Lessons Learned from Countries That Have Introduced Palliative Care Services into Their National Health System: A Narrative Review

Abstract

Objective:

This review aims at gaining a broad overview of national approaches about Palliative care (PC) implementation into health care systems in countries that have PC identified within their national policies and strategies.

Methods:

Paper searching was conducted using both peer-reviewed databases and gray literature sources covering governmental reports with PC strategies from 2000 onward. Articles published in English that cited at least 1 category of the WHO’s public health PC model were included. Qualitative content analysis was used for data analysis and synthesis of findings.

Results:

Thirteen reports met the inclusion criteria. Education and appropriate policies were the most frequent strategies covered by all countries included. Under education; information about training health care providers was needed for the effective introduction of a PC program. Reviewing standards of care required to deliver PC effectively, and financial support for PC service development were considered the central policies needed. Furthermore, partnerships and collaborations across the health systems as well as providing care based on patients’ needs were required for the provision of a PC program.

Conclusion:

It is of the essence to learn from countries demonstrating enhanced PC practices before the implementation of a new PC program in a given country. Such practices could be used as a guide and to address barriers that may hinder the development of PC at a national level. Best practices can be achieved by focusing on educational and policy-based strategies through identifying patients’ needs, assessing general public awareness, health care providers’ knowledge and training as well as incorporating stakeholders’ perspectives.

Keywords

health care system implementation services lessons learned palliative care national plans national policies

Get full access to this article

View all access options for this article.

References

Sepulveda

Marlin

Yoshida

Ullrich

. Palliative care: the World Health Organization’s global perspective. J Pain Symptom Manage. 2002;24(2):91–96.

Connor

, Sepulveda Bermedo MC. Global Atlas of Palliative Care at the End of Life. The World Health Organization—Worldwide Palliative Care Alliance; 2014.

World Health Organization. Strengthening of Palliative Care as a Component of Comprehensive Care Throughout the Life Course. World Health Organization; 2014.

Worldwide Hospice Palliative Care Alliance. Civil society report: Update on implementation of the 2014 World Health Assembly resolution on palliative care. Worldwide Hospice Palliative Care Alliance; 2016.

Stjernsward

Foley

Ferris

. The public health strategy for palliative care. J Pain Symptom Manage. 2007;33(5):486–493.

Centeno-Cortes

Pons-Izquierdo

Lynch

Donea

Rocafort

Clark

. EAPC Atlas of Palliative Care in Europe 2013-Cartographic Edition. 2013. Accessed January 3, 2020. http://www.rehpa.dk/wp-content/uploads/2019/06/EAPC-Atlas-of-Pallaitive-Care-in-Europe-2013-webudgave.pdf

World Health Organization. Cancer Pain Relief and Palliative Care: Report of a WHO Expert Committee [meeting held in Geneva from 3 to 10 July 1989]. World Health Organization; 1990.

World Health Organization. Strengthening of palliative care as a component of integrated treatment throughout the life course. J Pain Palliat Care Pharmacother. 2014;28(2):130–134.

The Economist Intelligence Unit. The 2015 Quality of Death Index. Ranking Palliative Care Across the World. The Economist Intelligence Unit (EIU); 2015.

10.

Rochmawati

Wiechula

Cameron

. Current status of palliative care services in Indonesia: a literature review. Int Nurs Rev. 2016;63(2):180–190.

11.

Zeinah

Al-Kindi

Hassan

. Middle East experience in palliative care. Am J Hosp Palliat Care. 2013;30(1):94–99.

12.

Elcigil

. The current status of palliative care in Turkey: a nurse’s perspective. J Pediatr Hematol Oncol. 2011;33(suppl 1):S70–72.

13.

McDermott

Selman

Wright

Clark

. Hospice and palliative care development in India: a multimethod review of services and experiences. J Pain Symptom Manage. 2008;35(6):583–593.

14.

Bingley

Clark

. A comparative review of palliative care development in six countries represented by the Middle East Cancer Consortium (MECC). J Pain Symptom Manage. 2009;37(3):287–296.

15.

Fadhil

Lyons

Payne

. Barriers to, and opportunities for, palliative care development in the Eastern Mediterranean Region. Lancet Oncol. 2017;18(3):e176–e184.

16.

Shawawra

Khleif

. Palliative care situation in Palestinian authority. J Pediatr Hematol Oncol. 2011;33(suppl 1):S64–67.

17.

Abu-Odah

Molassiotis

Liu

. Challenges on the provision of palliative care for patients with cancer in low- and middle-income countries: a systematic review of reviews. BMC Palliat Care. 2020;19(1):55.

18.

Basu

Mittag-Leffler

Miller

. Palliative care in low- and medium-resource countries. Cancer J. 2013;19(5):410–413.

19.

Soto-Perez-de-Celis

Chavarri-Guerra

Pastrana

Ruiz-Mendoza

Bukowski

Goss

. End-of-life care in Latin America. J Glob Oncol. 2017;3(3):261–270.

20.

Donkor

Luckett

Aranda

Phillips

. Barriers and facilitators to implementation of cancer treatment and palliative care strategies in low- and middle-income countries: systematic review. Int J Public Health. 2018;63(9):1047–1057.

21.

Ddungu

. Palliative care: what approaches are suitable in developing countries? Br J Haematol. 2011;154(6):728–735.

22.

Rhee

Garralda

Torrado

, et al. Palliative care in Africa: a scoping review from 2005–16. Lancet Oncol. 2017;18(9):e522–e531.

23.

Fraser

Powell

Mwangi-Powell

, et al. Palliative care development in Africa: lessons from Uganda and Kenya. J Global Oncol. 2017;4:1–10.

24.

Seymour

Cassel

. Palliative care in the USA and England: a critical analysis of meaning and implementation towards a public health approach. Mortality. 2017;22(4):275–290.

25.

Green

Johnson

Adams

. Writing narrative literature reviews for peer-reviewed journals: secrets of the trade. J Chiropr Med. 2006;5(3):101–117.

26.

Cipriani

Geddes

. Comparison of systematic and narrative reviews: the example of the atypical antipsychotics. Epidemiologia e psichiatria sociale. 2003;12(3):146–153.

27.

Urbis. Evaluation of the National Palliative Care Strategy 2010 Final Report. Urbis; 2010. Accessed January 5, 2020. https://www.health.gov.au/sites/default/files/evaluation-of-the-national-palliative-care-strategy-2010.pdf

28.

NSW Ministry of Health. End of Life and Palliative Care Framework 2019-2024. 2019. Accessed January 8, 2020. https://www.health.nsw.gov.au/palliativecare/Publications/eol-pc-framework.pdf

29.

Department of Health. End of Life Care Strategy: Promoting High Quality Care for All Adults at the End of Life. HMSO; 2008. Accessed January 8, 2020. http://www.cpa.org.uk/cpa/End_of_Life_Care_Strategy.pdf

30.

National Palliative and End of Life Care Partnership. Ambitions for Palliative and End of life Care: a national framework for local action 2015-2020. 2015. Accessed January 12, 2020. http://endoflifecareambitions.org.uk/wp-content/uploads/2015/09/Ambitions-for-Palliative-and-End-of-Life-Care.pdf

31.

Ministry of Health. The New Zealand Palliative Care Strategy. 2001. Accessed January 15, 2020. https://www.health.govt.nz/system/files/documents/publications/palliativecarestrategy.pdf

32.

Ministry of Health. Resource and Capability Framework for Integrated Adult Palliative Care Services in New Zealand. 2013. Accessed January 15, 2020. https://www.health.govt.nz/system/files/documents/publications/resource-capability-framework-adult-palliative-care-services-v2.pdf

33.

Department of Health and Children. Report of the National Advisory Council on Palliative Care. Ireland Department of Health; 2001. Accessed January 18, 2020. http://hospicefoundation.ie/wp-content/uploads/2012/07/Report-of-the-National-Advisory-Committee-on-Palliative-Care-2001.pdf

34.

Department of Health Social Services and Public Safety. Living matters dying matters: a palliative and end of life care strategy for adults in Northern Ireland. 2010. Accessed January 18, 2020. https://www.health-ni.gov.uk/sites/default/files/publications/dhssps/living-matters-dying-matters-strategy-2010.pdf

35.

Keirse

Beguin

Desmedt

, et al. Organisation of palliative care in Belgium-supplement. 2009. Accessed January 20, 2020. https://kce.fgov.be/sites/default/files/atoms/files/d20091027342.pdf,115

36.

Hospis Malaysia. Palliative care needs assessment, Malaysia. 2016. Accessed January 24, 2020. https://www.hospismalaysia.org/wp-content/uploads/2016/10/Palliative-Care-Needs-Assessment-Malaysia-2016.pdf

37.

Palliative Care Association of Uganda. Palliative care for all in need in Uganda. Strategic Plan 2017-2021. 2017. Accessed January 25, 2020. https://www.pcauganda.org/wp-content/uploads/2019/PCAU%20Strategic%20Plan%202017-2021.pdf

38.

Association Lalla Salma De Lutte Contre Le Cancer. National cancer prevention and control plan: 2010-2019. 2009. Accessed January 28, 2020. https://www.iccp-portal.org/system/files/plans/Morocco%20National-Cancer-Axes-and-Measures_0.pdf

39.

Soueidan

Osman

El-Jardali

. K2P Policy Brief: Integrating Palliative Care into the Health System in Lebanon. 2018. Accessed February 2, 2020. https://www.aub.edu.lb/k2p/Documents/K2P%20Policy%20Brief-%20Palliative%20Care-August%207%202018.pdf

40.

Mayring

. Qualitative content analysis: theoretical foundation, basic procedures and software solution. Austria: Social Science Open Access Repository (SSOAR); 2014.

41.

Connolly

. Global Colloquium on Palliative Care. All Ireland Institute of Hospice and Palliative Care. 2015. Accessed January 20, 2021. https://aiihpc.org/wp-content/uploads/2015/10/Colloquium-Programme-No-Crop-Marks.pdf

42.

Ayed

Sayej

Harazneh

Fashafsheh

Eqtait

. The Nurses’ knowledge and attitudes towards the palliative care. J Educ Pract. 2015;6(4):91–99.

43.

Abu-Saad

Dimassi

. Palliative care in Lebanon: knowledge, attitudes and practices of physicians and nurses. J Med Liban. 2007;55(3):121–128.

44.

Budkaew

Chumworathayi

. Knowledge and attitudes toward palliative terminal cancer care among Thai generalists. Asian Pac J Cancer Prev. 2013;14(10):6173–6180.

45.

Abudari

Zahreddine

Hazeim

Assi

Emara

. Knowledge of and attitudes towards palliative care among multinational nurses in Saudi Arabia. Int J Palliat Nurs. 2014;20(9):435–441.

46.

Kassa

Murugan

Zewdu

Hailu

Woldeyohannes

Assessment of knowledge, attitude and practice and associated factors towards palliative care among nurses working in selected hospitals, Addis Ababa, Ethiopia. BMC Palliat Care. 2014;13(1):6.

47.

Ross

McDonald

McGuinness

. The palliative care quiz for nursing (PCQN): the development of an instrument to measure nurses’ knowledge of palliative care. J Adv Nurs. 1996;23(1):126–137.

48.

Yun

Kim

Lee

, et al. Patient-reported assessment of quality care at end of life: development and validation of Quality Care Questionnaire-End of Life (QCQ-EOL). Eur J Cancer. 2006;42(14):2310–2317.

49.

Burman

Swami

Gagliese

Rodin

Zimmermann

. Validation of the QUAL-EC for assessing quality of life in patients with advanced cancer. Eur J Cancer. 2011;47(4):554–560.

50.

Aslakson

Wilson

, et al. Patient- and caregiver-reported assessment tools for palliative care: summary of the 2017 agency for healthcare research and quality technical brief. J Pain Symptom Manage. 2017;54(6):961–972.e916.

51.

Hirai

Kudo

Akiyama

, et al. Public awareness, knowledge of availability, and readiness for cancer palliative care services: a population-based survey across four regions in Japan. J Palliat Med. 2011;14(8):918–922.

52.

Benini

Fabris

Pace

, et al. Awareness, understanding and attitudes of Italians regarding palliative care. Annali dell’Istituto superiore di sanita. 2011;47(3):253–259.

53.

McIlfatrick

Hasson

McLaughlin

, et al. Public awareness and attitudes toward palliative care in Northern Ireland. BMC Palliat Care. 2013;12(1):34.

54.

Westerlund

Tishelman

Benkel

, et al. Public awareness of palliative care in Sweden. Scand J Public Health. 2018;46(4):478–487.

55.

Al-Drees

AlHubail

Elzubair

. Palliative care: knowledge and attitude among Saudi residents, 2016. J Palliat Med. 2019;22(11):1401–1409.

56.

Alkhudairi

. General public awareness, knowledge, and beliefs toward palliative care in a Saudi population. J Nat Sci Med. 2019;2(1):48–53.

57.

Kelley

Clark

Brown

Sitzia

. Good practice in the conduct and reporting of survey research. Int J Qual Health Care. 2003;15(3):261–266.

58.

Bate

Robert

. Experience-based design: from redesigning the system around the patient to co-designing services with the patient. Qual Saf Health Care. 2006;15(5):307–310.

59.

Hannon

Zimmermann

Knaul

Powell

Mwangi-Powell

Rodin

. Provision of palliative care in low-and middle-income countries: overcoming obstacles for effective treatment delivery. J Clin Oncol. 2016;34(1):62–68.

60.

Callaway

Connor

Foley

. World Health Organization public health model: a roadmap for palliative care development. J Pain Symptom Manage. 2018;55(suppl 2):S6–S13.

61.

Cagle

Van Dussen

Culler

, et al. Knowledge about hospice: exploring misconceptions, attitudes, and preferences for care. Am J Hosp Palliat Care. 2016;33(1):27–33.

62.

Wilson

Avalos

Dowling

. Knowledge of palliative care and attitudes towards nursing the dying patient. Br J Nurs. 2016;25(11):600–605.

63.

Igarashi

Miyashita

Morita

, et al. A population-based survey on perceptions of opioid treatment and palliative care units: OPTIM study. Am J Hosp Palliat Care. 2014;31(2):155–160.

64.

Kirshbaum

Purcell

Nash

. Talking about dying and death: a focus group study to explore a local community perspective. Nurs Rep. 2011;1(1):e8–e8.

65.

Seymour

Almack

Kennedy

. Implementing advance care planning: a qualitative study of community nurses’ views and experiences. BMC Palliat Care. 2010;9:4.

66.

Lynch

Clark

Centeno

, et al. Barriers to the development of palliative care in Western Europe. Palliat Med. 2010;24(8):812–819.

67.

Kumar

SK.

Kerala, India: a regional community-based palliative care model. J Pain Symptom Manage. 2007;33(5):623–627.

68.

Kellehear

O’Connor

. Health-promoting palliative care: a practice example. Crit Public Health. 2008;18(1):111–115.

69.

Abel

Bowra

Walter

Howarth

. Compassionate community networks: supporting home dying. BMJ Support Palliat Care. 2011;1(2):129–133.

70.

Gauvin

F-P

Abelson

Lavis

. Citizen brief: Improving access to palliative care in Ontario. 2013. Accessed March 15, 2020. https://www.mcmasterforum.org/docs/default-source/Product-Documents/citizen-briefs/access-to-palliative-care-in-ontario-cb.pdf?sfvrsn=2

71.

Khoshnazar

Rassouli

Akbari

, et al. Structural challenges of providing palliative care for patients with breast cancer. Indian J Palliat Care. 2016;22(4):459–466.

72.

Aldridge

Hasselaar

Garralda

, et al. Education, implementation, and policy barriers to greater integration of palliative care: a literature review. Palliat Med. 2016;30(3):224–239.

73.

Wallace

Grossman

Campbell

Robert

Lange

Shea

. Integration of end-of-life care content in undergraduate nursing curricula: student knowledge and perceptions. J Prof Nurs. 2009;25(1):50–56.

74.

Paice

Ferrell

Virani

Grant

Malloy

Rhome

. Graduate nursing education regarding end-of-life care. Nurs Outlook. 2006;54(1):46–52.

75.

Weissman

Ambuel

von Gunten

, et al. Outcomes from a national multispecialty palliative care curriculum development project. J Palliat Med. 2007;10(2):408–419.

76.

Centeno

Rodriguez-Nunez

. The contribution of undergraduate palliative care education: does it influence the clinical patient’s care? Curr Opin Support Palliat Care. 2015;9(4):375–391.

77.

Pulsford

Jackson

O’Brien

Yates

Duxbury

. Classroom-based and distance learning education and training courses in end-of-life care for health and social care staff: a systematic review. Palliat Med. 2013;27(3):221–235.

78.

Luyirika

Namisango

Garanganga

, et al. Best practices in developing a national palliative care policy in resource limited settings: lessons from five African countries. Ecancermedicalscience. 2016;10:652–652.

79.

Ansari

Rassouli

Akbari

Abbaszadeh

Akbarisari

. Palliative care policy analysis in Iran: a conceptual model. Indian J Palliat Care. 2018;24(1):51–57.

80.

Higginson

Hart

Koffman

Selman

Harding

. Needs assessments in palliative care: an appraisal of definitions and approaches used. J Pain Symptom Manage. 2007;33(5):500–505.

81.

Temkin-Greener

Ladwig

Caprio

, et al. Developing palliative care practice guidelines and standards for nursing home-based palliative care teams: a Delphi study. J Am Med Dir Assoc. 2015;16(1):86.e81-87.

82.

National Consensus Project for Quality Palliative Care. Clinical Practice Guidelines for Quality Palliative Care. 4th ed. 2018:16. Accessed January 9, 2020. https://www.nationalcoalitionhpc.org/wp-content/uploads/2018/10/NCHPC-NCPGuidelines_4thED_web_FINAL.pdf

83.

African Palliative Care Association. APCA standards for providing quality palliative care across Africa. 2010. Accessed February 8, 2020. http://www.thewhpca.org/images/resources/npsg/APCA_Standards_Africa.pdf,FirstEdition

84.

World Health Organization. Planning and implementing palliative care services: a guide for programme managers. 2016. Accessed March 2, 2020. file:///C:/Users/18071326r/Downloads/9789241565417-eng.pdf

85.

Groeneveld

Cassel

Bausewein

, et al. Funding models in palliative care: lessons from international experience. Palliat Med. 2017;31(4):296–305.

86.

Kaplan

Porter

. How to solve the cost crisis in health care. Harv Bus Rev. 2011;89(9):46–52, 54, 56–61.passim.

87.

Smith

Brick

O’Hara

Normand

. Evidence on the cost and cost-effectiveness of palliative care: a literature review. Palliat Med. 2014;28(2):130–150.

88.

Hasselaar

Payne

. Integrated Palliative Care. Radboud University Medical Centre; 2016.

89.

Higginson

Bausewein

Reilly

, et al. An integrated palliative and respiratory care service for patients with advanced disease and refractory breathlessness: a randomised controlled trial. Lancet Respir Med. 2014;2(12):979–987.

90.

den Herder-van der Eerden

Hasselaar

Payne

, et al. How continuity of care is experienced within the context of integrated palliative care: a qualitative study with patients and family caregivers in five European countries. Palliat Med. 2017;31(10):946–955.

91.

Bone

Morgan

Maddocks

, et al. Developing a model of short-term integrated palliative and supportive care for frail older people in community settings: perspectives of older people, carers and other key stakeholders. Age Ageing. 2016;45(6):863–873.

92.

World Health Organization. Essential medicines in palliative care: executive summary. 2013. Accessed March 10, 2020. https://www.who.int/selection_medicines/committees/expert/19/applications/PalliativeCare_8_A_R.pdf

93.

All Ireland Institute of Hospice and Palliative CARE. Briefing paper: public health approaches to palliative care. 2017: 18. Accessed January 11, 2020. https://aiihpc.org/wp-content/uploads/2015/02/Briefing-Paper-Public-Health-Approaches-to-Palliative-Care-Nov-2017.pdf

94.

Richardson

Sitzia

Brown

Medina

Richardson

. Patients’ needs assessment tools in cancer care: principles and practice. 2005:1–133. Accessed March 20, 2020. https://www1.kcl.ac.uk/teares/nmvc/external/docs/ar-patients-needs-assessment-final.pdf

95.

Brinkman-Stoppelenburg

Rietjens

van der Heide

. The effects of advance care planning on end-of-life care: a systematic review. Palliat Med. 2014;28(8):1000–1025.

96.

Khandelwal

Kross

Engelberg

Coe

Long

Curtis

. Estimating the effect of palliative care interventions and advance care planning on ICU utilization: a systematic review. Crit Care Med. 2015;43(5):1102–1111.

97.

Silbermann

Arnaout

Daher

, et al. Palliative cancer care in Middle Eastern countries: accomplishments and challenges. Ann Oncol. 2012;23(suppl 3):15–28.

98.

Manalo

MF.

End-of-life decisions about withholding or withdrawing therapy: medical, ethical, and religio-cultural considerations. Palliat Care. 2013;7:1–5.

99.

Long

. Cultural and spiritual considerations in palliative care. J Pediatr Hematol Oncol. 2011;33(suppl 2):S96–101.

100.

Abu Seir

Kharroubi

. Implementation of palliative care in Palestine: cultural and religious perspectives. Palliat Med Hosp Care Open J. 2017;SE(1):S4–S9.