Palliative Care: The Nigerian Perspective

*Nnadi Daniel Chukwunyere*

## **Abstract**

Palliative care is an area of healthcare that focuses on relieving and preventing the suffering of patients. It utilizes a multidisciplinary team approach to ensure a "holistic" care of the patient. It is a relatively new concept in medicine and the Nigerian experience has not been widely studied. Despite its introduction into the nation over two decades ago, it still faces a lot of challenges in terms of integration into the health care system, implementation and governmental policy. With increasing longevity, urbanization, high prevalence of HIV/AIDS and chronic diseases including malignancies, there will be an increasing number of Nigerians requiring palliative care.

**Keywords:** palliative care, holistic approach, Nigeria

### **1. Introduction**

When treatment for cure is not possible and the only option is palliative, the patient is said to be terminally ill [3]. In a patient that is terminally ill, the estimated life expectancy is less than or equal to 6 months, under the assumption that the disease will run its natural course [3, 2].

Care of the terminally ill, infirm and elderly individuals has been a key part of many societies. Since the fourth century, Rest house, Sarai, Sanatorium and Hot springs, were developed as special places to attend to their needs [1–3]. It has been realized that the needs of terminally ill patients were not met by the then prevailing specialist or non-specialist health system. Terminal care was not as elaborate as it is performed today. It was initially carried out by nuns and other charitable organizations. Palliative care was not included in the existing health care system of those days. Individuals and groups with a Christian commitment have been important in establishing pioneering palliative care programs in many places, and again have usually seen in education the best hope of contributing to care for the dying. From the 1980s rapid progress was made in developing palliative care as a discipline in the health care delivery.

The word "palliative" in Latin means "caring" [1]. This is the total care of patients whose conditions do not respond to curative treatment. It relieves suffering and improves the quality of life for both patients and families throughout an illness experience, not just at the end of life. Sometimes palliative care and hospice care are confused, and they have similar goals. However, hospice care is specifically for terminally ill patients while palliative care is more general and offered to patients whose conditions are not necessarily terminal. Palliative care begins when illness is diagnosed and continues regardless of whether the patient receives treatment directed at the disease.

According to the World Health Organization (WHO), palliative care is defined as "an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psycho-social and spiritual" [1]. It is the comprehensive care of the individual whose is considered as having a body, soul, spirit and family members who require support. It is also about living as well as dying with dignity. It is a good practice for the physician to refer his patients who require palliative care to access such care. This will not necessarily diminish our status as health care providers. Palliative care is often referred to as end-of-life care, but when properly carried out, it has been found to improve outcomes of patients with terminal diseases even leading to increased survival. The focus is not on death, but on compassionate specialized care for the living. Most health services are designed for prevention, diagnosis and treatment of diseases, but there is a huge need for ongoing care those who do not get better.

Palliative care is usually an organized care, which can be given, in a hospital setting, hospice or in the home of the patients. Resource constraints in developing countries, direct the site of care. Home-based care is cheap and acceptable to the family and the patient, and can offer care that respects cultural practice and removes the need for family attendance at hospital [4, 5].

The approach to patients care is "holistic," meaning that the patient is viewed as a person with physical, psychological, social and cultural gifts and needs which are special to that person [4]. The holistic approach looks after problems in four groups:


It thus involves a multi-professional team approach. This is a team of professionals who are committed to working together to provide the patient and her family comprehensive care. Palliative care is "a calling." The team must be prepared to offer selfless service without expecting reward and function as a family, showing love for each other and those who visit them—patients, relations, and visitors. Recognize that every member of the team is precious. Volunteers are expected to attend a course to allow them see the depth of hospice care. Confidentiality and ethical issues are a priority.

The pioneering works of Dame Cicely Saunders in the United Kingdom and of Anne Merriman in Africa drew the attention of the medical community and the public to the evolution of palliative care in the 1960s [1, 6]. In the African continent, Uganda, South Africa and Kenya are among the earliest to develop palliative care. In November 2002, in Cape Town South Africa, the African palliative care association (APCA) was formed [7]. It was registered in 2003 and opened its headquarters in Uganda in 2005 as a non-governmental organization (NGO), with a regional mandate to promote and scale-up culturally appropriate and affordable palliative care for people with progressive, life-threatening and life-limiting illness. Palliative care is still at a developmental stage in Nigeria despite decades of its introduction by Mrs. Fatunmbi and Dr. Anne Merriman in Nigeria in 1993 [8]. The year 2003 was when palliative care was properly introduced to the Nigerian government, policymakers and general public. It is now known as the Center for Palliative Care Nigeria

**83**

state [8].

**Figure 1.**

*Palliative Care: The Nigerian Perspective DOI: http://dx.doi.org/10.5772/intechopen.85235*

**2. Palliative care in Nigeria**

*outreach services for home-based care.*

services goes to the highest bidder.

(CPCN), located at the University College Hospital (UCH), Ibadan [8]. In 2007, CPCN launched its day-care hospice within the UCH as shown in **Figure 1**. A pain and palliative care unit was established in 2008 at the multidisciplinary oncology

*The center for palliative care at the University College Hospital (UCH), Ibadan. It provides day care and* 

Nigeria is the most populous country in Africa. It has an estimated population of 160–180 million scattered around six geopolitical zones and 774 local government areas (LGA). The country has the third largest number of people living with HIV/ AIDS after South Africa and India [10]. Approximately 100,000 new cases of cancer occur annually in Nigeria and thus there are large numbers of patients needing palliative care [9]. There is a gradual erosion of the hitherto extended family support and patients get isolated both at home and in the hospitals. The life expectancy is lower than in most of the developed countries with low gross domestic product (GDP). The annual national budget for health is a ridiculous 1.5–3%, oscillating whenever there is a change in Government. Medical services are provided through out-pocket payment or user fees. Health insurance is provided mainly to the 1% of the population employed in the civil service. Thus, provision of adequate health

Palliative care is still new to the country owing to the fact that it is not included as an area of specialization for health professionals across the country. It is now currently offered as an undergraduate course at the College of Medicine, University of Ibadan and postgraduate diploma in a privately owned University in Ilorin, Kwara

In 2006, Dr. Oyebola Folaju, became the first specialist in palliative medicine in Nigeria following a postgraduate training in palliative medicine at the famous University of Cape Town, South Africa [8]. He pioneered palliative medicine in Nigeria and became the first full-time pain and palliative care physician by establishing the first pain and palliative medicine department at the Federal Medical

center of the University of Nigeria in Enugu, South-eastern Nigeria [9].

#### **Figure 1.**

*Palliative Care*

According to the World Health Organization (WHO), palliative care is defined as "an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psycho-social and spiritual" [1]. It is the comprehensive care of the individual whose is considered as having a body, soul, spirit and family members who require support. It is also about living as well as dying with dignity. It is a good practice for the physician to refer his patients who require palliative care to access such care. This will not necessarily diminish our status as health care providers. Palliative care is often referred to as end-of-life care, but when properly carried out, it has been found to improve outcomes of patients with terminal diseases even leading to increased survival. The focus is not on death, but on compassionate specialized care for the living. Most health services are designed for prevention, diagnosis and treatment of diseases, but there is a huge

Palliative care is usually an organized care, which can be given, in a hospital setting, hospice or in the home of the patients. Resource constraints in developing countries, direct the site of care. Home-based care is cheap and acceptable to the family and the patient, and can offer care that respects cultural practice and

The approach to patients care is "holistic," meaning that the patient is viewed as a person with physical, psychological, social and cultural gifts and needs which are special to that person [4]. The holistic approach looks after problems in four groups:

3.Social: family needs, issues of food, work, housing and relationships

4.Spiritual: questions of meaning of life and death, the need to be at peace

It thus involves a multi-professional team approach. This is a team of professionals who are committed to working together to provide the patient and her family comprehensive care. Palliative care is "a calling." The team must be prepared to offer selfless service without expecting reward and function as a family, showing love for each other and those who visit them—patients, relations, and visitors. Recognize that every member of the team is precious. Volunteers are expected to attend a course to allow them see the depth of hospice care. Confidentiality and ethical

The pioneering works of Dame Cicely Saunders in the United Kingdom and of Anne Merriman in Africa drew the attention of the medical community and the public to the evolution of palliative care in the 1960s [1, 6]. In the African continent, Uganda, South Africa and Kenya are among the earliest to develop palliative care. In November 2002, in Cape Town South Africa, the African palliative care association (APCA) was formed [7]. It was registered in 2003 and opened its headquarters in Uganda in 2005 as a non-governmental organization (NGO), with a regional mandate to promote and scale-up culturally appropriate and affordable palliative care for people with progressive, life-threatening and life-limiting illness. Palliative care is still at a developmental stage in Nigeria despite decades of its introduction by Mrs. Fatunmbi and Dr. Anne Merriman in Nigeria in 1993 [8]. The year 2003 was when palliative care was properly introduced to the Nigerian government, policymakers and general public. It is now known as the Center for Palliative Care Nigeria

need for ongoing care those who do not get better.

1.Physical: symptoms

issues are a priority.

removes the need for family attendance at hospital [4, 5].

2.Psychological: worries, fears, sadness, anger

**82**

*The center for palliative care at the University College Hospital (UCH), Ibadan. It provides day care and outreach services for home-based care.*

(CPCN), located at the University College Hospital (UCH), Ibadan [8]. In 2007, CPCN launched its day-care hospice within the UCH as shown in **Figure 1**. A pain and palliative care unit was established in 2008 at the multidisciplinary oncology center of the University of Nigeria in Enugu, South-eastern Nigeria [9].

#### **2. Palliative care in Nigeria**

Nigeria is the most populous country in Africa. It has an estimated population of 160–180 million scattered around six geopolitical zones and 774 local government areas (LGA). The country has the third largest number of people living with HIV/ AIDS after South Africa and India [10]. Approximately 100,000 new cases of cancer occur annually in Nigeria and thus there are large numbers of patients needing palliative care [9]. There is a gradual erosion of the hitherto extended family support and patients get isolated both at home and in the hospitals. The life expectancy is lower than in most of the developed countries with low gross domestic product (GDP). The annual national budget for health is a ridiculous 1.5–3%, oscillating whenever there is a change in Government. Medical services are provided through out-pocket payment or user fees. Health insurance is provided mainly to the 1% of the population employed in the civil service. Thus, provision of adequate health services goes to the highest bidder.

Palliative care is still new to the country owing to the fact that it is not included as an area of specialization for health professionals across the country. It is now currently offered as an undergraduate course at the College of Medicine, University of Ibadan and postgraduate diploma in a privately owned University in Ilorin, Kwara state [8].

In 2006, Dr. Oyebola Folaju, became the first specialist in palliative medicine in Nigeria following a postgraduate training in palliative medicine at the famous University of Cape Town, South Africa [8]. He pioneered palliative medicine in Nigeria and became the first full-time pain and palliative care physician by establishing the first pain and palliative medicine department at the Federal Medical

#### *Palliative Care*

Centre Abeokuta, Nigeria. This was the first hospital-based palliative medicine services and the beginning of integrating chronic pain management, palliative and end-of-life care, into an acute care hospital in the country [8]. Through his efforts the country today can boast of more than 15 similar facilities in Nigeria making use of their local institutional policies to move forward. Most families prefer the home-based care. It provides familiar environment, opportunity to attend to siblings, access to family and friends and privacy are advantages. This is performed in conjunction with family, primary care team and specialist within the hospital or hospice.

Despite the prescriptions of the WHO in 2002 and its re-emphasize at the 2004 WHO general assembly that palliative care should be integrated into all nations' health care system, several African countries including Nigeria are yet to approve it as a policy. This situation had contributed significantly to the slow level of palliative care development in Nigeria, as the palliative care practitioners have no access to the nation health budget.
