**5. Palliative care practices in the world**

Throughout the history of humanity, all societies have endeavored to provide adequate care, support, and respect to patients and the dead. In this historical process, as a result of the ever-increasing innovations in drug therapy since the 1950s and the better understanding of the dying patient's psychosocial and spiritual needs, the foundation of palliative care principles was laid [4]. Hospices were first established at the beginning of Christianity during the Roman Empire. In the fourth century AD, these places were transferred to religious institutions. Although this tradition was tried to be kept alive in the middle ages, many of the hospices were closed or converted into monasteries during the Reform period. This continued until the nineteenth century until Jeanne Garnier opened the first hospice center (Calvaire) in France in 1842, dedicated to terminal patients [11].

The first modern hospice named "Saint Christopher," founded by Dr. Cicely Saunders in London in 1967, laid the foundations for palliative care in the world and inspired other countries and people. With this hospice, protocols for palliative care of terminal patients were identified, and the number of palliative care providers increased rapidly in the United Kingdom and other European countries [25]. America and other

western countries began to establish hospices for palliative care. Until the mid-1980s, the concept of palliative care was used instead of hospice care. In the early 1990s, the concept of palliative care was used for the care of individuals dying of cancer in America. Besides, individuals with other chronic diseases such as heart failure and lung disease also began to benefit from palliative care. Palliative care began to develop as a special branch in the mid-1990s and currently covers the care of patients with chronic diseases [4, 10, 26]. Over time, the understanding of palliative care has changed. Following this, the WHO defined palliative care and in 2004 published the "National Palliative Care Guidelines." Due to the need for palliative care and the need to provide effective care for patients, an independent area of expertise called "palliative medicine" was introduced in the United Kingdom, and specialists were trained in this field [25].

The European Association for Palliative Care demands formal certification programs and expertise in palliative care from policymakers and national councils. The European Association for Palliative Care conducts studies on training in palliative care and publishes guidelines on this issue. Through palliative care training manual for nurses [17, 25] and a guide to developing palliative care training in medical education, issues to be considered in palliative care training (palliative care and its importance; management of pain and other symptoms; psychosocial and spiritual care; ethical and legal issues in palliative care; communication and teamwork) by universities were identified [17, 27, 28].

The first palliative care in Germany began in 1983 with the establishment of a palliative service in the surgical department of the University of Cologne. The number of palliative care centers increased rapidly with the launch of a sample study by the German Ministry of Health between 1991 and 1996. According to Germany's 2005 data on palliative care, 111 hospice services, 131 hospices with beds, palliative care units in 116 hospitals, and 40 home-based palliative care services are actively performed [17, 29].

Italy is the leading country in palliative care, professional training, and research. The Academy of Palliative Medical Sciences in Bologna has been carrying out the necessary educational activities for the development of PC culture since 2007. The academy strengthened many international cooperation programs to be active in PC training activities [8, 10, 19]. To develop specialist nurses who have palliative care qualities and can provide the best palliative care services with evidence-based practices, Australia established a palliative care curriculum for nursing education and integrated palliative care into the undergraduate curriculum [10, 17].

Palliative care covers many disciplines. The palliative care process, which is developed parallel to the prevalence of cancer in the world, is carried out in different levels in developed and developing countries. Some countries where palliative care is considered a separate area of expertise include the United States, the United Kingdom, Canada, and Australia. There are guidelines for the treatment of different symptoms (bone pain, neuropathic pain, vomiting, depression, dyspnea, muscle spasm, terminal delirium, etc.). The American Medical Association applies a training program for end-of-life care for doctors and nurses. These programs include standards for the control of symptoms (pain, delirium, dyspnea anxiety, etc.) seen in the terminal stage [17, 27, 29].

The American Medical Association applies a training program for end-of-life care for doctors and nurses. These programs include standards for the control of symptoms seen in the terminal stage. Harvard University's Palliative Care Center organizes regular programs for nurses and doctors on palliative care. These programs aim to create awareness of interdisciplinary palliative care and to train educators specializing in palliative care [4, 10, 17]. Harvard University's Palliative Care Center organizes regular programs for nurses and physicians on palliative care to create an interdisciplinary palliative care awareness and train trainers who are specialized in palliative care [4, 17, 27]. Harvard University created the "Palliative

**99**

[4, 8, 17, 28].

*Palliative Care Services from Past to Present DOI: http://dx.doi.org/10.5772/intechopen.88990*

minor in Israel [4, 17, 28].

ing to the following criteria [8, 22]:

ring funds from other funds

• Availability of morphine

• Palliative care throughout the country

and End-of-Life Care Training Project" in 1997 to train health professionals and increase their clinical competence in palliative care. This project was supported by the American Medical Association, the Robert Wood Johnson Foundation, the National Cancer Institute of America, and some national organizations, and more than 2000 trainers in 16 countries have received training under this project to this day. With a distance education program of 16 modules, the training program for

The Middle East Cancer Consortium organizes postgraduate courses for health professionals from member countries such as Cyprus, Israel, and Jordan. In undergraduate nursing education in Israel and Jordan, palliative care is part of clinical education. In the Arodaphnousa Hospice in Nicosia in Cyprus, the second and third year nursing students practice for 2 weeks. There are plans to make palliative care a

According to the Worldwide Palliative Care Alliance (WPCA) 2014 report, 234 countries in the world have been classified in 4 groups that have sub-groups according to palliative care development. The WPCA has classified palliative care accord-

• Comprehensive palliative care service integrated into the health system

• Palliative care awareness in the local community and health personnel

Today, palliative care services vary according to the level of development of

*Group 1 countries whose hospice-palliative care activities are unknown*: this group includes 75 countries (32%) such as Afghanistan, Chad, Guinea, Comoros, Korea, Libya, and Uzbekistan. There is no hospice-palliative care in these countries. Also, these countries do not have any palliative care policies that cover the whole country

*Group 2 countries whose hospice-palliative care services are being developed*: this group includes 23 countries (10%) such as Azerbaijan, Bolivia, Algeria, Haiti,

• Participation of health personnel and local associations

• Advanced and defined palliative care training systems

• Effective and continuous palliative care policies

• Academic cooperation with universities

• National palliative care associations

**5.2 Palliative care service classification**

countries as seen below [4, 8, 17, 28].

• The inclusion of palliative care in general public health policies and transfer-

health professionals has been continuing for about 17 years [10, 17, 30].

**5.1 Palliative care criteria of the worldwide palliative care alliance**

*Palliative Care Services from Past to Present DOI: http://dx.doi.org/10.5772/intechopen.88990*

*Palliative Care*

universities were identified [17, 27, 28].

in the terminal stage [17, 27, 29].

western countries began to establish hospices for palliative care. Until the mid-1980s, the concept of palliative care was used instead of hospice care. In the early 1990s, the concept of palliative care was used for the care of individuals dying of cancer in America. Besides, individuals with other chronic diseases such as heart failure and lung disease also began to benefit from palliative care. Palliative care began to develop as a special branch in the mid-1990s and currently covers the care of patients with chronic diseases [4, 10, 26]. Over time, the understanding of palliative care has changed. Following this, the WHO defined palliative care and in 2004 published the "National Palliative Care Guidelines." Due to the need for palliative care and the need to provide effective care for patients, an independent area of expertise called "palliative medicine" was introduced in the United Kingdom, and specialists were trained in this field [25]. The European Association for Palliative Care demands formal certification programs and expertise in palliative care from policymakers and national councils. The European Association for Palliative Care conducts studies on training in palliative care and publishes guidelines on this issue. Through palliative care training manual for nurses [17, 25] and a guide to developing palliative care training in medical education, issues to be considered in palliative care training (palliative care and its importance; management of pain and other symptoms; psychosocial and spiritual care; ethical and legal issues in palliative care; communication and teamwork) by

The first palliative care in Germany began in 1983 with the establishment of a palliative service in the surgical department of the University of Cologne. The number of palliative care centers increased rapidly with the launch of a sample study by the German Ministry of Health between 1991 and 1996. According to Germany's 2005 data on palliative care, 111 hospice services, 131 hospices with beds, palliative care units in 116 hospitals, and 40 home-based palliative care services are actively performed [17, 29]. Italy is the leading country in palliative care, professional training, and research. The Academy of Palliative Medical Sciences in Bologna has been carrying out the necessary educational activities for the development of PC culture since 2007. The academy strengthened many international cooperation programs to be active in PC training activities [8, 10, 19]. To develop specialist nurses who have palliative care qualities and can provide the best palliative care services with evidence-based practices, Australia established a palliative care curriculum for nursing education

and integrated palliative care into the undergraduate curriculum [10, 17].

Palliative care covers many disciplines. The palliative care process, which is developed parallel to the prevalence of cancer in the world, is carried out in different levels in developed and developing countries. Some countries where palliative care is considered a separate area of expertise include the United States, the United Kingdom, Canada, and Australia. There are guidelines for the treatment of different symptoms (bone pain, neuropathic pain, vomiting, depression, dyspnea, muscle spasm, terminal delirium, etc.). The American Medical Association applies a training program for end-of-life care for doctors and nurses. These programs include standards for the control of symptoms (pain, delirium, dyspnea anxiety, etc.) seen

The American Medical Association applies a training program for end-of-life care for doctors and nurses. These programs include standards for the control of symptoms seen in the terminal stage. Harvard University's Palliative Care Center organizes regular programs for nurses and doctors on palliative care. These programs aim to create awareness of interdisciplinary palliative care and to train educators specializing in palliative care [4, 10, 17]. Harvard University's Palliative Care Center organizes regular programs for nurses and physicians on palliative care to create an interdisciplinary palliative care awareness and train trainers who are specialized in palliative care [4, 17, 27]. Harvard University created the "Palliative

**98**

and End-of-Life Care Training Project" in 1997 to train health professionals and increase their clinical competence in palliative care. This project was supported by the American Medical Association, the Robert Wood Johnson Foundation, the National Cancer Institute of America, and some national organizations, and more than 2000 trainers in 16 countries have received training under this project to this day. With a distance education program of 16 modules, the training program for health professionals has been continuing for about 17 years [10, 17, 30].

The Middle East Cancer Consortium organizes postgraduate courses for health professionals from member countries such as Cyprus, Israel, and Jordan. In undergraduate nursing education in Israel and Jordan, palliative care is part of clinical education. In the Arodaphnousa Hospice in Nicosia in Cyprus, the second and third year nursing students practice for 2 weeks. There are plans to make palliative care a minor in Israel [4, 17, 28].

### **5.1 Palliative care criteria of the worldwide palliative care alliance**

According to the Worldwide Palliative Care Alliance (WPCA) 2014 report, 234 countries in the world have been classified in 4 groups that have sub-groups according to palliative care development. The WPCA has classified palliative care according to the following criteria [8, 22]:


#### **5.2 Palliative care service classification**

Today, palliative care services vary according to the level of development of countries as seen below [4, 8, 17, 28].

*Group 1 countries whose hospice-palliative care activities are unknown*: this group includes 75 countries (32%) such as Afghanistan, Chad, Guinea, Comoros, Korea, Libya, and Uzbekistan. There is no hospice-palliative care in these countries. Also, these countries do not have any palliative care policies that cover the whole country [4, 8, 17, 28].

*Group 2 countries whose hospice-palliative care services are being developed*: this group includes 23 countries (10%) such as Azerbaijan, Bolivia, Algeria, Haiti,

Montenegro, and the Vatican. There are no active palliative care units in these countries. However, efforts are being to establish palliative care services [4, 8, 17, 28].

*Group 3* countries which have only local palliative care services and hospices:

*Group 3A countries*: these countries have an insufficient number of localized clinics and low-capacity palliative care. These units are not integrated into the health system and are mostly funded by personal donations. Morphine availability is limited. Governments do not adequately support palliative care activities. This group includes 74 countries (31.6%), including Angola, Bahrain, Bangladesh, Brazil, Bulgaria, Iran, Kuwait, Lebanon, Mozambique, Paraguay, and Sudan [4, 8, 17, 28].

*Group 3B countries*: localized palliative care services are not integrated with the general health system. Financial resources are personal donations, public and private health insurance, and local government resources. There are limited educational activities carried out by associations. Morphine is easily accessible. This group includes 17 countries (7.3%). Some of them are Portugal, Cyprus, Argentina, Malta Turkey, India, Nepal, Lithuania, Croatia Bosnia, and Herzegovina [4, 8, 17, 28].

*Group 4* countries with hospice-palliative care services integrated into a health system:

*Group 4A countries*: several palliative care services are shared in these countries. Healthcare staff and people are aware of the importance of palliative care in these countries. Morphine and strong analgesics are easily accessible. These countries have limited palliative care policies and national palliative care associations. This group includes 25 countries (10.7%). Some of these are Costa Rica, Kenya, China, Denmark, Israel, Finland, Hungary, New Zealand, Malaysia, Mongolia, the Netherlands, and Spain [4, 8, 17, 28].

*Group 4B countries*: this group includes 20 countries (8.6%). Comprehensive palliative care services are available throughout these countries. These countries have active palliative care policies. There are advanced palliative care education systems and national palliative care associations that cooperate with universities. Some of these countries are Romania, Singapore, Sweden, Switzerland, Uganda, the United Kingdom, the United States, Australia, Iceland, Austria, Belgium, Canada, France, Germany, Hong Kong, Poland, Ireland, Italy, Japan, and Norway [4, 8, 17, 28].

In developed countries, a comprehensive palliative care service is available, while in developing countries, palliative care is under development. According to the WHO-WPCA 2014 report, in 2006, 21 countries (9%) had hospice-palliative care units, while in 2011, 136 (58%) of 234 countries had 1 or more palliative care units [8, 30]. The report indicates that there were positive developments in palliative care services in 2013. Seventy-five countries do not have palliative care; in 23 countries, palliative care services are being developed; 91 countries provide palliative care through local services; and 45 countries provide palliative care services integrated to health services. In short, developments are continuing in palliative care services in many countries of the world [17].

#### **6. Palliative care practices in Turkey**

The first step of palliative care in Turkey was performed by the Ministry of Health Department of Cancer Control in 2008: to eliminate the problems related to palliative care, the relevant units of the Ministry prepared a project called "Palli-Turk" with the contribution of many institutions, especially the WHO, and launched this project as of 2011 [11, 31, 32].

Nowadays, the increase in the number of palliative care centers is of great importance for the patients and their relatives. The Ministry of Health supports

**101**

*Palliative Care Services from Past to Present DOI: http://dx.doi.org/10.5772/intechopen.88990*

prioritized.

certificate programs.

other areas of medicine.

and families who need palliative care.

**7. Conclusion**

these centers both in terms of institutionalization and training of employees. For this reason, both the Ministry of Health and the palliative care association organize workshops and training programs [16, 31]. Moreover, guidelines prepared by the Ministry of Health according to the conditions and priorities of Turkey aim at identification and institutionalization of palliative care; development of awareness of palliative care, gradually increasing the number of palliative care services until 2023; creation of trained and experienced professional teams in the field of palliative care; and service to patients in need of palliative care. The reasons for the neglect of palliative care services in Turkey until today include family structure, problems in human power, lack of curriculum, lack of expertise in palliative care,

The number of palliative care centers in Turkey is not yet sufficient. However, serious efforts in the last 15 years have led to a significant increase in the number of palliative care centers. According to current data, as of May 2018, palliative care services are provided with 3971 beds in 307 health facilities in 80 cities [25, 33, 34]. The infrastructure and trained staff needs of these centers need to be

Parallel to the developments in the world in the area of palliative care, the progress (although the level of education in developed countries has not been achieved yet) is continuing in the field of palliative care in Turkey. However, palliative care services in Turkey cannot be provided by expert teams. The teams that provide palliative care in hospital-based units do not consist of professionals who receive a training program at the level of palliative care expertise. Medical faculties do not include palliative care as a minor after graduation or as a graduate education program at nursing schools [4, 8, 10, 17, 19]. Curricula for primary medicine and nursing include only limited hours of palliative care training. However, palliative care services are in the process of development in our country, and health professionals (medical oncologists, nurses, and other health professionals) want to participate in postgraduate training programs related to palliative care [8, 10, 17, 35]. Also, palliative care training programs for nurses are organized with the cooperation of universities and hospitals. In this context, it is aimed to reach all nurses who provide palliative care services in 81 cities in Turkey through

In conclusion, a rapid increase in the number of people with chronic, life-threatening or incurable diseases, and health professionals' interest in the quality care of these patients has allowed rapid integration of palliative care, a new discipline, into

The main objective of palliative care, which is a philosophy of care, is to maintain the life quality of a patient in his/her last days when medical treatment is incapable and the healing process has stopped. Therefore, it is not the life span but the life quality of an individual that is important in palliative care. Therefore, the content of palliative care may vary depending on the individual's needs and the course of the disease. Today, there is a significant increase in the number of patients in need of palliative care, and this number is expected to increase further soon. For this reason, palliative care should be made in high quality and accessible all over the world. This can only be achieved through the development of national health policies, increasing the quality of training for health personnel, and further cooperation between countries. These steps will undoubtedly improve the life quality of patients

and lack of awareness in health workers and patients [9, 33].

#### *Palliative Care Services from Past to Present DOI: http://dx.doi.org/10.5772/intechopen.88990*

*Palliative Care*

Sudan [4, 8, 17, 28].

Netherlands, and Spain [4, 8, 17, 28].

in many countries of the world [17].

**6. Palliative care practices in Turkey**

launched this project as of 2011 [11, 31, 32].

system:

Montenegro, and the Vatican. There are no active palliative care units in these countries. However, efforts are being to establish palliative care services [4, 8, 17, 28]. *Group 3* countries which have only local palliative care services and hospices: *Group 3A countries*: these countries have an insufficient number of localized clinics and low-capacity palliative care. These units are not integrated into the health system and are mostly funded by personal donations. Morphine availability is limited. Governments do not adequately support palliative care activities. This group includes 74 countries (31.6%), including Angola, Bahrain, Bangladesh, Brazil, Bulgaria, Iran, Kuwait, Lebanon, Mozambique, Paraguay, and

*Group 3B countries*: localized palliative care services are not integrated with the general health system. Financial resources are personal donations, public and private health insurance, and local government resources. There are limited educational activities carried out by associations. Morphine is easily accessible. This group includes 17 countries (7.3%). Some of them are Portugal, Cyprus, Argentina, Malta Turkey, India, Nepal, Lithuania, Croatia Bosnia, and Herzegovina [4, 8, 17, 28]. *Group 4* countries with hospice-palliative care services integrated into a health

*Group 4A countries*: several palliative care services are shared in these countries. Healthcare staff and people are aware of the importance of palliative care in these countries. Morphine and strong analgesics are easily accessible. These countries have limited palliative care policies and national palliative care associations. This group includes 25 countries (10.7%). Some of these are Costa Rica, Kenya, China, Denmark, Israel, Finland, Hungary, New Zealand, Malaysia, Mongolia, the

*Group 4B countries*: this group includes 20 countries (8.6%). Comprehensive palliative care services are available throughout these countries. These countries have active palliative care policies. There are advanced palliative care education systems and national palliative care associations that cooperate with universities. Some of these countries are Romania, Singapore, Sweden, Switzerland, Uganda, the United Kingdom, the United States, Australia, Iceland, Austria, Belgium, Canada, France, Germany, Hong Kong, Poland, Ireland, Italy, Japan, and Norway [4, 8, 17, 28].

In developed countries, a comprehensive palliative care service is available, while

in developing countries, palliative care is under development. According to the WHO-WPCA 2014 report, in 2006, 21 countries (9%) had hospice-palliative care units, while in 2011, 136 (58%) of 234 countries had 1 or more palliative care units [8, 30]. The report indicates that there were positive developments in palliative care services in 2013. Seventy-five countries do not have palliative care; in 23 countries, palliative care services are being developed; 91 countries provide palliative care through local services; and 45 countries provide palliative care services integrated to health services. In short, developments are continuing in palliative care services

The first step of palliative care in Turkey was performed by the Ministry of Health Department of Cancer Control in 2008: to eliminate the problems related to palliative care, the relevant units of the Ministry prepared a project called "Palli-Turk" with the contribution of many institutions, especially the WHO, and

Nowadays, the increase in the number of palliative care centers is of great importance for the patients and their relatives. The Ministry of Health supports

**100**

these centers both in terms of institutionalization and training of employees. For this reason, both the Ministry of Health and the palliative care association organize workshops and training programs [16, 31]. Moreover, guidelines prepared by the Ministry of Health according to the conditions and priorities of Turkey aim at identification and institutionalization of palliative care; development of awareness of palliative care, gradually increasing the number of palliative care services until 2023; creation of trained and experienced professional teams in the field of palliative care; and service to patients in need of palliative care. The reasons for the neglect of palliative care services in Turkey until today include family structure, problems in human power, lack of curriculum, lack of expertise in palliative care, and lack of awareness in health workers and patients [9, 33].

The number of palliative care centers in Turkey is not yet sufficient. However, serious efforts in the last 15 years have led to a significant increase in the number of palliative care centers. According to current data, as of May 2018, palliative care services are provided with 3971 beds in 307 health facilities in 80 cities [25, 33, 34]. The infrastructure and trained staff needs of these centers need to be prioritized.

Parallel to the developments in the world in the area of palliative care, the progress (although the level of education in developed countries has not been achieved yet) is continuing in the field of palliative care in Turkey. However, palliative care services in Turkey cannot be provided by expert teams. The teams that provide palliative care in hospital-based units do not consist of professionals who receive a training program at the level of palliative care expertise. Medical faculties do not include palliative care as a minor after graduation or as a graduate education program at nursing schools [4, 8, 10, 17, 19]. Curricula for primary medicine and nursing include only limited hours of palliative care training. However, palliative care services are in the process of development in our country, and health professionals (medical oncologists, nurses, and other health professionals) want to participate in postgraduate training programs related to palliative care [8, 10, 17, 35]. Also, palliative care training programs for nurses are organized with the cooperation of universities and hospitals. In this context, it is aimed to reach all nurses who provide palliative care services in 81 cities in Turkey through certificate programs.
