Palliative care in the ‘Kingdom in the sky’: Lesotho

What can we learn and adapt from each other? 

While nearly 6,000 miles apart, Wales in the UK and Lesotho in Southern Africa have much in common: similar size, landscape, bilingualism … and now palliative care. Dr Mary Hughes, a GP in South Wales, explains what happened when she and Dr Frances Gerrard from Cardiff Medical School accepted an invitation from a Welsh/Lesotho (DolenCymru) charity to deliver some palliative care teaching.

“No-one discusses death.”

“There is little community care here.”

“If I tell someone they have cancer they get depressed, they die.”

“If that’s euthanasia? I’m in!”

Dr Mary Hughes.

A few of the quotes from doctors on the training week that Frances Gerrard and I taught on last year in the mountain kingdom of Lesotho.

We had responded to a request from DolenCymru to help deliver some palliative care teaching in the town of Leribe where they have an innovative course developed in collaboration with Boston University training doctors to become family medicine specialists.

 

Ahead of the visit: The Challenges

Before the visit we received brief information about the group of doctors and the programme, the official Lesotho drug formulary and an African Palliative Care document. It was not entirely clear though as to the exact need. We prepared as best we could and set off to discover the reality of this beautiful mountain kingdom.

What we found on arrival: The Reality

Most health care in Lesotho is delivered from hospitals and clinics. Many staff in these centres felt they were not for ‘palliative’ patients and would discharge them to die in the community. Sadly, there is limited community health care in the areas our doctors worked in. Unsurprisingly, the relatives (unsupported) would bring patients back to hospital to seek further treatments or a doctor with a different opinion who might offer alternative advice.

There was a huge reluctance, driven by culture and attitudes of the country, to discuss the possibility of death, the poor prognosis of a patient or any relevant wider issues. The doctors already had huge responsibilities and roles. Many were medical directors in the hospitals they worked in. They were performing emergency care in casualty, Caesarian sections, looking after all inpatientcare over all specialities, as well as managing staff and the budget. Their general medical knowledge was wide-ranging. On top of this, the doctors were studying hard for their extra qualification.

Doctors on the family medicine training week in Leribe.

Tailoring the course: The Week

Our week in Leribe was a steep learning curve as we discovered the above and tried to tailor the course. The formulary we had seen did not reflect what medications were obtainable (e.g. opioids were available but limited and doctors ordering them closely interrogated) – much of our prepared work on drug management was not relevant.

Symptom management sessions included some helpful discussion but there was rising awareness of the doctors’ extensive experience of assessing symptoms, alongside their difficulty in lacking access to investigations and poor drug availability.

Introducing general palliative principles and the concept of total care provoked helpful discussions.  A session on breaking bad news brought out some amazing acting skills as well as stimulating more discussion. We facilitated debates on: ‘Euthanasia’ (none had come across the concept), ‘Don’t tell my mother she is dying’ and ‘The appropriateness of using resources on palliative patients.’ All of the doctors were very vocal and engaged in these sessions. We also used the TalkCPR video to introduce resuscitation discussions. (See links below).

Some members of the group reviewing the TalkCPR video media pack.

Outcomes of the week

The doctors had great ideas and enthusiasm to get palliative care started, including:

• The need to look at team building between healthcare personnel.
• A resource study on cost for multiple, potentially unnecessary admissions, compared to planned ongoing palliative care – using saved money to fund palliative beds.
• Education across healthcare professionals, as well as in the community.

All these ideas and plans will be the same as many others in similar situations but no less exciting and inspiring to see that growth potential.

Whatever the doctors gained from the week we came away having learned much and with a clearer idea of what we would do another time. The programme hopes to run the course again in two years’ time and it would be a privilege to be part of that.

Links and resources

• DolenCymru – the charity we travelled with.
• Byw Nawr/ Live Now coalition NHS Wales TalkCPR– who kindly donated a couple of video media packs to take out, showcase and leave.
• The Lesotho-Boston Health Alliance (LeBoHA).
• LeBoHa Facebook page.
• Contact Dr Mary Hughes by email.

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We’d love to hear more stories like this one about different initiatives in different countries of Africa and elsewhere in the world. Please email Avril Jackson if you would like to contribute.