Report on IAHPC Traveling Fellowship to
St. Petersburg , Russia
John C. Ely M.D.
Background:
With the generous support of a traveling fellowship grant from the International Association of Hospice and Palliative Care, I spent two weeks in St. Petersburg , Russia in October 2004 as a faculty member presenting an ongoing Palliative Medicine Curriculum course to Russian physicians and nurses.
This ongoing course is a diploma-level program in Palliative Medicine, with certification of graduates through the Pavlov Medical University in St. Petersburg in cooperation with Anglia University in the UK . The course represents the combined collaborative efforts of these institutions and the UK-based charitable organization St. Petersburg Healthcare Trust.
The dedicated, highly skilled physicians and nurses participating in this course have a keen interest not only in developing and maintaining their state-of-the-art clinical skills, but also in elevating the status of palliative medicine in Russia to that of specialty-level care.
Activities:
A strenuous week-long teaching schedule was maintained presenting a didactic and hands-on symposium entitled “Biomedical Aspects of Advanced Cancer Care” to Russian palliative care physicians and nurses in St. Petersburg . This symposium included modules in symptom management, ethical decision making and language in end-of-life care, procedural workshops, and specialist-level palliative care case studies. In addition, our group of presenters, including myself, Dr. Kelvin Bengston, Ms. Terry Magee, Director of Education, and Ms. Beverly Snowball, MacMillan Nurse (all from St. Helena Hospice in Colchester, Essex, England) spent time at several hospices in St. Petersburg with patients, staff and administrative personnel. This on-site time afforded us many opportunities to compare clinical management approaches with our Russian colleagues, to do hands-on teaching at the bedside, and to discuss strategies, problems, and patient care protocols
Our group, along with a large number of local citizens, had the pleasure of attending a performance of Mozart’s “ Symphony Number 25 in G Minor Requiem” at the Grand Philharmonic Hall on October 18 th in St. Petersburg . The beneficiaries of this charitable event were originally intended to be the hospices in the St. Petersburg area, but a change was made and proceeds were subsequently directed to support the victims and families of the Beslan school hostage-taking crisis that had occurred one month earlier. The generous hearts of many Russian people were in evidence at this benefit performance.
Accomplishments:
-Participation in the delivery of ongoing palliative care education to Russian clinicians.
-Participation in this education at a University-recognized diploma level course, which facilitates the elevation of Palliative Medicine to specialty level in Russia , thus validating the professional status of Palliative Medicine clinicians in the eyes of their medical specialist colleagues.
Observations:
Morphine in particular, a mainstay in the treatment of end-of-life symptoms, is not readily available to clinicians for their hospice patients. The parenteral morphine that is available must be given intramuscularly, due to bureaucratic regulations that require a physician to “sign for” each dose of opioid administered, as well as to dated misconceptions about the risk of prescribed opioids for end-of-life patients. The maximum dose of morphine available to each patient daily is often limited to 50 mg. Oral morphine preparations are relatively unavailable and prohibitively expensive, due to bureaucratic issues as well as corruption, crime and concerns about distribution.
The culture of the Russian medical system as a whole is not oriented toward giving patients full disclosure and accurate information about their diagnoses. Our Russian colleagues indicated that patients who are referred to them are often surprised when palliative care team members willingly and openly discuss diagnoses and prognoses in detail. Russian palliative care physicians and team members are challenging an entrenched cultural norm as they lead by example in providing information much wanted by patients and their families.
In some instances, due to poverty and societal instability, the presence of a hospice necessitates the presence of an orphanage or other facility to care for children following the death of a parent, particularly that of a mother. At times, in spite of strong and loving connections that are characteristic of many Russian families, surviving family members are simply not financially capable of meeting the needs of orphaned children, and these children are left without support. I was particularly impressed by the extraordinarily creative efforts of the nuns and nurses at Lakhta Hospice in providing these services to the surviving children of their patients.
Progress is being made, albeit in some instances slowly, in the advancement of palliative medicine within the Russian medical system. On a positive note, a new hospice facility is being completed and scheduled to open in the Kaliinsky district of St. Petersburg; less encouraging is the fact that an experienced palliative care physician was not chosen as the medical director of this facility.
Globalization and its effects are ubiquitous. Although St. Petersburg (or simply “Peter” as it is referred to by locals) can boast of one of the most beautiful city centers in Europe, automobile traffic problems have taken on a huge proportion in this city; this made our efforts to travel to the individual hospices in the evenings for Master Class sessions a daunting task.
The level of engagement and dedication on the part of our Russian colleagues was truly inspirational. The doctors and nurses we were privileged to work with are extraordinarily competent clinicians, providing outstanding care to their patients in spite of material and bureaucratic limitations, and were a pleasure to be involved with during our time in St. Petersburg.
Future Activities:
Our teaching group will return to St. Petersburg in April and October of 2005 to present further modules of this diploma-level course, to establish further connections with the Russian hospice community, and to continue to teach and learn from our Russian colleagues.
My sincere thanks to the IAHPC for their generosity in supporting international palliative care initiatives such as the one I participated in.
John C. Ely M.D.
St. Paul , Minnesota USA
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