Story: Sarinthorn Ratjaroenkhajorn
In other countries, hospice is a term for centres that provide end-of-life care for terminally-ill patients. In Thailand, there are many places providing services in the manner of hospices, such as Wat Phrabat Nam Phu in Lopburi district, which has looked after people with AIDS for a long time. Arokyasan Wat Kham pramong in Sakonburi is a rehabilitation and nursing centre for cancer patients. There is also Thammasat University, which is funding a hospice through the support of Thammasat Thammarak Centre and Mahidol University, with Siriraj Hospital and Ramathibodi Hospital overseeing the its construction in the outskirts of Bangkok.
That being said, hospices and hospice care had not been clearly defined in Thai society in the past. Therefore, research synthesis conducted with the objective of improving the Thai hospice care system have had to draw on research from abroad on the components, forms and developments made in hospice care. They have also examined the elements and structures of palliative care in Thai hospitals in order to improve palliative care services, formulate a set of proposals for developments in palliative care and guide proposals for palliative care benefits to be funded by different sources of welfare.
The study defined hospice care as the provision of palliative care to terminally-ill patients by a multidisciplinary healthcare team in an appropriate place and environment with the objective of alleviating pain and suffering and augmenting the quality of life of patients and their families through caring for their well-being. Palliative care encompasses the terminal phase of the patient’s life and the initial period after the patient’s passing, which is called the bereavement phase. Hospices are defined as “nursing homes that provide a good quality of life at the end of life”.
It should be noted that the definition of hospice care above is to provide clarity, as in practice, there is confusion over the caregiving methods and services of the overlapping forms and functions of various traditional nursing homes, between long-term care, home health care and palliative care. The main objective of the definition is to constructively contribute to the organisation of the country’s healthcare system, and not as a replacement for the terms of other forms of medical treatment.
TBetween 2016-2017, the study collected data by surveying Thailand’s 12 health districts and interviewing experts and people with direct experience in palliative care. It thoroughly researched healthcare institutions that offered palliative care services. Moreover, the study analysed information and hospitals’ stances on palliative care and terminally-ill patients by polling 1,188 healthcare institutions, covering a range of different institutions in the public and private sectors, from which they received 600 responses in total.
An interesting insight is that nurses play a significant role in managing the care of terminally-ill residents of nursing homes from laying the foundations of the home, overseeing its administration and attending a variety of additional training programs to supplement their knowledge etc. Most hospitals offer palliative care services in different forms, such as setting aside their nicer rooms for terminally-ill inpatients, consultation services for outpatients, or providing regular care for patients at home, to name a few. In addition to this, the study found that hospitals have created multidisciplinary teams for treating terminally-ill patients, and have opened up opportunities for volunteers to get involved in end-of-life care. Notably, the majority of patients that receive palliative care are cancer patients.
Furthermore, the data shows that palliative care services place importance on the role of family members and friends who are the patient’s caregivers, involving patients and their loved ones in deciding on a treatment plan that centers the patient’s quality of life and the happiness of their loved ones. This aligns with developments in palliative care policy in the direction of home-based and community-based care, rather than hospitals and other types of nursing homes.
The study found that an obstacle to the development of palliative care systems is that different groups, including doctors, nurses, workers in other professions, caregivers and the public, need to have the same level of awareness and understanding of palliative care, so that patients have the choice of receiving palliative care. This is critical for doctors that fixate on completely curing the disease and do not see palliative care as a valid form of treatment, but a cessation of treatment. Therefore, when doctors refuse to send their patients to palliative care treatment, patient access to care is limited.
Another obstacle is that different hospitals are facing different challenges. For example, community hospitals still lack access to analgesics, while tambon health promotion hospitals have relatively few terminally-ill patients, and so their palliative care teams lack expertise and confidence in providing the service. Also, evidence or paperwork indicating the patient’s preference for a natural death in the case of an emergency, is often missing.
Other limitations found by the study include a shortage of essential equipment, such as syringe drivers, and inadequacies in the referral of patients and the coordination of information between different healthcare institutions and spaces. Furthemore, there has yet to be clear oversight of palliative care services in the private sector.
One insight garnered from the study is that the work of ensuring that terminally-ill patients have a good quality of life is a public health challenge. For the essence of modern medicine, in particular, is to “rid” a patient of “disease”; it does not prepare, understand through practice, nor diagnose, from the heart, that a patient is ready to peacefully and happily “rid themselves of the world”.
The next observation concerns the bereavement phase, which includes assisting in both ritual and legal aspects of the funeral arrangement, and looking after the emotional well-being and after-lives of the bereaved. Therefore, healthcare workers have designated roles in the initial period after the death. However, there are discrepancies in the goals and duration of bereavement care that should be clarified.
One last important insight is that the study has illuminated that development of end-of-life care is moving in the direction of home and community-based care, as opposed to healthcare institutions, which is a valuable opportunity for communities to learn and acquire skills in end-of-life care with healthcare workers. Communities will also play an important role in providing close-knit support in the aftermath of loss. Therefore, “compassionate communities” will be at the heart of end-of-life care that encompasses physical, social and spiritual well-being.
Jirut Sriratnaban et al (2018). Research Synthesis for the Development of Hospice Care Services in Thailand Part 1: An Overview of Hospice Care in Thailand. The Thailand Center for Health Services System (TRC-HS), the Chulalongkorn University Faculty of Medicine and Chula Unisearch. Funded by the Health Systems Research Institute. The study can be downloaded here: http://kb.hsri.or.th/dspace/handle/11228/4924