Palliative care needs and war in Ukraine

Richard Armitage is a GP and Public Health Specialty Registrar, and Honorary Assistant Professor at the University of Nottingham’s Academic Unit of Population and Lifespan Sciences. He is currently providing primary care to internally displaced people in the east of Ukraine. He is on twitter: @drricharmitage

Prior to the Russian invasion, over 500,000 people each year were estimated to be in need of palliative care and pain relief for life-limiting conditions in Ukraine, driven largely by the country’s burden of cancer and HIV (up to 35% of cancers in Ukraine are diagnosed in Stage III or IV, while up to 10,000 deaths occur annually due to HIV/AIDS).¹  While the provision of palliative care and pain relief has significantly improved in the country over recent years, the current landscape of end of life care in Ukraine is unable to meet the substantial burden of need, which is rapidly escalating due to the on-going conflict.

Provision of palliative care and pain relief in Ukraine is undertaken by both governmental providers (controlled by the Ministries of Health and Social Policy) and non-governmental organisations (including social enterprises and churches).²  The All-Ukrainian League on Palliative and Hospice Care, a non-governmental organisation formed in 2011, acts to improve accessibility of palliative care and pain relief services by improving the country’s regulatory framework, facilitating access to relevant medications, implementing education and training programs for healthcare professionals, and raising public awareness of end of life care.¹  The resulting progress towards this essential component of universal health coverage³ is reflected in the European Association for Palliative Care upgrading its categorisation of palliative care services in Ukraine from Level 3a in 2013 (denoting isolated provision of palliative care characterised by sparse and poorly supported palliative care activism, substantial dependence on donor funding, inadequate access to opioid analgesics, and limited availability of palliative care services relative to population size)⁴ to Level 4a in 2020 (reflecting preliminary integration of hospice and palliative care services into the mainstream health system).⁵

Despite this welcomed progress, access to palliative care and pain relief remains deeply inadequate in Ukraine, particularly across the country’s rural communities.  This unmet need is primarily driven by the country’s pharmaceutical regulations, which are some of Europe’s most markedly opiophobic and substantially limit access to opioid analgesics for use in medical, surgical and palliative care.^1,6  Accordingly, in 2015 Ukraine had an estimated 120mg of distributed opioid morphine-equivalent annually per patient with serious health-related suffering, which satisfied only 7% of the country’s total palliative care need, and less than 1% of its overall healthcare needs.⁷  Today, in the context of the on-going conflict with Russia, this discrepancy is increasing at an alarming pace.

The direct and indirect impacts of war in Ukraine are compounding the country’s need for palliative care and pain relief services, and widening the existing access gap to them, in three general ways: firstly, severe traumatic injuries sustained by participation in or proximity to violent hostilities regularly necessitate surgical intervention requiring opioid analgesia, and may ultimately result in life-limiting conditions necessitating the provision of palliative care; secondly, the interruption of treatment for curable diseases, such as radio-, immuno- and chemo-therapy interventions for oncological illness, may allow disease progression beyond its curable stages, rendering patients in need of palliative care;⁸ thirdly, disruption of existing secondary and community palliative care services, that would otherwise provide essential care for patients with life-limiting conditions, due to the destruction of health system infrastructure (including deliberate targeting by Russian forces),⁹ the evacuation of healthcare professionals to areas of safety, and the enormous migration of internally displaced people that inadvertently concentrates the growing need for healthcare on increasingly pressurised and over-burdened health systems.¹⁰

For as long as the war in Ukraine continues, the country’s existing substantial unmet need for palliative care and pain relief will increasingly intensify, and ever greater numbers of people with life-limiting conditions will experience intolerable yet preventable suffering at the most vulnerable stage of life.  While significant progress has been made in the previous decade to develop and implement the systemic changes that deliver this vital element of universal health coverage, the urgent need to close the palliative care access gap in Ukraine is now even more pressing.  A fundamental step to achieving this aim is to establish sustainable pathways for access to controlled essential medicines (especially opioid analgesics such as injectable and oral immediate-release morphine) for the management of distressing yet controllable symptoms associated with life-limiting conditions, and to educate those healthcare practitioners on the clinical front-line who provide care for people at the end of their lives – specifically hospice physicians and community family doctors – in the safe and appropriate use of these crucial medications.  Such steps are desperately needed to prevent the Ukrainian population from suffering the compounding double injustice of war and unmet palliative care needs.

References

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2. A Wolf. Palliative and hospice care in Ukraine: How care is organised. European Association for Palliative Care 25 June 2018. https://eapcnet.wordpress.com/2018/06/25/palliative-and-hospice-care-in-ukraine-how-care-is-organised/ [accessed 08 May 2022]
3. World Health Assembly, 67 (‎2014)‎. Strengthening of palliative care as a component of comprehensive care throughout the life course. https://apps.who.int/iris/handle/10665/162863 [accessed 08 May 2022]
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6. Human Rights Watch. Uncontrolled pain: Ukraine’s Obligation to Ensure Evidence-Based Palliative Care. 12 May 2011. https://www.hrw.org/report/2011/05/12/uncontrolled-pain/ukraines-obligation-ensure-evidence-based-palliative-care [accessed 08 May 2022]
7. WE Rosa, L Grant, FM Knaul, et al. The value of alleviating suffering and dignifying death in war and humanitarian crises. The Lancet16 April 2022; 399(10334): 1447-1450. DOI: 10.1016/S0140-6736(22)00534-7
8. D Kizub, N Melnitchouk, A Beznosenko, et al. Resilience and perseverance under siege: providing cancer care during the invasion of Ukraine. The Lancet Oncology 01 May 2022; 23(5): 579-583. DOI: 10.1016/S1470-2045(22)00189-9
9. World Health Organization. WHO records 100th attack on health care in Ukraine. 07 April 2022. https://www.who.int/news/item/07-04-2022-who-records-100th-attack-on-health-care-in-ukraine [accessed 08 May 2022]
10. R Armitage. War in Ukraine and the inverse care law. The Lancet Regional Health Europe 30 April 2022; 100401. DOI: 10.1016/j.lanepe.2022.100401

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