Palliative Care in Saudi Arabia: An Updated Assessment Following the National Vision 2030 Reforms

Abstract

Background:

Palliative care (PC) plays a crucial role in improving the quality of life for terminally ill patients and their families. In Saudi Arabia, the Reform of Healthcare Vision 2030 has recognized the importance of PC and aimed to enhance its availability and quality.

Objectives:

This study evaluates the current state of PC in Saudi Arabia post-Vision 2030 reforms.

Design:

A cross-sectional survey-based research was conducted at a ministry of health health care facility to assess the accessibility and quality of PC services.

Setting/Subjects:

The survey collected quantitative and qualitative data from PC managers in Saudi Arabia. Retrospective analysis of annual death records determined the demand for PC.

Results:

The results indicate notable progress in developing PC services in Saudi Arabia, including increased number of PC units, community home care services, outpatient services, and consultations. However, challenges persist in terms of geographical distribution, resource allocation, and availability of pain medications, particularly opioids. The study highlights the substantial need for PC for both cancer and noncancer patients, emphasizing the importance of expanding these services.

Conclusions:

To further improve PC, policymakers and stakeholders should prioritize resource allocation, health care workforce, and access to pain medications. These efforts will address the growing demand for PC and benefit terminally ill patients and their families in Saudi Arabia.

Introduction

Palliative care and end-of-life care

Medicine and Health underwent drastic changes over the years. Nowadays, medicine shifted away from the idea of being limited to treating illness as its primary goal, and toward viewing patients as whole beings, especially in chronic and untreatable conditions. This shift in view allowed physicians and health staff to consider various dimensions besides patients' physical illnesses and paved the way for the arrival of palliative care (PC). PC is intended to improve the quality of life for terminally ill patients and their families.¹ This method addresses all facets of the patient's life, whether they be physical, psychological, or spiritual, and focuses on issues such as pain.

Saudi demographic shift and burden of disease

With an estimated 36.4 million citizens, the Kingdom of Saudi Arabia (KSA) is one of the most prominent nations in the Middle East. The quickly growing populace has raised the need for health care services. The demographic pattern in Saudi Arabia also underwent a significant shift, necessitating a change in the health care system. For instance, demographic shifts brought about by a rise in life expectancy and a decrease in fertility rate have changed illness trends, which called for new health services to address these shifts. The prevalence of cancer in Saudi Arabia is predicted to increase 5-fold to 10-fold by 2030. The middle aged and elderly are the age groups most impacted by cancer, so this outcome is anticipated by shifting demographics.

Need for PC

PC initiatives were not integrated into the Saudi Arabian health care system in the past, and it was not offered as a service.² The first hospice care center was created in 1992 by the King Faisal Specialist Hospital and Research Center in Saudi Arabia (KFSHRC), and it has since spread throughout the country.² PC programs were subsequently incorporated into the health care systems but were focused solely on the hospital system rather than being a nationally set system of care.³

As part of the Reform of Healthcare Vision 2030, the ministry of health (MOH) introduced the last phase initiative, which focused on improving the current situation of PC in the country. MOH saw this as a tremendous chance to advance the field on a national level. The development of the last step interventions took a very lengthy, careful, and effective process. This article makes an effort to summarize the latest updates in this transformational process.

PC strategy in Saudi Arabia

The KSA has been eager to develop strategies and plans for PC through the MOH to alleviate the physical and mental suffering of patients and enhance their quality of life through patient service and respect for the patient's life, with a number of a multidisciplinary team (MDT). National Palliative Care Strategy (National Strategy) is a commitment by the government to ensure that evidence-based quality PC is available to everyone who requires it.⁴ This National Palliative Care Strategy articulates a vision for PC in the KSA, where people with life-limiting illnesses receive the care they require to live well.

People who require PC may be at various stages of a disease's progression; they may be young or old, with varying cultural, social, emotional, relational, and spiritual needs; and they may require PC for a brief period of time, intermittently, or consistently over the course of months or years. Regardless of their circumstances, people with life-limiting illnesses, as well as their caregivers and families, may benefit from the diverse PC services available. The ultimate objective of PC is to assist individuals in living as well as possible for as long as possible.⁵

The KSA was excited to develop a strategy for promoting the inclusion of PC in all health benefits packages and manage PC coverage through national health systems or private health insurance, increase the quantity and variety of services, with particular emphasis on home care and outpatient programs, and optimize the multilateral geographic distribution of PC services.^3,6,7

The National Palliative Care Association, the MOH, and international experts created the PC strategy. The strategy suggests that PC service delivery can be conceptualized on geographically defined levels. These levels can provide fundamental, specialized, and developmental services (including education and research).⁵

The primary objective of this study is to comprehensively evaluate the current state of PC in Saudi Arabia. Given the significant transformations that have taken place in recent years, it becomes crucial to conduct this study to ascertain the prevailing situation accurately. Furthermore, the assessment of the need for PC in Saudi Arabia assumes paramount importance, as reliable data on this aspect are currently lacking. By conducting this study, we aim to gather extensive and reliable information regarding the status of PC services in Saudi Arabia.

The findings will shed light on the existing gaps, challenges, and opportunities in the provision of PC, considering the evolving health care landscape. This will facilitate the development and implementation of effective strategies and policies to enhance PC services and meet the growing demand in the country. This study will ultimately serve as a significant resource for health care professionals, policymakers, and stakeholders in Saudi Arabia, leading their efforts to improve PC and eventually improve the quality of life for patients with end-of life diseases and their families.

Materials and Methods

Population and assessment

A cross-sectional survey-based research was conducted by a MDT of medical and PC experts. The study aimed to capture the present state of PC at a Saudi MOH-run health care facility using a structured survey with English as its language. The survey tool was developed by conducting a comprehensive search of relevant studies on PubMed, focus groups, and expert opinions. The final draft was refined by 10 health care workers' (HCWs’) feedback, ensuring its reliability and validity. The online survey was sent to 22 PC managers through Google Forms, and 18 hospice care providers responded with an 82% response rate (Supplementary Appendix S1).

There were two parts to the survey. The availability of PC at their facility was the subject of the first segment. The number of hospice units, PC units, caretaker training programs, bereavement programs, interdisciplinary team members, hotline phone numbers, and opiate access were all questioned. The second part of the survey was made up of open-ended questions with the goal of identifying the advantages and disadvantages of the present patient care.

Estimating the need for PC

Estimating the demand for PC in this study involved considering the objective set forth by the Saudi MOH, which aims to monitor key health indicators and provide PC coverage in the final year of life through domiciliary care. To accomplish this, a retrospective approach was employed, utilizing annual death records as the primary data source.

The retrospective approach assumed that the number of individuals requiring PC during a given year would be representative of those who ultimately passed away within the same period. This assumption is based on the understanding that PC services predominantly focus on delivering end-of-life care. This aligns precisely with the objective of this study, making the retrospective approach appropriate and relevant.^8–11

The annual death records for the year 2021 were collected from the MOH death registry and analyzed to identify individuals who would have likely benefited from PC services in their final year of life. The demographic and clinical information of these individuals, such as age, gender, and underlying medical conditions, were also collected to provide a comprehensive understanding of the PC needs within the study population.

By employing this methodology, the study aims to generate valuable insights into the demand for PC services in accordance with the objectives set by the Saudi MOH. These findings will inform health care policies and contribute to the development of appropriate strategies to ensure the provision of high-quality PC for individuals in their final year of life.

Study setting

The research team distributed the survey links electronically through HCWs' online instant messaging applications over one week (July 22 to July 27, 2022) and used the Google Forms platform. The survey link was shared through online messaging platform WhatsApp, e-mail invitations, as well as through personal contacts of the research team. The survey covered almost all regions in Saudi Arabia including central, northern, southern, eastern, and western regions.

The selection criterion for participants in this study consisted of PC professionals who had a proactive eagerness to actively participate in the survey. The eligible participants were intentionally selected from a wide group of HCWs across the entire country. In addition, participants were informed about the possibility of extending the research project. They were asked whether they would be ready to provide updated information on the current status of PC. Participants with limited expertise or minimal engagement in the field of PC services were deliberately excluded from the study group.

Statistical analysis

For quantitative data, descriptive statistics were presented as numbers and percentages (%) for all qualitative variables, whereas mean and standard deviation were used to present all quantitative variables. Regarding qualitative data, participants' responses were identified using a thematic analysis approach.¹² Themes were generated to capture all participants' perspectives about the strengths and weaknesses of the current service being provided at their health care center.¹³ Themes produced were portrayed through quantitative data alongside the qualitative findings through descriptive statistics, that is, frequencies and percentages and graphical presentations.

Ethical consideration

The participants completed an informed consent form outlining the secrecy and privacy of their data and statements to adhere to ethical standards. In addition, the study was approved by the institutional review board (IRB 23-298) at King Fahad Medical City.

Results and Discussion

Current situation in Saudi Arabia

Five divisions make up the Saudi Arabian government's health care system: central, west, east, north, and south. This system is currently held by the health holding company, which is a new holding company appointed by the Saudi government to take over the country's public health care system. Every unit is further split into clusters, each of which contains a number of facilities.

In Saudi Arabia, hospice care treatments are distributed as follows (Fig. 1):

FIG. 1.

The distribution of the PC units supervised by the Saudi MOH. MOH, ministry of health; PC, palliative care.

22 PC units

8 Community palliative home care services

22 PC outpatient services

22 PC consultation services

4 PC hospice services.

The number of PC units in Saudi Arabia in 2014, including the private sector, was ∼15 and was limited to cancer institutions.³ In addition, the Atlas of PC study found that there were 25 PC services.¹⁴ Currently, the public health care system (MOH) in Saudi Arabia offers >78 PC services, which is a significant improvement. Furthermore, the concept of PC has evolved considerably over the past few years and is now available to anyone in need rather than just those with specific illnesses.

PC became available to all patients, including those with end-stage chronic illnesses such as heart failure, dementia, chronic obstructive pulmonary disease (COPD), and autoimmune illnesses. In addition, no previous hospice services, outpatient services, or home care services were offered. With this new development, a MDT approach was formed to provide patients with the best health care possible.

This team includes a treating physician, clinical pharmacist, social worker, spiritual/religious advisor, psychologist, case manager, dietitian, physical therapist, occupational therapist, and nurse to provide the health care needed, including palliative health care. The accessibility to these services differs from one area to another, with more inclusive services provided in the central, eastern, and western regions. Even with the drastic improvement of the service provided, there are many drawbacks that hinder the quality provided by this service.¹⁵

There are still places like the southern region, especially Najran, that lack personnel and beds. In several PC units across Saudi Arabia, there is an imbalance between the number of physicians, nurses, and beds, which might be seen as a waste of resources; therefore, MOH must utilize its resources for more efficient care. As shown in Figure 1, there are >68 PC physicians distributed across the kingdom.

According to a study done in 2021,¹⁴ there are 83,505 individuals in Saudi Arabia who require PC, indicating that even with the PC services of the private sector, there is a demand for additional PC physicians with adequate training. Thus, there is still a need for more PC providers and centers in all areas. Although from a strategic standpoint, some areas need more centers and providers than others.

A sufficient quantity of nurses is needed in PC facilities. A minimum of one nurse per patient, and preferably 1.2 nurses per bed, should make up the palliative care nursing staff.¹⁶ Unfortunately, Saudi Arabia has a nursing staff shortage because there are more beds than nurses. This makes it difficult to execute high-quality PC and lowers the effective use of the country's plentiful bed supply.

It is essential to increase PC facilities' availability of pain medications, particularly opioids, to deliver the best standard of treatment possible. The WHO also urged nations to examine their drug policy guidelines to make sure that people get the opioid prescriptions they need for pain management. As addictive medicines, opioids are subject to strict regulation because of the risk of abuse and drug dependence.^17,18 Opioids of all kinds are widely available in the central, western, and northern regions.

Opioids are also accessible in other areas, but not all kinds. Since opioids are typically accessible almost everywhere in Saudi Arabia, improving human resources, including doctors, nurses, and other professionals, should be the primary focus of hospice care. Opioids are generally available almost everywhere in Saudi Arabia; hence, enhancing human resources such as physicians, nurses, and others should be the major emphasis of PC (Table 1).

Table 1.

SWOT Analysis of the Current Palliative Care Provided in Saudi Arabia (n = 18)

Strengths	Weaknesses
• Governmental support through financing and legislation • Availability of opioids • Postgraduate training programs provided to physicians and nurses • A multidisciplinary approach to patient care • Development of a national guideline for PC management	• Insufficient PC centers in all regions • Shortage of PC physicians and nursing staff • Insufficient hospice units available
Opportunities	Threats
• Inclusion of PC as a part of the health reformation plan under the new Saudi Vision 2030 • Integration of PC concept and training in undergraduates curriculum • International guidelines, recommendations, and studies to enhance the hospice care given	• Lack of awareness about the importance of PC among patients and family members • Health care professionals' misunderstandings of the notion of hospice care • Redirecting physicians and nurses, and other members of the PC team to different sectors after training them • Lack of realization of the importance of making PC a separate specialized unit

PC, palliative care; SWOT, strengths, weaknesses, opportunities, and threats.

Estimated need for PC

The table provides an overview of the estimated need for PC in different clusters and regions of Saudi Arabia, along with population sizes and mortality statistics (Table 2). Here is an overall interpretation of the estimated PC needs in Saudi Arabia:

Table 2.

Estimated Need for Palliative Care Across Saudi Arabia

Cluster/RHD	Population size	Estimated mortalities/year	Death due to chronic illness	Estimated need for palliative cancer/year	Prefer hospice/community PC	Monthly target for palliative cancer care	Estimated need for palliative noncancer/year
Riyadh First Health Cluster	1,989,425	4775	3104	1086	543	91	2017
Riyadh second Health Cluster	2,200,693	5282	3433	1202	601	100	2232
Riyadh third Health Cluster	804,684	1931	1255	439	220	37	816
Al-Qassim Health Cluster	1,015,290	2437	1584	554	277	46	1030
Eastern Health Cluster	1,932,020	4637	3014	1055	527	88	1959
Al-Hassa Health Cluster	902,514	2166	1408	493	246	41	915
Hafr-Albaten	357,813	859	558	195	98	16	363
Makkah	1,233,881	2961	1925	674	337	56	1251
Jeddah	2,215,991	5318	3457	1210	605	101	2247
Al-Taif RHD	839,830	2016	1310	459	229	38	852
Al-Quenfedah	192,862	463	301	105	53	9	196
Madinah Health Cluster	1,408,965	3382	2198	769	385	64	1429
Baha RHD	289,292	694	451	158	79	13	293
Aseer RHD	1,218,835	2925	1901	665	333	55	1236
Jazan RHD	1,039,336	2494	1621	567	284	47	1054
Najran RHD	663,770	1593	1035	362	181	30	673
Bisha RHD	150,642	362	235	82	41	7	153
North Borders	283,609	681	442	155	77	13	288
Al-Jouf RHD	284,171	682	443	155	78	13	288
Hail Health Cluster	489,855	1176	764	267	134	22	497
Tabouk RHD	661,900	1589	1033	361	181	30	671
Al-Qurayyat	139,965	336	218	76	38	6	142
Total	20,315,343	48,757	31,692	11,092	5546	924	20,600

Palliative cancer care

The total estimated need for palliative cancer care in Saudi Arabia is 31,692 cases per year. This includes individuals with chronic illnesses and cancer-related deaths. The highest estimated needs are observed in Riyadh Second Health Cluster, Jeddah, and Riyadh First Health Cluster.

Preferred hospice/community PC

A significant portion of individuals requiring palliative cancer care (5546 cases per year) express a preference for hospice or community-based PC services. This highlights the importance of providing accessible and patient-centered care options in these settings.

Monthly targets

The monthly targets for palliative cancer care are 924 cases across different clusters and regions. These targets reflect the ongoing need for regular and consistent PC services to meet the demands of patients.

Palliative noncancer care

The estimated need for palliative noncancer care in Saudi Arabia is 20,600 cases per year. This emphasizes that PC is not limited to cancer patients alone but extends to individuals with various chronic illnesses and conditions. Overall, the estimated PC needs in Saudi Arabia are substantial, with a significant focus on providing palliative cancer care. The data underscore the importance of expanding PC services, particularly in regions with higher population sizes and mortality rates.

It also highlights the necessity of establishing comprehensive and integrated PC programs that address both cancer- and noncancer-related PC needs. By recognizing and addressing these needs, Saudi Arabia can enhance the quality of life for individuals with chronic illnesses and ensure they receive the necessary support, pain management, and comfort during their journey.

Educational programs in PC

Since 2001, the Saudi Commission for Health Specialties (SCFHS) has developed specialized educational programs in Riyadh's King Faisal Specialist Hospital and Research Center. In 2016, it evolved into a fellowship program for palliative medicine within the SCFHS. There are seven training centers in the kingdom, from which >20 doctors are graduated annually: King Faisal Specialist Hospital and Research Center, Riyadh, provides training centers; King Faisal Specialist Hospital and Research Center of Jeddah; King Fahad Medical City, Riyadh; King Abdulaziz Medical City Jeddah; King Fahad Specialist Hospital Dammam; King Abdulaziz Medical City National Guard Hospital Riyadh; and King Abdullah Medical City, Mecca.

Future and expectations

There should be a wide range of fundamental PC services available at the local level for people with generally uncomplicated simple PC needs (Table 3). The main goal is to deliver as much PC as possible in the patient's home neighborhood, when appropriate, whether that is in their home or a community setting, which might include their general practitioner offices or a hospital outpatient clinic while taking into account the preferences of the patient and family caregivers. Basic PC services should be given to the maximum degree feasible by qualified professionals and community personnel already in place.^17,19

Table 3.

Clinical Services Provided at the Level of Care

	Services		Services
Local care	• PC consultation services • Virtual clinic • MDT (social services, nurses, pharmacist, physiotherapist, spiritual support) • Outpatient services	Specialized care	• Hospice services • Community services (home care service) • Helpline service

MDT, multidisciplinary team.

Locally, the following fundamental functions should be provided: counseling, care preparation, symptom and pain management using validated instruments for evaluation and quantification of symptoms and pain, evaluation of the patient's state and service needs, assessment of competent services that are accessible, taking medication as directed, and observation of hospice care including both medical and professional PC services, moreover, providing end-of-life care as needed and providing patients' relatives with information,^3,17 and assistance at end-of-life care.^14,20

Local PC should be available to patients with stable illnesses and few or no comorbidities. Establishing and adhering to protocols that outline when a patient needs to be sent to specialized hospice care services are essential. Protocols are likely to take problem persistence, severity, and complexity into account. For those with complex needs, specialized PC should be made regionally accessible.^4,20

Services of specialized PC include management of both physical and mental ailments; input from specialized PC physicians regarding care planning conducted in collaboration with the care recipient, their family, and health care professionals; evaluation and management of symptoms with the appropriate medical treatments and medications; nursing care includes assistance with daily tasks, clear communication, and nursing interventions; and physical therapy and occupational therapy are examples of therapies.

Prescription counseling, medication preparation, and distribution services are offered by pharmacies; counseling, pain management support, psychological therapies, bereavement support, spiritual and religious services; social services provide assistance with specific equipment purchases, respite care, legal and financial concerns, and/or vacations; clinical information (such as diseases and symptom management) and social care information are among the topics covered by information services.⁵

Many services should be offered more effectively at the national level by a coalition of PC. These include establishing standards of care, gathering data on needs, utilization, and costs, polling patients, caregivers, fundraisers, volunteers, and members of the general public regarding their perceptions of PC, running national campaigns to increase awareness of these services, and contributing to education and research initiatives.¹⁷

Strengths and limitations

This study has both limitations and strengths that must be considered when interpreting the results. As a cross-sectional survey, the research is subject to sampling and response biases. The sampling technique may cause selection bias—as the study included only PC units within MOH, generalization of the findings may be limited. Response bias may occur in participants' answers due to social desirability or misunderstanding of questions. In addition, our retrospective approach may underestimate the need for PC, as many people require such care even before they reach the end stage of their condition.

Despite these limitations, the study's strengths include being the largest scale research on PC in Saudi Arabia and gathering responses from 18 PC units throughout the country. Furthermore, this is the first and largest study that assesses PC needs in Saudi Arabia across each region. Even though the data are from 2021, it represents the latest available information on the subject. It provides valuable insights into the current and future strategies of PC in Saudi Arabia, which is particularly significant given the limited number of publications in this field.

Conclusion

In light of the Vision 2030 reforms, Saudi Arabia has made commendable strides in PC, with increased facilities and services. However, a significant challenge remains in the geographical distribution of these services. Some regions, such as the central, eastern, and western areas, are well served, but areas such as the southern region face shortages of personnel and beds. Addressing these disparities in service distribution is crucial.

Moreover, the accessibility of essential pain medications is still an issue in many parts. As the demand for PC rises, it is imperative to optimize resource allocation for an efficient and equitable spread of services, bolster the health care workforce, and ensure uninterrupted access to necessary medications. These insights offer a roadmap for policymakers aiming to refine PC, ensuring that all patients and families in Saudi Arabia can benefit.

Footnotes

Acknowledgments

We acknowledge the administrative support provided by King Fahad Medical City, King Saud University, and King Salman bin Abdulaziz Medical City.

Authors' Contributions

Conceptualization of this study was contributed by A.B.; data curation was done by M.A.; formal analysis was carried out by I.A.; funding acquisition was taken care by S.A.; investigation was done by A.A.; methodology was carried out by S.A., I.A., and M.A.; resources were taken care by S.A.; supervision was by A.B. and A.A.; validation was taken care by A.A.; writing—original draft preparation was by I.A. and A.A.; and writing—review and editing was by I.A. and M.A.

Funding Information

No funding was received for this article.

Author Disclosure Statement

No competing financial interests exist.

Supplementary Material

References

Connor

, Sepulveda Bermedo

. Global Atlas of Palliative Care at the End of Life. Worldwide Hospice Palliative Care Alliance. World Health Organization; 2018.

Saylor

The circle of health: A health definition model. J Holist Nurs, 2004; 22(2):97–115.

Alshammary

, Abdullah

, Duraisamy

, et al. Palliative care in Saudi Arabia: Two decades of progress and going strong. J Heal Spec, 2014; 2(2):59.

Tatum

, Mills

. Hospice and palliative care: An overview. Med Clin, 2020; 104(3):359–373.

Anonymous. National Palliative Care Strategy 2018. n.d. Available from: https://www.health.gov.au/resources/publications/the-national-palliative-care-strategy-2018?language=en [Last accessed: February 22, 2023].

Alshammary

, Duraisamy

, Albalawi

, et al. Development of palliative and end of life care: The current situation in Saudi Arabia. Cureus, 2019; 11(3):3–4.

Smyth

Politics and palliative care: Saudi Arabia. Int J Palliat Nurs, 2019; 25(11):570.

Armijo

, Abbot

, Espinoza

, et al. Estimation of the demand for palliative care in non-oncologic patients in Chile. BMC Palliat Care, 2023; 22(1):1–7.

Yang

, Woon

, Teoh

CCO

, et al. Adult palliative care 2004–2030 population study: Estimates and projections in Malaysia. BMJ Support Palliat Care, 2022; 12(e1):e129–e136.

10.

Knaul

, Farmer

, Krakauer

, et al. Alleviating the access abyss in palliative care and pain relief—An imperative of universal health coverage: The Lancet Commission report. Lancet, 2018; 391(10128):1391–1454.

11.

Murtagh

FEM

, Bausewein

, Verne

, et al. How many people need palliative care? A study developing and comparing methods for population-based estimates. Palliat Med, 2014; 28(1):49–58.

12.

Kiger

, Varpio

Thematic Analysis Qualitative Data; 2020. Available from: https://www.tandfonline.com/doi/full/10.1080/0142159X.2020.1755030Medicalteacher

13.

Clarke

, Braun

. Thematic analysis. J Posit Psychol, 2017; 12(3):297–298; doi: 10.1080/17439760.2016.1262613

14.

Sánchez-Cárdenas

, Garralda

, Van Steijn

, et al. The atlas of palliative care in the Eastern Mediterranean Region 2021: A participative process of stakeholders across the region. East Mediterr Heal J, 2022; 28(8):614–621.

15.

Gomes

, Calanzani

, Gysels

, et al. Heterogeneity and changes in preferences for dying at home: A systematic review. BMC Palliat Care, 2013; 12(1):1–13.

16.

Payne

, Harding

, Williams

, et al. Revised recommendations on standards and norms for palliative care in Europe from the European Association for Palliative Care (EAPC): A Delphi study. Palliat Med, 2022; 36(4):680–697.

17.

Merriman

, Harding

. Pain control in the African context: the Ugandan introduction of affordable morphine to relieve suffering at the end of life. Philos Ethics Humanit Med, 2010; 5(1):1–6.

18.

WHO. World Health Organization. Integrating Palliative Care and Symptom Relief into Primary Health Care: A WHO Guide for Planners, Implementers and Managers. 2018.

19.

Gwyther

, Brennan

, Harding

. Advancing palliative care as a human right. J Pain Symptom Manage, 2009; 38(5):767–774.

20.

Mosoiu

, Mitrea

, Dumitrescu

. Palliative care in Romania. J Pain Symptom Manage, 2018; 55(2):S67–S76.

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.02 MB