Palliative care in Thailand: Development and challenges

Thailand is a constitutional monarchy located in Southeast Asia with an estimated population of 67 million people. The majority of Thai are Buddhist. According to the World Bank Report (2016), the Thai GDP per capita averaged $5,977.4 U.S. and Thais live an average of 74.4 years. Cancer and coronary heart disease have been the top leading causes of death in Thailand and more than 50% of the deaths are in hospitals. Thailand was positioned 44th in the quality of death ranking (The Economist Intelligence Unit, 2015). In response to an increasing aging population in the near future, a well-developed palliative care provision is needed.

PALLIATIVE CARE DEVELOPMENT IN THAILAND

Palliative care has been developing in Thailand since the late 1990s. Initially, it had slow progress during the first decade of the development. However, recently it has seen rapid growth and increasingly received attention from both government and non-government organizations. Milestones in the Thai palliative care movement are shown in Table 1.

Table 1.

Milestones of palliative care development in Thailand

Year	Key activities
1997	The National Cancer Prevention and Control Programme 1997–2001 recommended palliative care as an intervention in the tertiary prevention plan.
2006	The Healthcare Accreditation Institutes set palliative care as part of the hospital accreditation standard.
2007	The National Health Act 2007, Section 12, approved the right of terminally ill patients to palliative care.
2009	The Consortium of Thai Medical Schools established the Medical Schools Palliative Care Network.
	Nursing Institutes published a Standard of Nursing Care in Hospital, including the care for terminally ill patients.
	The National Health Commission of Thailand created Thailivingwill website, aiming to disseminate knowledge related to the living will and to make public awareness of peaceful natural death.
2012	The Thai Palliative Care Society (THAPS) and Thai Palliative Care Nurses Society (PCNS) were established.
	Faculty of Nursing, Prince of Songkla University, ran a capacity building workshop ‘Caring for persons at the end of life’, which was supported by UICC and the collaboration from Sunnybrook Health Science Centre, Toronto, Canada.
2013	The 10th Asia Pacific Hospice Conference was organized in Bangkok.
2013	The National Cancer Control Programme 2013–2017 set palliative care as one of seven strategies of cancer control program.
2013	Palliative care was also mentioned in cancer care program in Service Plan.
2014	The National Strategic Plan on Health Promotion for Good Death 2014–2016 was approved by the National Health Commission.
2014	Department of Medical Services, the Ministry of Public Health, published End of Life Care Guideline.
Late 2014	A national health policy on palliative care was launched targeting the establishment of a palliative care unit in every regional, general hospital and 300 community hospitals by 2016 and proposing a full-time trained nurse acts as the coordinator of care in the unit.
2015	1 st National Palliative and Hospice Care Conference (NPHC) was held in Bangkok and organized by Department of Medical Services, Ministry of Public Health.

To date, several initiatives are underway to enhance the development of palliative and end-of-life care in Thailand. The National Health Security Office, Department of Medical Services, Ministry of Public Health, and National Health Commission Office of Thailand are the predominant partnerships supporting this work. Each of these organizations takes different roles in palliative care development. While the National Health Security Office supports a palliative care network among hospitals, the Department of Medical Services focuses on promoting the provision of palliative care in public hospitals at all level of care. The National Health Commission Office of Thailand acts as coordinator among key stakeholders, from both government and non-government organizations, to draft the National Strategic Plan on Health Promotion for Good Death.

The Thai Nursing Council is also involved in supporting the palliative care movement. In 2015, the Thai Nursing Council appointed expert nurses from both clinical and academic settings to develop a set of competencies and training courses for nurses who work on palliative care. The Nursing Practice Guideline on Palliative Care for Adults and Children and a manual of skill development on palliative care for nurses were published from this work. Furthermore, non-government organizations take actions on promoting public awareness on palliative care and end-of-life issues. For example, Buddhika, a non-government organization, has organized workshops on facing death in a peaceful manner for more than 10 years and published several books on death and dying issues from the Buddhist perspective.

CHALLENGES

Although there were huge efforts to develop palliative care in my country, palliative care provision was not fully integrated into the Thai Public Health Care System. Key challenges are described below.

Promoting sustainable development

Palliative care development in Thailand was classified into group 3a where there is isolated palliative care provision (Lynch, Connor, & Clark, 2013). The characteristics of group 3a includes: palliative care activism is spotty in scope and not well-supported; source of funding that is often heavily donor-dependent; limited availability of morphine; and a small number of hospice-palliative care services that are often home-based in nature and limited in relation to the size of the population. In order to promote sustainable development, continuing support from the government by national health policy is needed.

Promoting adequate training and skills in medical and nursing staff

Nurses are proposed to act as care coordinators in palliative care units. However, they felt they did not have adequate skill and training for this role. Palliative care content was taught in classroom lectures for two hours in Bachelor and Master degrees of nursing. Nursing students learn about caring for patients at the end of life mainly in practicum courses. After graduation, a few nurses have been trained for at least one month intensive course on palliative care (Phungrassami, Thonkjamcharoen, & Atthakul, 2013). Most nurses participate in the palliative care conferences or workshops lasting less than a week, which might not be sufficient for improving their competencies to respond to palliative care needs of their patients. Similarly, most medical doctors do not gain sufficient knowledge and experience about palliative care during their academic preparation or study. Both doctors and nurses express it is difficult to initiate end-of-life care discussion with patients and families. Consequently, defining persons who need palliative care remains problematic in Thailand. Lack of knowledge and skills results in delaying patient access to palliative care services. Often, patients are referred to a palliative care consult team only when they were in an active dying stage.

Supporting drug availability in community hospitals

Drug availability is one of four components of the WHO Public Health Model for palliative care. Issues related to drug availability and equality of access to treatment and care remain unresolved. It was found that most opioids are available in regional and tertiary/university hospitals while it is limited in community hospitals (Thonkhamcharoen, Phungrassami, & Atthakul, 2013, 2014), yet the majority of persons with advanced stage spend their last year of life at home in their own community. In addition, the regulation of opioid amount per prescription and the pattern of opioid prescriptions varied in different types of hospitals. The majority of community hospitals have problems of formulary deficiencies. Thai medical doctors have absolute authority in opioid prescriptions while nurses help assess and evaluate effectiveness of treatments; pharmacists, in some hospitals, help correct and confirm doses. When doctors from regional/university hospitals prescribe drugs that are not available in community hospitals, pharmacists look for compatible drugs and confirm with the doctors in order to adjust doses.

Translating research into practice

To date, recently several research articles from Thailand regarding palliative and end-of-life issues have been published in national and international journals. However, most research studies were descriptive. There is very little intervention research to promote quality of life among palliative care patients and their families. Application of the findings of research studies conducted in countries where the cultural background is different to Thai patients may not be appropriate in our settings. Staff members at the Faculty of Nursing, Prince of Songkla University, and nurses from different care levels who are interested in palliative care have worked together to develop a research map. We are aiming to build a body of knowledge related to palliative and end-of-life care and, ultimately, to improve quality of care and quality of life of persons living at the end of life. The research foci are on gaining a better understanding of patients’ and families’ experiences in living towards end of life, exploring nurses’ experiences in caring for dying patients in various settings and establishing a program to develop and test the efficacy of nursing interventions in palliative care. However, the process of translating research into practice is unclear for many. Strategies to promote knowledge translation are required.

Strengthening social relations and compassionate community based care

Social relations is one attribute of social capital, which has been acknowledged as a key factor to sustain end-of-life care (Lewis, DiGiacomo, Luckett, Davidson, & Currow, 2013). Traditionally, an extended family with strong family ties is a unique aspect of Thai families. In addition, community life, particularly in rural area, is characterized as homogeneity with kinship relations. This social kinship relation is knitted by loving kindness and compassion. Due to modernization, young generations migrate to work in the city and leave alone the elders in communities. Consequently, the nuclear family has become common in modern Thais. This phenomenon loosens the strong ties and coherence of social relationship in a community. As nearly 50% of Thais died at home, strengthening social relations and building compassionate community-based care is important for enhancing end-of-life care in community and for supporting persons to die peacefully at home.

CONCLUSION

Over the past decade, palliative care development in Thailand has realized steady and accelerated progress. However, there remains a long way to move forward to reach a high standard and excellence of care for all persons at the end of life. With the collaboration and strong commitment of government and non-government organizations and international support, we strongly believe that we will be there soon.