Integrating palliative care and symptom relief into responses to humanitarian crises

The medical and moral imperative that palliative care be integrated into standard responses to humanitarian crises can be fulfilled by basic training and an essential set of medicines, equipment, social support and protocols

Humanitarian crises often cause both extensive loss of life and widespread suffering. Yet humanitarian crisis response virtually never fully integrates palliative care, the discipline devoted to preventing and relieving suffering. Recently, the World Health Organization (WHO) recognised the necessity of integrating palliative care and symptom relief into responses to humanitarian crises of all types and published a guide to this integration.1 In this article, we summarise the WHO recommendations, explain why inclusion of palliative care as an essential part of humanitarian response is medically and morally imperative, and describe how to ensure that palliative care is accessible for those affected by humanitarian crises.

Why is palliative care an essential function of humanitarian response?

Humanitarian crises are large scale events that threaten the health or wellbeing of community groups or societies. They often result in massive physical, social, spiritual and psychological suffering, including high death tolls. They may be due to natural hazards (earthquakes, major storms, floods), epidemics of life‐threatening infections, or violent political or ethnic conflict. In recent years, over 100 million people per year have needed humanitarian assistance.2

The WHO defines palliative care as the prevention and relief of physical, social, spiritual and psychological suffering of patients with serious illness. Palliative care attends to both adult and paediatric patients and to the suffering of their families.3 It is not provided instead of curative or life‐sustaining therapies for the seriously ill or injured, but should be provided concomitantly with such therapies.

Traditionally, humanitarian health care responses have focused primarily on saving lives and have lacked a concerted focus on palliating suffering. Recent studies show that, despite the massive scale of suffering caused by humanitarian crises, palliative care has been largely neglected by humanitarian medicine.4,5 Yet the principles of humanitarianism explicitly require prevention and alleviation of human suffering.6,7 Many patients deemed “expectant” (expected to die) suffer severely before they die. In addition to the principles of humanitarianism, the medical ethical principles of beneficence and non‐abandonment require provision of palliative care and symptom control for expectant patients.8 Neglecting to provide aggressive and prompt symptom management for such highly vulnerable patients during humanitarian response is tantamount to abandonment. Palliative care and lifesaving treatment can and should complement each other. For example, while providing palliative care, responders may determine that a patient deemed expectant may be saveable. In addition, many who survive the crisis endure severe suffering acutely or chronically, and even the physically unscathed may experience debilitating psychological, social or spiritual suffering. Provision of palliative care is ethically imperative for these patients as well.

In addition to this ethical argument, there is also a medical argument for integration of palliative care into responses to humanitarian crises. Excellent symptom relief may reduce morbidity and mortality. For example, patients with serious traumatic injuries who do not receive prompt opioid analgesia appear to be at greater risk of developing post‐traumatic stress disorder than patients who do receive opioid analgesia.9 Inadequate peri‐operative pain control has been associated with complications such as myocardial infarction, deep vein thrombosis, pneumonia, pulmonary embolism, anxiety and depression.10 Failure to diagnose and treat depression, post‐traumatic stress disorder and other common psychological sequelae of trauma experiences often results in chronic social dysfunction.11 Thus, aggressive pain control and attention to psychosocial support in humanitarian crises are both ethical and medical imperatives.

Considerations for integrating palliative care into responses to humanitarian crises

The consequences of humanitarian crises may vary greatly depending on the specific type of crisis as well as the vulnerabilities of the affected population. The following formula may be used to estimate the risk of such crises on populations: Risk = Hazard × Vulnerability.

Poor people and those living in low income settings generally are most vulnerable to unnecessary suffering and death because health care and social support systems in these areas may be dysfunctional, inaccessible or overburdened. In addition, in the setting of violent conflict and sudden onset disasters, any health facilities that have not been destroyed by the disaster are often inundated with patients. With such limited remaining health infrastructure, acutely ill and injured patients often receive priority. This may result in neglect of highly vulnerable patients such as those with chronic conditions, older people, and women of reproductive age, leading to still more avoidable suffering.

Regardless of the type of humanitarian crisis or the types of suffering it causes, several principles apply to the triage process (Box).1,12

• Relief of suffering is paramount. Saving lives is a crucial way to relieve suffering, but not the only way. There is no dichotomy between saving lives and palliative care, and palliative care should be integrated as much as possible into treatment of patients triaged in the immediate/red category.
• Any patient triaged into the expectant/blue category should be provided with immediate palliative care.
• Patients triaged into the delayed/yellow or minimal/green categories should receive a palliative care assessment, as there may be symptom relief and/or palliative care needs.

To provide palliative care for people affected by humanitarian crises, the following are essential:1

• recognition that people affected by humanitarian crises may suffer physically, psychologically, socially or spiritually;
• a set of safe, effective, inexpensive, off‐patent and widely available medicines;
• a small set of simple and inexpensive equipment;
• basic social supports; and
• human resources trained to apply the above appropriately, effectively and safely, and to provide psychological and spiritual support.

Essential medicines include oral fast‐acting morphine and injectable morphine. Without these effective pain relief and palliative care are not possible. Essential medicines also include an oral and injectable benzodiazepine (diazepam), a selective serotonin uptake inhibitor (fluoxetine or sertraline), and an oral and injectable neuroleptic (haloperidol), to treat psychological distress such as anxiety, depression, and delirium.1 Other injectable medicines such as midazolam and ketamine may be needed for conscious sedation and invasive procedures. Essential equipment varies depending on existing resources but typically includes a secure lock box for controlled medicines such as opioids, adult nappies (or cotton and plastic to fashion rudimentary nappies) to minimise family or caregiver burden, and a rechargeable flashlight to enable family or caregivers to provide patient care at night where there is no other source of light. Essential social supports also vary depending on the situation but may include food packages, sleeping mats, shoes, soap and toothbrushes.

Essential human resources consist almost entirely of existing humanitarian responders but with additional training in basic palliative care lasting 35–70 hours.1 Basic palliative care training should include the following topics:

• definition and moral imperative of palliative care;
• prevention, assessment and pharmacotherapy of pain and other physical symptoms and psychological distress;
• psychological first aid and communication skills such as delivering bad news;14
• assessment and relief of social suffering;
• assessment for spiritual distress and engaging qualified local spiritual supporters;
• training local clinicians in palliative care and technical assistance to integrate palliative care into the local health care system; and
• clinician resilience, and prevention, assessment and response to burn‐out.

In most situations, clinicians with basic primary palliative care skills can respond adequately to the palliative care needs of the affected population. Assistance with the most difficult cases can be provided via telemedicine. For unusual crises resulting in many patients with very severe or complex symptoms, we recommend the addition of a palliative care physician or nurse practitioner who has undergone disaster medicine training to address the immediate palliative care needs of patients and to assist local providers to integrate palliative care services into the affected health system. In such large scale humanitarian crises, we also recommend involvement of mental health experts to treat the resulting long term psychological trauma and to partner with local providers to integrate mental health care into the affected health system.

Detailed guidance on assessment and treatment of mental health problems in humanitarian crises is available from the WHO.13,14,15

Conclusion

It is medically and ethically imperative that palliative care, the prevention and relief of suffering, be included as an essential function of responses to humanitarian crises. Disaster response teams can take concrete steps to ensure that they are equipped with an essential palliative care package that includes safe, effective and inexpensive medicines, simple equipment and social supports, and to ensure that team members have the necessary basic training to apply these materials effectively.