Bhutan is an exemplar to the world in responding to the Covid-19 pandemic. Guided by the compassion and wisdom of His Majesty The King, the government along with the unprecedented support from every agency and the collective responsibility of every citizen, Bhutan continues to grow stronger to fight Covid-19.
Nevertheless, the pandemic is still accelerating, posing a greater threat to the world. The World Health Organisation (WHO) has recognised Covid-19 as a humanitarian emergency and the WHO and the international palliative care community recommends integrating palliative care in response to this crisis. With India, most likely to be the next global hotspot, Bhutan still remains at a significant risk, and perhaps there may not be a better time than now to introduce palliative care and how palliative care could support Bhutan’s response to Covid-19.
What is palliative care?
Palliative care is an approach of care that improves the quality of life of patients diagnosed with advanced illness and their families through the early identification, prevention and relief of suffering.
Modern palliative care began in the 1960s as care for terminally ill cancer patients focussing mainly on end-of-life care. Today, however, palliative care is recognised as an essential approach to care from the time of diagnosis of any life-limiting disease both in adults and children. While it is well established in the developed countries, palliative care is inadequate or non-existent in developing countries. In 2014, the 67th World Health Assembly passed a resolution urging all member states to integrate palliative care into the countries’ health systems. Further, palliative care, a multi-disciplinary approach, is identified as an essential component of Universal Health Coverage, recognising it as fundamental to improving quality of life, comfort, well-being and human dignity for individuals even when there is no cure to the disease. Besides helping patients and families to navigate through the difficult phases of the disease process, palliative care can also reduce healthcare costs, enhance patient and caregiver satisfaction, and improve quality of life and survival. Palliative care is essential in meeting the Sustainable Development Goal Target 3.8 by 2030.
Identified as ‘low cost, high impact’ and ‘care beyond cure’, palliative care can be provided along with a therapeutic management of the disease and continued throughout the illness trajectory until the end-of-life and even beyond, providing bereavement support to the families, if needed.
The need for palliative care in Bhutan is increasing with the growing trend of an aging population which is associated with an increased prevalence of cancer and other chronic diseases. Our health care system is underpinned by compassion and equity, and the beliefs and philosophy of ‘holistic’ care are embedded in the principles of Gross National Happiness. However, palliative care, a medical specialty, is an emerging concept in the country. With a handful of doctors and nurses trained in Kerala, India, in 2018, a home palliative care group was initiated in JDWNRH. In addition, three beds were allocated for palliative care at the oncology ward. Since then, some training and awareness programs for health care professionals and monks from the Central Monastic Body have been conducted. With HRH Princess Kesang Wangmo Wangchuck, as the patron, expansion of palliative care in Bhutan is promising.
Palliative care and Covid-19 in Bhutan
A palliative care approach in Covid-19 can immensely benefit both patients and their families, as well as the health care workers involved in caring for them. The Lancet Report, April 11, 2020 stated: “Indeed palliative care ought to be an explicit part of national and international response plans for Covid-19.”
Covid-19 patients often go through ‘total pain’, which means they are not only affected physically but also psychologically, emotionally and spiritually. In Bhutan, as Covid-19 patients go through physical pain and discomfort, the psychological effects of the virus can include fear and anxiety of the unknown outcome, fear of transmitting the virus to others and discrimination by the society; worry and guilt of having brought the virus home, and being a burden to the government; the emotional distress such as anger and frustrations related to the isolation and not being able to meet the loved ones; and the spiritual suffering such as ‘why is it me?’, ‘what have I done wrong?’ and questions over one’s own Karma.
Along with physically caring for patients with Covid 19, palliative care measures such as active listening, counselling, reassurance and provision of a virtual forum for question and answer sessions or through hotline services can further reduce such distress. The National Mental Health Response Team led by Dr Chencho Dorji, a senior Consultant Psychiatrist in the country, have put in place commendable nationwide measures to respond to the pandemic. Spiritual distress may be helped by measures such as connecting to one’s root masters, reading spiritual books or listening to spiritual teachings, prayers, yoga, reflection and meditation and other healing practices as applicable to individuals. Ensuring we stay connected despite physical isolation improves quality of life during such crisis.
Similarly, among the families of Covid-19 patients, the psychological pain and distress can be enormous. Because of the impacts the pandemic has had globally, these families would have already been worried for months having their relative abroad. Knowing that their loved ones are coming home can cause apprehension as to whether they will turn out to be Covid-19 positive. Fear and anxiety can be significant when families are informed that their son, daughter, niece, nephew or grandchild, has tested positive. Distress and anguish are further exacerbated when families are unable to visit and support their loved one. Palliative care in the form of Choeshey Lerim (religious/spiritual teachings), education and provision of hotline services for question and answer sessions, well supported by the mental health team, are laudable measures to ease the families’ anxiety and distress.
All the specified symptoms of Covid-19 may not be present in all patients and families, and palliative care may not be needed for everyone. However, palliative care being patient- and family-focussed, identifying individual needs may help recognise those vulnerable to complications including long term implications. Although palliative care is generally perceived as being a “soft” discipline—a ‘gentle and compassionate companionship’ to the very ill and dying patients, it is actually much more a professional discipline of ‘active total care’ for patients and families.
Further, as emphasised by the mental health team, the needs of our frontline healthcare workers cannot be denied. When hundreds of doctors and nurses around the world have lost their lives from Covid-19, our doctors, nurses, technicians, cleaners and drivers, and their families can experience enormous fear, anxiety and distress. Strategic systems have been put in place where they work for two weeks and then get quarantined for another two weeks. Nonetheless, as cases increase and more hospitals are involved, coupled with the challenge of limited resources and manpower, it may become overwhelming for those at the frontline causing physical, psychological and emotional burnout. Identifying the needs of not only the patients and families but also the needs of health workers and supporting them accordingly is the cornerstone of palliative care.
Along with ensuring adequate personal protective equipment, education and training opportunities provided by the mental health response team and learning from reliable sources like WHO open platform, where free online courses are available, may improve the competence, confidence and satisfaction levels of our health care workers at the frontline.
While Bhutanese warriors, be it in the defence or health care professionals at the frontline, are always selflessly motivated to serve the Tsawa-Sum (The King, country and the people), it is such an inspiration that the nation acknowledges, appreciates and applauds these heroes. Palliative care is also improving the morale and self-esteem of the care providers.
Contributed By Tara Devi Laabar,