Palliative Medicine and Hospice Care – Open Journal

This review article critically examines the health status, healthcare policies, and specialized medical care for older adults in Japan and the United States, with a focus on the cultural underpinnings that shape these differences. The article synthesizes existing literature to provide insights into the challenges and potential solutions for providing care to aging populations in both countries.

The coronavirus disease-2019 (COVID-19) pandemic emphasized the role of palliative care as an essential service to patients and families affected by life-threatening illnesses. Challenges encountered included: patients were not able to access services due to lockdown or restricted movement, limited or no home-based care and visits, opioid analgesic supplies were depleted, high frequency of uncontrolled symptoms and psychosocial distress, limited patient-caregiver-clinician communication, reduced family interactions due to fear of infecting the already sick family members, few training opportunities for health care workers (HCW) and HCW distress and burn-out. To address these challenges, the following strategies were employed; utilization of digital technologies to match resources, innovation in provision of PC including adapting etiquette for patient care using digital technology, advocating policy changes, education, use of technology such as video calls among family members support for HCW.

Introduction
Palliative care as a medical subspecialty in the United Arab Emirates (UAE) is very much in its formative stage of development. There are a small number of healthcare facilities that provide a specialist palliative care service, the most recent of which is the Palliative and Supportive Care Service at Burjeel Medical City (BMC), a private hospital in Abu Dhabi.
Aim
This retrospective review of all the referrals to our palliative and supportive care service within the first 9-months of operation is a direct reflection of the challenges we currently face in the day-to-day delivery of palliative care in the UAE.
Result
Of a total of 360 referrals received during the study period, under 50% were for local, Emirati patients with international expatriates making up the rest. Most of the referrals received were for symptom control (including pain) and end-of-life care (EoLC), with 85% of the patients having a diagnosis of cancer. One third of the referrals received were for EoLC, with 90% of the patients who received EoLC on a hospital ward having a valid do not attempt resuscitation (DNAR) status in place. For the patients who received EoLC, all but one patient received EoLC in the hospital setting.
Conclusion
Our experiences are consistent with the challenges that other colleagues in the Middle East and North Africa (MENA) region face in providing palliative care. The majority of referrals to the palliative and supportive care service were for patients with a diagnosis of cancer with only 15% reflecting a non-cancer diagnosis. Of the 150 decedents cared for during this study period, more than 75% had a valid DNAR status in effect suggesting a growing awareness and acceptance of a less medicalized EoLC period.

Care of persons weighing over 500 lbs. poses additional challenges. For at least the past 20 years, training methods, resources, and equipment have been available to meet the demands of people weighing up to 500 pounds. However, this is not the case when exploring care options for the person weighing greater than 500 pounds. Hospital beds, magnetic resonance imaging (MRI) and computerized tomography (CT) scan beds, etc. are not usually designed to bear the weight of over 500 lbs. persons. According to Hale and others (2020), in 2017-2018 the age-adjusted prevalence of obesity in adults was 42.4%, and there were no significant differences between men and women among all adults or by age group. This case report illustrates the unique challenges and opportunities encountered by morbidly obese patients and healthcare professionals during end-of-life (EoL) care situations. It also categorically highlights the challenges, contextual discussions, and potential opportunities for healthcare delivery models to standardize and implement safe, effective, efficient, compassionate, person-centered, cost-effective care when serving bariatric persons.

The need for specialist palliative care services has never been higher as the ongoing coronavirus disease (COVID) pandemic has highlighted. Yet even in the absence of the pandemic, specialist palliative care services in hospitals, hospices and within communities were already stretched beyond their capacity. The current fiscal climate within which most healthcare systems operate are undergoing global economic constraints making it a necessity that healthcare systems explore new ways of working to develop efficient high-quality services, maximising resources whilst maintaining good clinical governance. We describe how a hospital palliative and end-of-life care (PEoLC) specialist team, can harness an existing electronic incident reporting system Datix, adapting it to
automatically track the longitudinal performance of the patient-centred, end-of-life care (EoLC) services that they deliver, along national standards in keeping with the Care Quality Commission (CQC) and the National Institute for Health and Excellence (NICE) guidelines for end-of-life care in the UK. Such automated systems can inform the quality of PEoLC services, improve the use of time and resource within specialist palliative care teams, support the delivery of evidence-based clinical governance
standards, whilst supporting benchmarking across organisations, strategy development, insight into local/regional variations, and the establishment of standardisations of care.

Regions in the Middle East are still experiencing political and military hostilities which negatively affect the health and health services of millions of people. Cancer is one of the major causes of high morbidity and mortality in the region. Palliative care for the cancer patient is one of the care options available for all those suffering from such a life-threatening disease. The Middle East Cancer Consortium (MECC) initiated a regional plan to implement palliative care approaches both in hospitals and the community. Moreover, the region lacks experienced professionals who could pave the way for establishing national palliative centers and guide primary care physicians and nurses to exercise this relatively new discipline in clinical practice. This report describes, in short, the endeavors, barriers and successes of this project, which are intended to bring medical professionals closer, thereby promoting understanding, respect and tolerance among individuals and communities in conflict.

Since the implementation of the first National Cancer Prevention and Control Plan (PNPCC1) in 2010, palliative care in Morocco has been a strategic approach in its own right, alongside the prevention, early detection and cancer management approaches. Since then, several measures have been put in place to facilitate the deployment of the actions representing this axis, i.e. the development of the palliative care network, pain management, palliative care research, as well as social and family support for palliative cancer patients.

Purpose
The objective of the survey is to evaluate the knowledge and opinion of Howard University College of Pharmacy first-year professional pharmacy students regarding the use of the sleep medication melatonin.
Methods
A survey questionnaire comprising 20 questions on melatonin was developed and response obtained from 42 students. Demographic data and responses were gathered and evaluated. Descriptive statistics were used to analyze the responses.
Results
Most of the respondents had adequate knowledge about melatonin ranging from 54.8 to 92.6%. There was no statistical difference when responses were analyzed based on the gender of the survey participants. To specific questions whether melatonin is
associated with weight gain, can help with signs and symptoms of cancer, recommend sleep hygiene instead of melatonin, and
whether melatonin is addictive, the majority (57.1%, 42.9%, 64.3% and 69.0%, respectively) provided the wrong responses.
Conclusion
More than half of the respondents had good levels of knowledge and opinion about melatonin, with the highest being 92.6% to
a specific question on the use of melatonin. The students were only deficient in areas of melatonin being associated with weight
gain, melatonin helping with signs and symptoms of cancer, recommending sleep hygiene, and melatonin causing addiction.
There are significant differences between the age groups and whether those who worth healthcare area, or not in their response
to some of the survey questions.

Skills in biomedical ethics are limited in the African health care systems. This significantly affects the bioethics discourse in the medical practice. The main reason for the paucity in knowledge and skills in bioethics is minimal or no training at all imparted to healthcare professionals. Where there is training, it is not well-structured like other courses in the training institutions. This report summarizes the status of bioethics training and outlines the implementation, processes, outcome and future outlook of a bioethics teaching project for masters in medicine residents (students) in a tertiary referral hospital in Africa. This project was part of postgraduate studies in biomedical ethics by a practicing physician. It entailed teaching bioethics to first year master’s in medicine residents (students). The teachings occurred in the author’s affiliated institution monthly for six-months. The topics covered were: general introduction to bioethics, ethical issues at end-of-life (EoL), informed consent, basics of research ethics, plagiarism and doctor-pharma interaction. These topics were selected due to their relevance to the residents in their practice and because they
needed to undertake research studies to graduate from the masters training program. In addition, these basic bioethics training provided the residents with the foundation to develop knowledge geared towards improving skills in analyzing diverse areas in the contemporary bioethics’ environment such as end-of-life care (EoLC), human research ethics, doctor-pharmaceutical relationships while looking at them within the context of political, cultural, socio-economic, and environmental determinants.

Background
Advance directives (ADs) describe individuals’ preferences for life-sustaining treatments and/or surrogate decision-makers, to
help avoid unwanted, burdensome treatments at the end-of-life. However, only 36.7% of adults have completed an AD. There is
growing interest in adopting a public health approach to end-of-life care, including ADs. We describe the experience of Honoring Choices Tennessee (HCT) which developed a pilot program, Advance Directives at Work in Tennessee (AD@WorkTN), to
enhance AD completion by the general public workforce.
Methods
The AD@WorkTN initiative targeted adults in the Tennessee workforce by engaging human resource (HR) leaders in educational
presentations. Each workshop provided resources to employers to integrate ADs into the employee orientation and benefits enrollment process. Educational materials, web tools, podcasts, AD forms, and a demonstration of how to complete an AD were
included. Participants were directed to the HCT website which contains the state advance directive documents and with detailed
instructions, as well as the co-branded MyDirectives app (MYD), to securely upload completed ADs. In April 2021 a HCT sponsored PBS documentary on advance care planning was produced with statewide distribution.
Results
Over a 2-year period, 58 workshops were conducted for 260 human resources leaders representing 958 businesses. As a result,
23 businesses have included ADs as part of the employee benefit process. Additionally, a 2-year multifaceted public outreach
campaign between 2019-21 has reached 2,950 employees and 958 businesses. Approximately 81,500 Tennessee viewers have seen
the Public Broadcasting Service (PBS) documentary on advance care planning. There have been 2,954 visits to the HCT website
and 411 visits to the co-branded MyDirectives site.
Conclusion
AD@WorkTN is a promising model to promote integration of ADs into the employee orientation and benefits enrollment
processes. Enhanced discussion and completion of ADs among employed individuals and enhanced public discourse such as
podcasts and television productions may encourage intergenerational conversations about end-of-life care and documentation in
healthcare records.

Introduction
Giving care to a patient at the end-of-life can be a challenging experience. The responsibilities of caregiving may include executing
complex physical and mental tasks, financial planning, patient care, decision-making, emotional support and coordination of care.
This mixed-methods observational study aims to identify the psychosocial and economic effects of caregiving for terminally-ill
patients by carers on the Hospice Africa Uganda Kampala program. It used both quantitative and qualitative data of caregivers
caring for terminally-ill patients attending Hospice Africa Uganda Kampala. Simple random sampling was conducted to select
caregivers who were invited to participate in the study.
Results
Results indicate that the majority of patients who were receiving palliative care (60.9%, 103) had been diagnosed with cancer. Most
participants (62%, n=105) had spent less than one year caring for their patients, while (18%, n=31) were cared for between 1-5
years. Our results show that the responsibility of caregiving has significant effects on the psychosocial well-being of caretakers.
In particular, it reduced the amount of time they spent attending social gatherings and caring for their children, their religious
commitment (p<0.05), as well as their level of fatigue and exhaustion (p<0.05), and negatively impacted job finding activities.
Conclusion
Terminal caregiving has significant effects on the psychosocial well-being and incomes of caretakers, and their ability to find a
job alongside caring for the patient. Based on these findings, it is therefore recommended that caregivers be given ongoing support to help them provide care to their own family members and patients with life limiting illnesses early in the disease trajectory.

The World Health Organization (WHO) defines palliative care
as: “an approach that improves the quality of life of patients and their
families facing the problem 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.” Thus, palliative care is associated with chronic, serious illnesses. However, coronavirus disease 2019 (COVID-19) is a novel disease presenting acutely with acute symptoms but requiring the level of care, even in an urgent manner that patients with chronic serious illnesses that are normally associated with palliative care require. Palliative care clinicians are uniquely equipped
to address the suffering of COVID-19, especially where the health
system is significantly strained. This is accomplished through
high-level communication and symptom management skills and
a transdisciplinary approach to address physical, emotional, and
existential suffering.  It is within the ability and the ethical duty of
palliative care to relieve suffering, physical pain and other symptoms.

Advance care planning (ACP) which includes a discussion of
goals of care and preferences about future care improves
patient-centered care at the end-of-life. However, completion of
ACP remains low with an estimated 36.7% of adults having completed an advance directive in the United States1
and this number
is lower in many other societies worldwide. Social stigma, personal
difficulty accepting the finality of life, and agism all contribute to
avoidance of discussions of end-of-life care. The topic of ACP
is an intensely personal one, and optimally a longitudinal communication-based conversation between individuals, families, and
trusted healthcare professionals. In the absence of ACP urgent discussions necessitated by medical crises, while necessary, are often
traumatic and may limit involvement of the affected individual and
place increased burden on the surrogate decision maker.

Arterial embolization is used as one of the palliative procedure in the control of bleeding. We have demonstrated this procedure
to be effective in the control of the bleeding in various malignancies in our center. This is our first case report in a teenaged
nasopharyngeal cancer patient who had exhausted all his treatment as he had progressive disease and recurrent bleeding episodes
from the recurrent neck nodal mass. This was controlled well with arterial embolization with no significant side effects.

Reflexology is a non-invasive, complementary therapy that is
based on the theory that, by applying controlled pressure to
certain reflex zones in the palm and foot, channels along the nervous system are stimulated, thereby facilitating energy pathways
that may be blocked or congested.

Background
Cachexia is a syndrome which is a common feature in more than 80% of patients with advanced cancer and globally accounts for
over two million deaths per annum. At present there are no standard treatment guidelines for cancer cachexia management. Previous research conducted with the United Kingdom and Australia has highlighted different understanding and treatment practices
of health care professionals in cachexia management, however, no study has elucidated the understanding and current practices
of health care professionals in the United States.
Aim
The aim of this research was to explore the understanding and current practices of health care professionals in the United States
when providing care to an individual with advanced cancer who has cachexia.
Methods
This is a qualitative study underpinned by symbolic interactionism. Face-to-face semi-structured interviews were conducted (n=17)
with multi-disciplinary oncology staff and thematically analysed. Health care professionals were recruited from one large health
care facility in the United States, until data saturation was reached. NVivo was used for data management. Criteria for upholding
rigor (credibility, dependability, confirmability, transferability) were adhered to within this qualitative study. Full ethical approval
was obtained prior to data collection commencing.
Results
Analysis determined four main themes related to (1) recognizingthe signs and symptoms of cachexia; (2) the multidimensional
impact of cachexia on both patients and families; (3) complexities when treating cachexia; and (4) future direction of care delivery
for patients with advanced cancer who have cachexia.
Conclusion
Participants within this study recognized the multi-factorial pathophysiology of cachexia and its holistic impact which spanned
biological, psychological and social domains. Additionally, they recognized the impact of cachexia on not only patients but also
their family carers. In particular the feelings of helplessness family carers experience in trying to stop the progressive and involuntary weight loss associated with cachexia. Further research is required to examine how to best support the needs of patients with
advanced cancer who have cachexia and their family carers and equip staff to optimize delivery of this.

Background
Music therapy (MT) is part of the care plan in many end-of-life (EOL) settings, though several authors remain cautious about its
effectiveness to improve EOL symptoms and patient well-being.
Objective
Our primary goal was to design and test the feasibility of a clinical trial protocol that would address the main critiques of MT trials
previously reported in the literature.
Methods
We conducted a literature review guided by the questions: (1) What is the set of indicators and tools that can be used to measure
effectiveness of MT for seniors in palliative care and EOL settings? (2) What are the characteristics of a well-designed clinical trial
protocol that can measure effectiveness of MT in palliative care and EOL settings and can be used for a future large scale study?
Based on best practices from the review, we developed a clinical trial protocol and tested its feasibility.
Results
Ten participants were accrued. Approximately 25% of eligible participants chose to participate. The consent rate was 55% with
70% of participants completing all MT sessions. All participants completed more than 60% of questionnaires.
Conclusion
Although our protocol could not be considered feasible based on the parameters we originally set, we argue that our study provides
enough data to make adjustments to our original trial protocol, which could lead to the collection of reliable evidence related to the
effectiveness of MT for seniors at EOL. We recommend future studies to use block randomization and allocation concealment,
focus on one primary outcome and conduct intention-to-treat analysis.

Context
The Centers for medicare and medicaid services (CMS) and the Veterans Administration quality improvement objectives encourage completion of advance directives and palliative care consultation to enhance patient-centered care and to promote patient
autonomy. The prevalence of advance care planning documents in the electronic health record (EHR) and outpatient palliative
care consultation is low and strategies to improve outpatient advance care planning are needed.The aim of this feasibility project
was to risk stratify the older Tennessee Valley Healthcare System (TVHS) population, utilizing operations data, to target primary
palliative care consultation and completion of advance care planning documents.
Methods
We compared immediate outpatient palliative care consultation outcomes in two populations: Group 1: high-risk patients identified using a clinical risk calculator, the clinical assessment of need (CAN) compared to Group 2: consecutive patients presenting
to a geriatric clinic.
Results
The patient population identified systematically by high-risk CAN score for advance care planning (Group 1), N=52, increased
palliative care consultation prevalence to 35%. The prevalence of advance care planning documents in the EHR remained 30% for
this population. High-risk patients were more often referred for community-based services (29% versus 12%) and received more
hospice referrals (8% versus 4%) compared to a sample of consecutive patients presenting to a geriatric clinic (Group 2), N=26.
Conclusion
A systematic approach to identifying high-risk patients appears to target a population with more needs compared to a sample
of consecutive elderly outpatients presenting in the outpatient department. A clinically derived risk calculator can help identify
high-risk patients appropriate for focused care services, such as geriatric specialty care, home and community based services, and
advance care planning

As palliative care services across the globe struggle with creating a model of service that is financially viable and not dependent on
donation-based funds Sabar Health has created a national based hospice and home care unit that serves all sectors of the populations in all geographic areas of Israel. This model is financially stable and replicable in other parts of the world. The business,
service and medical model created by Sabar Health can serve as a blueprint for palliative care services worldwide. This article will
review the process of creating Sabar Health and discuss how each of the challenges was overcome.

Much like the US population in general, the prison population
is aging rapidly raising concerns about health care, end-oflife planning, and dying in prison. The impact of aging is amplified
within the prison system. Typically, the health status of inmates
in their 50’s is physiologically similar to community-dwelling individuals in their 70’s, making 55 old by prison standards.1 The 55+
age group is the fastest growing segment of the prison population2 increasing by 18.1% between 2000 and 2010 compared to a
17% increase in the overall prison population.3
It is estimated that
within the next ten years one in 5, or 20%, of inmates will be old.

The challenges of hospice care can scarcely be overstated, considering that the complexity of
managing the physical, psychosocial and spiritual issues of the patient and of the family may
seem daunting. The task becomes even greater when accommodating differences in culture and
religious beliefs. This study focuses on a case of bridging cultural gaps by a 26-year-old medical
student and his modern Orthodox Jewish family in Israel. The patient was diagnosed with
aggressive squamous cell carcinoma of the tongue two months before. The authors joined the
family as part of his palliative care team in January and accompanied them for 7 months until
his death in July. The case was not only medically and psychosocially complex, but religion
was an added factor which needed to be carefully managed. The family identified as religiously
observant Jews, while the hospice team, although Jewish and familiar with the traditions, identified
themselves as secular. The palliative care team worked with the patient and family to provide
a course of treatment that was acceptable for both parties. The team worked to alleviate the
patient’s suffering and ultimately enabled the patient to have the death of his choice, at home
with his family. Identifying as a member of an ethnic group, or as practicing a religion, does not
necessarily entail maintaining beliefs that may be associated with ethnicity or religion.1 As a
team, we needed to be sensitive to cultural nuances and family dynamics so that the family felt
comfortable to share their struggles of faith with us during their son’s/brother’s illness.

Palliative care has been well defined by the World Health Organization (WHO) as a
comprehensive care approach which “improves the quality of life (QoL) 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.”1 In 2000, the American
Academy of Pediatrics (AAP) emphasized the importance of offering an integrated model of
palliative care that continues throughout the course of the illness.

Pain is a significant symptom in patients with chronic and life-threatening illness. While pain is traditionally thought of as a physiological experience, total pain recognizes the interplay of psychological, cognitive, social, spiritual, and cultural factors that influence the pain perception and total experience. Comprehensive pain assessment and management are foundational goals within the scope of palliative care, and optimal management depends on addressing each domain of the total pain experience. An overview of the total pain experience is provided, and clinicians should consider psychological, cognitive, social, spiritual, and cultural aspects in assessing pain. Pain management also addresses all domains, and suggestions are provided which address pain management barriers and challenges. First, patients should be educated about the benefits of pain management and importance to adhere to the plan of care. Second, healthcare professionals need education in order to manage pain properly and should adhere to internationally recognized evidence-based guidelines to provide care. Third, barriers to overcome system issues need to be addressed, such as working with governments and Ministries of Health to increase opioid availability for those in need and to ensure that patients can have access to opioids whether in the hospital, home, city, or rural area. While pain is a complex phenomenon, a comprehensive management plan can alleviate suffering for patients and their families.

Background: Based on literature review, advanced stage cancer patients hold over-optimistic
perception of their prognosis. This phenomenon is presumed to be an implication of defense
and coping mechanisms, aiming to alienate the proximity of death. At such circumstances,
existential issues arise and when adaptive, serve as powerful psychological resources against
distress and despair. The first purpose of the study was to investigate the influence of advanced
stage Israeli cancer patients’ perception of prognosis on their existential well-being. The second
purpose of the study was to explore the role of ego-integrity as a mediator within the equation
of perception of prognosis and existential well-being.
Methods: Two hundred and ten Israeli stage 4 cancer patients completed self-report measures
of their perception of prognosis, ego-integrity and aspects of existential well-being: personal
meaning, inter-personal meaning, death and dying anxiety, satisfaction with life and will-tolive.
Results: Positive correlations were demonstrated between perception of prognosis with personal
meaning, interpersonal meaning, total meaning satisfaction with life, will-to-live and egointegrity.
In addition, negative correlations were demonstrated between perception of prognosis
with death-anxiety and dying-anxiety. Perception of prognosis was found to be a predictor of
existential well-being, so that the better the perception of prognosis the higher were satisfaction
with life (β=0.39, p<0.01), will-to-live (β=0.12, p<0.05), total meaning (β=0.22, p<0.01),
personal meaning (β=0.24, p<0.01), interpersonal meaning (β=0.13, p<0.05) and ego integrity
(β=0.24, p<0.01). Furthermore, the better the perception of prognosis the lower was death
anxiety (β =-.24, p<0.01). Moderating analyses revealed that only among patients low in egointegrity
a positive association existed between perception of prognosis and personal meaning
(β=0.30, p<0.05).
Conclusions: The study highlights the significant effect of the perception of prognosis on existential
well-being in advanced stage cancer patients. When death is imminent, an overestimation
of prognosis has a role of preserving existential well-being. Also, ego integrity was found
to be attributing for preserving existential well-being of people with terminal illnesses. In addition,
the moderating effect of ego-integrity emphasizes its virtue as a source of resilience for
the wholeness of the self at times of threat. A possible influence of cultural – ethnic attributes
on results is discussed, thereby emphasizing the complexity of the argument, whether acknowledging
one’s death has a positive or rather negative effect on one’s existential well-being.

According to the United Nations (UN) statistics, Pakistan is currently listed as a developing
country. Implementing palliative services has come across as a big challenge and possesses
various risks, not only because it is a developing country but also due to communal extremism.
Muslims being the predominant community, the country has been dealing with extremism
in the name of Islam . The citizens are constantly under the threat of extremists and religious
leaders who enforce them to follow stringent rules and restrictions, defying which can lead to
dangerous consequences.

Volunteering to teach abroad in a country where palliative care is not well-established, either as
a concept or service, is professionally stimulating and challenging. It provides an opportunity to
learn about other social and healthcare cultures and challenges one’s own views and attitudes.
Sharing knowledge and skills with others, is a two way experience that enriches one’s practice
and provides motivation for change. It is also an opportunity for reflection and re-focusing for
the busy professional and to be recommended. In this paper we seek to describe some of the
challenges you may face and ways around them. We look at subjects such as the need to know
and respect the culture we will travel to, explore ideas around truth-telling, concepts of honour
and shame and training in countries where there are limited resources and opioids. We shall
also comment on introducing new methods of teaching and making them relevant for different
subjects. This is drawn from over 20 years of experience by volunteer educators working under
the auspices of PRIME (Partnerships in International Medical Education), a UK charity.

The focus of this article was to highlight the influence of culture based on compiled notes
and observations, that resulted following various interactions with the Emirati and expatriate
care providers, in addition to the observed situations in a clinical setting, as patients and their
families try to steer their way through the complexities of making decisions related to the endof-
life. The emergence of a new policy like “Allow Natural Death”, may have brought a certain
degree of relief to the clinical practitioners, but to implement this policy, many measures should
be taken into account. Culture is one of the most important factors that influences communication,
the decision-making process, and perceptions regarding wellness and illness. As a result,
cultural factors must be considered while planning care and hospitality, especially in the treatment
of terminal diseases. The real challenge lies in understanding the unique structure of the
community and the work force in the healthcare sectors of United Arab Emirates (UAE). This
article presents culture as a unique example to run a fully functioning palliative care service
in UAE, where cultural diversity poses a challenge to the holistic approach we aim for when
dealing with patients as individuals.

Palliative Care (PC) is a relatively new discipline in Lebanon with some progress being made
in recent years. Based on our clinical experience, we describe and discuss the cultural aspects of
palliative care, the attitudes and the practice of physicians and nurses in PC, and the challenges
to implement it in our country. In our society, death is a taboo subject that is rarely discussed,
even with patients at the end-of-life. Under family pressure, physicians do not inform the patients
about their diagnosis or prognosis. With the extraordinary progress of medicine, more
deaths occur in institutions. These advances, in a context of repression of death, lead to overmedicalization
of the end-of-life and to the exclusion of the dying person. Several trends in
health care today decrease the chance of cancer patients to have access to palliative care. These
range from limited availability of palliative care services, to the philosophy of patient care that
dominates our health care system. Most patient care in our country is disease oriented. Care
is usually complex, and treatment involves many medical specialties with fragmentation and
limited coordination of patient care. One approach is to transform the current disease-focused
approach to a patient-centered philosophy. With the aging of our population and the increasing
number of cancer patients in Lebanon, the need for PC teams and programs will also increase.
The recognition of the specialty by the Ministry of Health and the adequate reimbursement
for PC services will encourage physicians in training to consider careers in PC. Education of
professionals in palliative care and clarification of the concept to the general public are also
essential steps to improve PC.

Palliative Care is Unique: It is a new specialty that helps patients and their families as fully
as possible when faced with a life-threatening illness. The population is aging which means
more people will need Palliative Care (PC) services in the future. Palliative care responds to
the population’s health needs and helps to build a bridge for better understanding amongst all
people. Palliative care involves the belief that no life is disposable or dispensable and that each
and every human being deserves to be heard and helped. The scope of palliative care is the
quintessential scope of the culture of peace.
Background: We have to respond to the needs of public health and provide services of optimal
care. To establish a palliative care system in Palestine, it is necessary to identify barriers to
provide palliative care service to the patients who are suffering with cancer or chronic illness
during treatment or at end-of-life.
Aim: The aim of this study is to identify barriers against providing palliative care in Palestine
from nursing perspective.
Methods: Family questions, staff and informal discussion, communication, attitude, psychosocial
and emotional needs have been noted as per author’s direct observation and experience. The
study was done at Pediatric Intensive Care Unit (PICU) at Makassed Hospital, East Jerusalem
between February 2014 to February 2017. The study is prospective and descriptive in design.
Results: The findings of this study are based on views and perceptions of patients as well as the
health professionals regarding the challenges of providing palliative care which include lack
of government strategies, lack of awareness among the professionals, insufficient training for
physicians and nurses, family concerns about cost and inadequate financial coverage from health
insurance. To establish structured palliative care services, we need to meet the challenges and
remove barriers by enhancing knowledge and awareness of healthcare professionals, educate
professionals and develop updated standards and treatment protocols.
Conclusion: In Palestine, there are no palliative care services or any other related services or
support towards patients and families, especially in case of life-threatening conditions in case
of emergency.

Clinical approach of palliative care is beneficial during an individual’s journey with illness, and
can be utilized through many care settings by all members of the health care team. Many complex
cultural issues can affect the patient and the families during the course of a life-threatening
illness. Palliative care services in all countries need to be delivered in a way that meets the
cultural and spiritual needs of its people.

Palliative care in Jordan is considered to be advanced in comparison to that of other Middle
East countries. According to Jordanian leaders of palliative care, Jordan is not different from
advanced countries in applying principles and approaches of palliative care. There are many
cultural challenges hinder provision of these services. First, fear of addiction by patients, family
and healthcare providers prevent them from providing adequate pain management. Second,
lack of adequate knowledge regarding pain management among healthcare providers is also
a great challenge. In addition, health policies and inadequacy of palliative services make the
problem worse. Third, fear of family and physician to refer patients to palliative care as it is
considered to be failure of treatment. Fourth, lack of family participation in most medical and
end-of-life decisions deprive patients from receiving proper palliative care. Finally, religious
misconceptions force patient to suffer pain to an intolerable level and prevent them from seeking
immediate medical help. To overcome these challenges, it is recommended to improve
palliative health policy at national level, include palliative care materials in health curriculum,
raise public awareness of palliative care, and provide more opportunities for palliative training
and research.

Culturally compatible palliative care presupposes understanding of that culture’s perspectives
of cancer and death. Iraq is a culturally diverse country with different perspectives towards
cancer and death. The concept of palliative care among Iraqi people and patients is primitive;
the majority of them have no idea what palliative care is about. As long as there is no national
palliative care program – most of the medical health care providers themselves are also not
familiar with palliative care – it is not more than a terminology they had read about during
under- and postgraduate course if this ever happened. The strength of the palliative care field in
this country lies in the area of culture, religion and psychosocial entities. Yet, negative impacts
also exist in the same culture. Health care in Iraq has witnessed remarkable regression in the
last three decades parallel with political and economic troubles, struggling to provide basic diagnostic
and therapeutic facilities. Hence, the idea of palliative care seems to be ‘’luxurious’’ in
these bad circumstances. Those in power and decision makers may think in this way: ‘’budget
from Ministry of Health or from NGOs is to be spent on buying essential medicine rather than
improving the quality of life (QoL) or decreasing the suffering of patients’’. Community awareness
is very important and even within the medical community palliative care terminology is
still embryonic and limited to part of the oncology medicine.

Palliative care is a human need, which is essential for patients with chronic disorders such as
cancer, and aims to prevent and relieve pain and improve the quality of life (QoL) of patients
and their families. Since culture is an important factor in predicting health behavior, it can be
effective in providing these services. Thus, this review study has been conducted to assess
the cultural aspects of palliative care in Iran. The findings were classified and provided based
on the definition of palliative care on three major topics including early diagnosis, during
treatment and disease period, and finally death and later. In the beginning of diagnosis, the
most important element of palliative care is informing the disease to the patient and family.
Disclosure of the disease in Iran is not culturally possible. The most important cultural barrier
is cancer stigma in Iran, which affects the related measures such as screening diagnosis. The
most important challenge in the treatment is pain management, which overshadowed factors
such as cultural beliefs. Despite the challenges in the diagnosis and treatment of patients, which
make the care difficult, the religious and spiritual context of Iranian people in the death and
bereavement, as well as the strong family connections, are considered as a strong point that is
helpful in the process of passing from the stage. According to the statement of the Union for
International Cancer Control in 2008 based on “a better attitude toward cancer by 2020 and
removing misconceptions about the disease”, the available cultural opportunities in the country
can be considered as areas in need of strengthening. The negative attitudes and beliefs can be
reformed by adopting strategies such as increasing the awareness of the community as the first
strategy in changing the culture.

End-of-life (EOL) care presents many challenges both for clinicians, as well as for patients and
their families. Moreover, the care of the dying patient must be considered within the context
of the psychological, physical, and social experiences of a person’s life. Foremost among
those who require EOL care are cancer patients at the EOL. Unfortunately, clinicians who
are responsible for the treatment of patients at the EOL commonly lack adequate training to
help guide EOL decisions and to deliver bad news to patients and families. They must also
face their own discomfort with discussions about death and deal with poor compensation for
the time spent discussing EOL care with patients and families. Given the unique process of
each person’s death, strategies are often inadequate to guide patients, their families, and the
clinicians who care for them through this complex and emotionally challenging process. It
would stand the clinician in good stead to be aware of these challenges and have an approach
towards dealing with such problems. In addition, organizations have a responsibility to ensure
that systems are in place to minimize its occurrence and ensure that staff are supported through
the process of resolving issues and conflicts that may arise.

As palliative care services across the globe struggle with creating a model of service that is financially viable and not dependent on
donation-based funds Sabar Health has created a national based hospice and home care unit that serves all sectors of the populations
in all geographic areas of Israel. This model is financially stable and replicable in other parts of the world. The business,
service and medical model created by Sabar Health can serve as a blueprint for palliative care services worldwide. This article will
review the process of creating Sabar Health and discuss how each of the challenges was overcome.

Much like the US population in general, the prison population
is aging rapidly raising concerns about health care, end-oflife
planning, and dying in prison. The impact of aging is amplified
within the prison system. Typically, the health status of inmates
in their 50’s is physiologically similar to community-dwelling individuals
in their 70’s, making 55 old by prison standards.1 The 55+
age group is the fastest growing segment of the prison population2
increasing by 18.1% between 2000 and 2010 compared to a
17% increase in the overall prison population.3 It is estimated that
within the next ten years one in 5, or 20%, of inmates will be old.

Most quality improvement in end-of-life care has been related to symptom management, goals
of care, cost-effectiveness, and adhering to patient preferences. The patient and family’s experience
of care, the environment of care, support for surrogate decision-makers, and public
engagement related to end-of-life care receive less attention. We describe three new quality
improvement models to improve the patient and family experience of care: 1) involvement
of the primary care providers (PCP’s) throughout the patient’s disease course, 2) modeling of
decision-making behavior for surrogates using narratives, and 3) increasing engagement with
end-of-life care among the public at large. We advocate for the continued development and
evaluation of new care models to improve the quality of end-of-life care and the widespread
sharing of best practices.

Introduction: Technological advances in public health have allowed the life expectancy of people
to increase. However, new challenges appear in populations that age as the greatest number
of chronic and oncological diseases requiring chronic and/or palliative care. In Peru, this is an
area that has not developed. The use of Information and Communication Technologies (ICT)
can optimize healthcare, and in the case of palliative care they could shorten the distances between
the specialist, the caregiver and the patient.
Objective: To know the needs of health professionals and caregivers of patients who are in palliative
care, regarding the management of information, knowledge, attitudes and the use of ICT
in palliative care.
Materials and Methods: As part of the TeleJampiq project, a first phase of qualitative study
is developed. A focus group was conducted with six caregivers. Family members’ information
was obtained through two field reports and two interviews. Finally, the exploration of the
needs and suggestions of palliative care specialists was carried out by ten in-depth interviews
(six physicians, one psychologist and three nurses). Through the data analysis we were able to
identify three major themes in which the results were classified: Management of information
on chronic diseases and terminal patients, knowledge and actions in palliative care and use of
ICT for palliative care.
Results: Management of information on chronic diseases and terminal patients. It is essential
to draw a distinction between terminability and palliation. Managing these concepts could
make a difference from the start of treatment. Knowledge and actions in palliative care. Nonfamily
caregivers’ knowledge of the meaning of palliative care is like that of specialists (doctors
and nurses). Use of ICT for palliative care. The use of mobile devices among health personnel
interviewed is overwhelming. Engaging in aspects of information management to other
specialists such as nutritionists and psychologists would be beneficial.
Conclusions: It is necessary to use ICT in the field of chronic and palliative care, being a fundamental
aspect the communication between personnel working in the system and the use of
scales, care protocols, among others.

Background: Guidance supporting care delivery in the last days of life has been implemented
across Wales for the past 16 years. Continuous central monitoring and recent developments for
care of the dying patient in England, provided the impetus to undertake a thorough overhaul of
the Welsh guidance.
Methods: Recommendations of the National Health Service (NHS) Leadership Alliance for
care of dying people, supported by outcomes of a Welsh electronic survey, resulted in prototype
guidance being drawn up. The new guidance was tested in a variety of care settings and agreement
reached it was fit for purpose.
Outcomes: This paper reports on the progress of reviewing the previous process-led guidance
to address the current focus on providing individualised care for the patient and those important
to them at the end-of-life. The new guidance resulting from this process is discussed, quality
monitoring systems are described and the national progress with implementation across Wales
reported.