Many countries, including the UK, take extensive measures to ensure that those who are dying are cared for at home, which is often the preferred place of care and death (Gomes, 2018). In other countries, there are limited options of hospitalisation and, therefore, home is the default place for end-of-life care (EoL) and death. Based on personal experience of teaching in developing countries, some of the challenges related to EoL care at home are as follows:
There are different models of community palliative care, and the International Association for Hospice and Palliative Care (IAHPC) outlines 12 of these, but the three main ones are discussed here (IAHPC, 2021). Application of these models differs among countries, as well as within countries.
Hands-on approach
Mainly delivered by nurses who are dually trained in palliative and community nursing, the success of this model depends on support from local GPs. Here, palliative care is delivered to terminally ill patients in their homes. The frequency of visits depends on patient needs and family support. Local palliative care services often provide or lend equipment, such as beds, to improve the comfort of dying patients. Although this service is one of the most useful ones for the patient, it comes with a huge cost to operationalise, and, without strong GP support, it is difficult to deliver. Further, it is hampered by a lack of succession planning, as other nurses or doctors are not trained to acquire palliative care skills.
Advisory palliative care service
The advisory team comprises palliative care physicians and specialist community palliative care nurses, who only take referrals from family doctors (GPs) and community nurses (CNs). Use of this service may expose the challenges highlighted above, in that some GPs and CNs may not be fully trained in palliative care to effectively assess and diagnose patients' symptoms to report to the advisory team. Therefore, the specialist advice may be given based on an inaccurate symptom characterisation, leading to ineffective interventions. However, should the patient require hospital admission, the advisory service facilitates this process and helps coordinate clinical investigations with specialists in the hospital. This service is effective in most countries, and, if availed of early in the patient's trajectory, it affords their wish of dying at home (IAHPC, 2021).
Comprehensive community palliative care service
This model is expensive and, therefore, operates in few countries. Teams of fully trained palliative care doctors and nurses provide this specialist service in dying patients' homes. These teams are qualified to prescribe medicines, order clinical investigations and even perform simple and safe procedures, such as blood transfusion and chemotherapy. Patients receive 24/7 medico-nursing care at home, and family members are also supported.
It can be argued that, although such comprehensive care benefits dying patients, it ‘deskills’ GPs and CNs by reducing their involvement in palliative care. This has further implications for the bereaved, as GPs and nurses may not know them to follow-up after death.
Final comments
In countries where palliative care is in its infancy, there are problems of pain control and other distressing symptoms. Lack of opioids, coupled with lack of knowledge on their use to control pain, often leaves patients in unbearable pain and suffering.
Therefore, it is important that experienced palliative care professionals from developed countries support CNs and GPs through training and visiting placements, so the latter can develop skills in palliative care assessment and treatment options. Anecdotally, developed countries are already supporting developing countries, but more needs to be done, since the COVID-19 pandemic has disrupted palliative care delivery in most countries. Once it becomes possible to travel, more effort and support should be offered to bolster specialist palliative care services in other countries.