Dear Editor,
According to the International Association for Hospice and Palliative Care (IAHPC), palliative care is the active holistic care of people with serious health-related suffering due to severe illness, especially those near the end of life (1). The World Health Organization (WHO) estimates that about 20 million people worldwide need end-of-life palliative care services each year, about 80% of whom live in low and middle-income countries (2). Providing palliative care improves the quality of life while reducing health care costs (3). Access to palliative care, as a pain relief procedure, is a human right. Palliative care is very effective in relieving the pain and suffering of people with a life-threatening illness. However, millions of people around the world cannot access palliative care, which can lead to severe pain and suffering (4). Therefore, developing palliative care is valuable for health systems in terms of many aspects.
Target groups for palliative care services can be defined considering a range of factors: advanced chronic condition or disease, limited life prognosis, multidimensional needs, and the need for comprehensive and integrated care (5). Palliative care should be an integral component of healthcare and humanitarian services in infectious disease outbreaks, as it is the response to serious health issues and a human right that should be available to all (6). There is evidence about the need for palliative care during viral epidemics such as SARS (7). There is also a need for palliative care services in the COVID-19 pandemic, although the palliative care approach is not sufficiently developed in Iran.
According to a survey generating 2017 data on the indicators of palliative care provision, countries are classified into six categories including (1) no known palliative care activity; (2) capacity-building; (3A) isolated provision; (3B) generalized provision; (4A) preliminary integration into the mainstream provision; and (4B) advanced integration. Iran is in the 3A category, and its characteristics include the development of palliative care activism in several locations with the growth of local support, multiple funding sources, the availability of morphine, some hospice palliative care services from a range of providers, and the provision of some training and education (8). Thus Iran’s situation is not too bad, but yet there is a long way to reach an acceptable level.
COVID-19 disease is rapidly spreading around the world. During this pandemic, patients, families, and healthcare providers have encountered many problems. The COVID-19 patients are coping with distress and physical suffering; psychological stress and fear of being exposed to an unknown illness, shortages of medical facilities, death, and infecting others; and spiritual crises. The families of these patients also are coping with psychological and physical distress of caring for patients, fear of infecting others, being unaware of their patient’s condition, and bereavement if patients die. Patients with the underlying disease will experience a high burden of distress if they have to go to hospitals. This pandemic also puts a high burden of distress on healthcare providers, including psychological distress and fear of infecting co-workers and their family; being away from family members and relatives; depression caused by bereavement due to multiple deaths, spiritual crises; physical and mental exhaustion due to heavy workload; lack of enough personal protective equipment; and lack of detailed knowledge of the novel coronavirus. Providing palliative care services is a solution for many of the mentioned pressures and concerns for all of these groups. However, unfortunately, the current palliative care service capacity in Iran is limited, and many care providers are not familiar with palliative care services.
Policymakers and healthcare providers should know why palliative care services during the disease outbreak are important. By reviewing palliative care services, we can find that each of them is applicable and necessary during infectious viral epidemics. People who are facing COVID-19 can benefit from pain and symptom management; psychological and spiritual consultations; discovering the concerns, values, and preferences of patients and families; advanced care planning; bereavement services; supportive social services; case management; communication services; drug management; end of life care; ethical care, human rights, and legal protection; and supportive care for family and care providers. Another important point to consider is to avoid unnecessary services in critical situations due to resource shortages. Research indicates that palliative care at the end of life reduces the likelihood of using intensive care units and also reduces hospitalization costs (9, 10). Some people who are infected by COVID-19 may not be interested in receiving life support services. By integrating the palliative care approach into the health system and disaster management structure, unnecessary procedures and services can be avoided. In this way, hospitals can prevent the excessive death of those who have the chance to survive by saving limited resources.
Despite the severe economic recession, great efforts have been made to control the COVID-19 pandemic. In the study by Meskarpour et al. (11), the response of Iran’s health system to addressing the COVID-19 pandemic has been categorized in seven main areas, including hygiene, treatment, education, logistic, crisis management, research management, and management of communication and information. One of the most important initiatives in Iran was the implementation of an online screening plan through the Ministry of Health’s website. However, the issue of contact tracking and controlling the disease transmission chain has been neglected. Furthermore, there is no comprehensive and integrated guideline for reducing or stopping social contacts and restricting the movement of the urban population (11). Due to several reasons such as economic and cultural problems, the pursuit of quarantine restrictions in Iran has been weaker than in countries such as China and some European countries.
It may still be hasty to judge Iran's level of success in the COVID-19 pandemic crisis, but according to available statistics, the number of patients identified after a downturn has an ascended trend again in a short period (12). This issue indicates a relatively low success rate in dealing with the crisis. There are still psychosocial issues among healthcare providers, patients, their relatives, and even the general population (13, 14). Besides, various countries around the world, especially developing countries such as Iran, are facing a serious shortage of resources and equipment (15). The situation would worse until experts gain much knowledge about the disease and find a definitive treatment or vaccine; it seems we have a relatively long way forward.
Providing palliative care is a solution for many of the problems caused by the COVID-19 pandemic. Even if we cannot take full advantage of palliative care in the current crisis, we can learn lessons for future planning and policy-making. The problems caused by the COVID-19 pandemic in Iran can remind policymakers, managers, the scientific community, and health care providers the importance of palliative care. Although the capacity for palliative care in Iran is relatively low, there are some international specific resources to palliative care in COVID-19 and other such future crises. However, the level of awareness and application of palliative care protocols in the pandemic is low in the health system. Palliative care is invaluable not only in critical situations but also in all situations in the health system, and attention should be paid to launching those services as soon as possible.
