summary of the International Symposium
Global Palliative Care: Challenges and Future Expectations
Hybrid symposium held on 22 June 2022 in Madrid, at the Ramón Areces Foundation, organised by the Global Palliative Care Observatory ATLANTES and the World Health Organization. It was attended by 450 participants.
Panel of experts I
Panel of experts II
→ Raimundo Pérez (FRA): Thank you and welcome.
→ Marie Charlotte Bouësseau (WHO): Palliative care (PC) has to be part of primary care services and its development conceived as the construction of a house whose indispensable parts are access to medicines, the training of professionals, the research, health policies, the empowerment of individuals and communities and the provision of integrated PC at different levels of care.
→ Joaquim Julia (SECPAL): The provision of PCs is subject pending in most of the world. In Spain, status is far from excellence and is heterogeneous between communities.
→ Paloma Grau (University of Navarra): The presence of universities in this subject of debates and meetings is crucial, as well as the multidisciplinarity necessary to address issues from different perspectives.
→ Ednin Hamzah: presentation of the panellists and moderation of colloquium.
→ Emmanuel Luyirika: Palliative care in Africa and lower-middle income countries.
Africa, in addition to minimal and unequal access to PC medicines and services, has been directly affected by COVID: lack of resources in translating PC communications for patients and families, diminished capacity of scarce palliative teams (lack of protective materials staff and palliative protocols to share with staff non-specialists), closure of hospitals due to economic impact, and restrictions on access to services and medicines. Public misinformation - mediated by unverified health information via mobile phones - does a lot of damage. However, there are some opportunities: technological capacity (telemedicine), advocacy work by the African CP association , and redirection of financial funds. Improvements include better use of networks of hospitals, clinics, schools, government agencies and national associations, as well as integration into national health systems, partnership between disciplines and increased investment in health. Furthermore, there is a need for the integration of PCs in the curricula of health care providers and the development of good indicators for planning purposes.
→ Eduardo Bruera: How to overcome the challenge of introducing palliative care in the academic world.
It is in evidence-based medicine that we fail patients. We need different processes, Structures and outcomes to inform decision-making. Palliative diagnostic and therapeutic resources are the same as they were 25 years ago and are not being implemented. More resources are needed: teachers, clinicians, same treatment from the university as other disciplines. The great achievements in palliative action required programs of study and academic content, but we not only need to make programs of study, but to use them. PC units are needed to alleviate suffering, and when suffering subsides, support, money and family. If there are no financial resources or family, it is important that there are compassionate places where the patient can be cared for and not be isolated. In the next few years, surely every hospital that has an intensive care unit will have a PC unit because it is not moral not to have one, every outpatient system will have a supportive care system to be able to see these patients early, and every medical school will have a separate PC department . The most effective way to help these patients and families is to integrate primitive treatment with PC, thus saving unnecessary interventions.
→ Julie Ling: Palliative Care in Europe: Facing unexpected challenges.
One of the key points of the World Health Assembly resolution is the right of access to PC for everyone, which is why association European Association for Palliative Care (EAPC) works in particular with the most disadvantaged countries in Europe. COVID and the war in Ukraine have directly affected PC. In the pandemic, although many PC experts transferred their expertise in symptom management, end-of-life care was disrupted: contact staff was lost, care was limited, and much staff was diverted to other tasks. There was also a social psychological shock due to images of the deceased, restrictions on funerals and the treatment of bereavement. In the Ukrainian war, the EAPC disseminated financial aid messages from different parts of Ukraine and put its members on contact to respond to people with health needs. Many sick people fled the war (unable to receive their care), health systems functioned at reduced capacity, and this had an effect on neighbouring countries. Palliative care workers from neighbouring countries moved to the border to help migrants in need of PC, with their health systems taking on new needs. In numbers, an estimated 6.4 million displaced people needed urgent financial aid . As a PC community, we need to think about how to help in humanitarian crises, perhaps by training the people working in these places.
→ Pedro Pérez: presentation of the panellists and moderation of colloquium.
→ Matías Najún: Palliative care for people without resources, the experience of the Good Samaritan Hospice.
Poverty reduces access to PCs: 76% of people in need of PCs live in low- or middle-income countries. Fifty per cent of the population receives less than 1% of the morphine distributed and the richest 10% of countries have 90%. If access to PCs is limited, it is even more so for poor people. This status can lead to higher bed occupancy in hospitals, or in the emergency room, and less participation in decision making. There is the concept of amplified total pain: not only physical or psychological pain, but all pain caused by situations such as isolation, poverty, misunderstanding or violence. The complexity of life is greater than the complexity of illness. Some of the lessons learned from Good Samaritan Hospice have been that, in order to care for the vulnerable, you have to recognise them, go out and find them, gain their trust, empower them, and get involved. PCs are a vaccine that changes the experience of suffering and in most cases bring abundance in the midst of poverty. Caring for poor people requires a missionary and the performance of the many volunteers who take financial aid to the highest level.
→ Nassim Pourghazian: Promoting palliative care in the Eastern Mediterranean (EMRO) through a network of regional experts.
One of the main problems in the region is communicating the message of what PCs are. The 2014 World Health Assembly resolution is an opportunity for some of the countries where policies and services are not available, as it marks a pathway for governments to commit to the inclusion of PCs. They have an opportunity for inclusion in universal health coverage, as they are one of the six key areas within the framework created from the World Health Assembly resolution for cancer, and from there, PCs can be pushed indirectly, forcing governments not to ignore them. Countries in the Eastern Mediterranean region cover 1% of the need for PCs and the levels of availability of oral morphine for pain relief are very low. This is why the WHO is trying to promote the research on PC in the region by including it among the key components of the WHO's department of the Technical Office for Non-Communicable Diseases, or by creating a network of regional experts, which has facilitated important advocacy and vitalisation work in recent years. Their initiatives include scientific programs of study , events to disseminate the reality of PC in their respective countries, and the planning of a meeting of all ministers of health in the region.
→ Katherine Pettus: Supporting palliative care in international organisations.
International bodies seek the inclusion of PCs within global health to achieve a world 100% free of health-related suffering. The International Association for Hospice and Palliative Care (IAHPC), together with the UN, advocate that PCs are embedded within larger cross-cutting values: human rights, the common good and equity of access to services as a public service. They promote the availability of controlled medicines, integration into primary care and universal health coverage, and ensuring access to PCs for the elderly. The cornerstone as promoters of PCs at the UN is the 1966 Covenant on Economic, Social and Cultural Rights. PCs are a component of the right to health. The IAHPC collaborates in four bodies and secretariats: Global Public Health, Human Rights, Controlled Medicines and group open on ageing. Some of its fruits are the list of essential medicines for PCs, the report on primary care in the 2018 Astana declaration, the meetings on universal health coverage in 2019, or the rights of older adults in 2021. Key challenges include misinformation, the global and public health narrative, the US opioid epidemic, lack of funding for Education and advocacy, public sector disinvestment and growth of for-profit services, and popular movements for euthanasia. Public support for compassionate communities, public procurement of controlled generic medicines, integration of PCs into health plans, and funding are the way forward.