Dr Avetis Babakhanyan, Hospital of Police of Armenia, Masis Medical Center, Armenia.
Armenia lies at the crossroads of Western Asia and Eastern Europe with a population of about three million. Palliative care is still under development here. In July 2011, a one-year ‘Home Palliative Care’ pilot project started, supported by the World Health Organization and Open Society Foundations. Since the end of the project in July 2012, we have continued to provide palliative care to those in need in a more informal way, working as volunteers. Now, just within the past few days, the palliative care mobile groups have started to function once again.
I’d like to tell you the story of a patient whom I visited when working as a volunteer palliative care mobile team member. This story reflects the main problems that have hindered the development of palliative care in our country: legislation that has not changed since the Soviet-era, patients’ opiophobia, lack of information at both patient and practitioner level, bureaucracy and a lack of State policy on palliative care services.
Mrs Hasmik was a 32-year-old lady, married with four children. She had inoperable cancer of the uterus and metastases in her liver. Her husband asked me to visit them and “do something because she’s getting worse”. The main complaint was the terrible pain. She had been using Analgin (metamisole), Ketonal and other non-steroidal anti-inflammatory drugs (NSAIDs) but nothing had worked. Mrs Hasmik’s family was aware of the diagnosis and I think that she was too. During our hour-long conversation I described my experiences with other patients with similar diseases and concluded that she needed stronger drugs. “Narcotics? Never!” Mrs Hasmik replied. Instead, she continued to use NSAIDs and herbal preparations from the ‘hekim’ (the self-proclaimed local ‘doctor’ who had promised to cure her).
Two weeks later I was called again. Mrs Hasmik begged me to do anything to ease her suffering. “The pain is literally killing me,” she said. It was about 7pm – too late to visit the district oncologist (the only practitioner allowed to initiate an opioid prescription). So we called the emergency service and finally managed to persuade the doctor to inject tramadol, the strongest analgesic he had. Getting Mrs Hasmik admitted to hospital was not an option because hospitals refuse to admit a patient who has a confirmed diagnosis of terminal cancer. A hospice or palliative care unit would have been a solution but as yet they do not exist in Armenia.
Next morning, having asked the oncologist to start the ‘prescription allowance process’ he prescribed tramadol (100mg×3/daily). It took him two days to get approval for a morphine prescription from a special commission that comprises three to five members including a police officer. (Heads of such commissions are the chiefs or vice-chiefs of hospitals and ‘ambulatories’ (polyclinics or outpatient clinics). So Mrs Hasmik started to get morphine (1%1ml × 3/daily i.m.) but her condition was rapidly getting worse. She became unconscious and died two days later.
What is so sad is that this story is usual and common in Armenia.
But this is just the beginning of our story. We are confident that real change will happen soon in Armenia. Thanks to the hard work of some dedicated people, led by Narine Movsisyan, we expect significant changes in palliative care this year: in education, legislation and practice. Please look out for Dr Moysisyan’s update in a future post. Meanwhile, we welcome your comments, either through the blog or by email.
Making the case for palliative care: stories from across the world
You can read other ‘best or worst case stories’ that show the need for palliative care on the web pages of the Prague Charter.
The Prague Charter demonstrates how we can all work together to advocate access to palliative care as a human right. Please visit the web page and think about sharing your story. (There are full instructions on how to submit your story on the web page).
Please support the Prague Charter by signing the petition.