Lebanon, Pakistan, Palestinian, Qatar, Kingdom of Saudi Arabia, Sudan, Sultanate of Oman, Turkey, United Arab Emirates and Yemen. PALLIATIVE CARE IN MIDDLE EASTERN COUNTRIES The population in the Middle Eastern countries, as in all other countries worldwide, is aging. Simultaneously, the risk of cancer and cancer prevalence is increasing, presenting a 2,3,4 major challenge to the healthcare system. Meeting this challenge requires the availability of planned and organized palliative care. Palliative care is a medical service that is delivered to people with life-threatening disorders, aimed at improving quality of life for patients and their families. Palliative care services are provided by a multidisciplinary team to patients at any stage of life and illness.5 It is a relatively new field in the Middle Eastern countries; however, it is available in one form or another in almost all of these countries either as an individually established service unit or as an integrated service.6 MIDDLE EASTERN CULTURE AND THE CHALLENGES FACED IN TREATING CANCER PATIENTS The conference started with a presentation discussing the diversity of the Middle Eastern culture that demands the provision of individualized, culturally relevant care to patients.2 For example, in the Middle East, the code status is discussed at a terminal, end of life stage, and is usually decided by others, rather than by the patient, despite the patient’s cognitive ability to make decisions.2 Moreover, the identity of a person in this culture is determined by his/her affiliation to a group-usually a tribal group - on whom he/she depends when trying to cope with illness.2 Patients seek treatment in the presence of their extended family, with the family viewing their presence in this situation as an obligation. Bad news is conveyed Copyright first to the family, especially to the oldest son to the son’s spouse, who are often the family ©2014 Silbermann M. This is an leaders. Females usually leave the decision- making to their husbands. Bad news is often open access article distributed un- delivered in stages. Families prefer not to reveal bad news to elder patients, and the truth is der the Creative Commons Attribu- often hidden, or a less serious diagnosis is given to the patient to protect him/her emotionally. tion 4.0 International License (CC BY 4.0), which permits unrestricted In order to accommodate these cultural norms when providing palliative care to Middle Eastern use, distribution, and reproduction patients, healthcare institutions must surmount a series of barriers ranging from palliative care in any medium, provided the origi- being focused at the tertiary care level, to the lack of trained personnel or resources; a lack nal work is properly cited.
of awareness of patients and professionals of geriatric specialty; and poor communication The issue of communication is a major one. It is Society of Clinical Oncology (ASCO),which works to improve a vital skill for healthcare professionals in caring for their quality of care delivered; enhanced research and innovation; and patients. Since the Middle East is made up of multilingual and health care professionals’ support and development. In doing so, multi-ethnic groups, people in diverse regions use language in ASCO provides an International Development and Education different ways, with the result that many patients view language Award (IDEA) in palliative care, pairing the recipient of the as a barrier to seeking healthcare in the health system. Health award with a mentor in palliative care who, after training, will literacy, and deeply rooted ideas about health and death, can be return to his/her home country to serve as an agent of change in major barriers in communicating with patients who have cancer.
integrating palliative care into local services. ASCO also runs For example, some people believe that illness is a test of their international workshops in palliative care and oncology for faith, or that it can reduce the burden of their sins.7 Such beliefs non-oncologists consisting of short, 2-5 day courses in various can hinder communication between the healthcare provider and aspects of palliative care and oncology. ASCO volunteers travel the patient. This generates a deeper problem in the delivery to different countries to deliver clinical instruction. These are of healthcare, namely the patients’ mistrust of the healthcare just a few examples of the many services provided by ASCO system, leading them to seek help from traditional healers and to enhance global services provided to low-to-middle income 6,8 the use of alternative medicine.6,8 Consequently, such patients countries that can be utilized in the fight against cancer.4 delay seeking help from medical personnel, with the result that 6 ASSESSING AGING CANCER PATIENTS cancer is diagnosed only at a late stage when the prognosis is poor, thus worsening the relationship of the patient and his One of the main areas of focus for preparing family with the healthcare provider due to lack of trust.
professionals in caring for the aging population is training them in the skills necessary to assess this population. Several PALLIATIVE CARE NEEDS ASSESSMENT IN MIDDLE EASTERN factors other than age can affect mortality and morbidity, namely COUNTRIES functional status, comorbid medical conditions, cognition, This year’s conference in Ankara was highlighted by nutritional status, psychological state, social support and the results of a survey of needs assessment carried out in Middle medications (poly-pharmacy). Consequently, a comprehensive Eastern countries. The survey aimed to assess awareness, activity, geriatric assessment can be highly productive in predicting and available resources related to palliative care in Middle mortality and morbidity as well as the toxicity of cancer patients. Eastern health care settings; understand barriers, challenges, This can result in better drug toxicity and survival prediction. It and satisfaction in organizing palliative care in the Middle East; can also detect any further undetected co-morbidities, leading and review topics of previous educational programs attended to better and more comprehensive care provision for these by respondents and their preferred learning methods. Some 16 older adults, and improved pain control and quality of life.
Middle Eastern countries took part in this survey, constituting a For instance, starting a comprehensive geriatric assessment, response rate of 78%. The results of the survey further validated or assessing the functional status of a patient, is considered a the points discussed during the conference. The most often valuable starting point in drawing up a care plan for the geriatric available palliative care services in the healthcare institutions in patient. A comprehensive geriatric assessment, however, can which the respondents worked were in descending order: pain predict a better match of treatment and fitness than clinical management consultative team or service; discharge planning for judgment alone.
patients with chronic illness; palliative care team or consultative One of the methods to assess the aging cancer patient service; ethics committee; palliative care unit; interdisciplinary is by using an exploratory model that assists in planning better care program for dying patients; nurses certified in hospice and care for these geriatric patients. The model should consider palliative nursing; professional education program in palliative involving a geriatrician, and age bias, or ageism, should be care; contractual relationship with one or more hospice programs; considered. A functional assessment should be performed at the program to promote advanced care planning; and program for start of the provision of palliative services. Additionally, when staff support in caring for dying patients. The least available 9 treating a patient, his/her life expectancy should be considered. service was the bereavement program.
The decision-making norms in the patient’s family and their Middle Eastern healthcare professionals are aware preferred communication style should also be assessed. Local of the lack of time, resources, and educational opportunities resources, community agencies and available support should be available. They are eager to learn more about palliative care and sought. Technology should be used wisely and creatively. An communication, with special attention to specific population interdisciplinary team should be on hand, involving community groups. They also recommend moving palliative care to home workers as well. Data should be collected and lessons should care.5 This motivation and readiness to provide improved be learned from mistakes. The pain threshold is high in the services is welcomed by several organizations that are ready older adult and their symp- -toms are often underreported. Pain to strengthen their international collaboration with the aim of management can face several barriers, including medical co- advancing palliative care services worldwide. An excellent morbidities, fear of causing delirium or presence of delirium, example of such an organization is the American and age bias. In addition, culture can play a major role in pain expression, although this has not yet been studied systematically.3 CHALLENGES AND OPPORTUNITIES IN ESTABLISHING suggested several plans that included raising the awareness of the PALLIATIVE CARE SERVICES IN MIDDLE EASTERN COUNTRIES public, the healthcare professionals and the health organizations.
They called for the creation of multidisciplinary teams that Palliative care faces many access and utilization can provide care based on the best available evidence. These barriers in Middle Eastern countries, ranging from lack of plans, however, were thought to be non-functional without the time, lack of funding and resources, and lack of governmental availability of proper funding and human resources. Notably, support, to problems related to political instability in some of human resources referred to health professionals as well as the countries. These challenges were also supported in a review 6 lay people in order to raise public awareness. One of the main earlier by Abu Zeinah, Al-Kindi and Hassan (2012). However, suggestions that were discussed in this conference, as at several with these challenges come many available opportunities which previous ones, was supporting the availability of treatment can be utilized to address the challenges faced by the palliative modalities-especially pain medication-in community settings, care. The healthcare professionals in Middle Eastern countries as well as moving palliative care from tertiary care settings to are well aware of the obstacles encountered regarding palliative primary healthcare settings, namely, community and home care.
care. Persistence and advocacy are the key components in establishing palliative care services. Several Middle Eastern In conclusion, while Middle Eastern culture is diverse countries have established successful non-governmental in its characteristics, including languages and religions, the aim agencies that provide palliative care. These efforts were exerted of the healthcare professionals is one and the same: to improve by individuals in these countries who were persistent in their the quality of life and the care delivered to all patients regardless demand for this service. An example of such an organization is of color, language, religion and origin. This can be accomplished AlSadeel, established in Palestine.12 if people, organizations and policies are put in place to strengthen the base of palliative care in Middle Eastern countries.
Several cultural barriers, as well as a lack of awareness, regarding palliative care services persist among healthcare