Palliative care Research educational program in Cuba
IAHPC Traveling Fellowship Report
Dr. Richard Harding
Lecturer Department of Palliative Care & Policy
Guy's King's & St Thomas ' School of Medicine London
Palliative care is in its infancy in Cuba, the goal of my visit was to provide an educational program designed to provide information about the growth and development of the discipline of hospice and palliative care. The Traveling Fellowship was made possible by a grant from the International Association for Hospice and Palliative Care (IAHPC) to cover the expenses of my trip in November, 2005.
The Cuban program was convened by Dr Ivan Justo Roll who is based in the Tomas Romay Policlinic in Old Havana. The clinic serves a local population of about 30,000 Cubans with a full range of primary care including dentistry and midwifery. It is open 24 hours/ day, seven days/week, and is the home to Dr Justo Roll’s palliative care service, one of the only specialist and dedicated palliative care services in Cuba.
The teaching program was offered daily and included half days of lectures and seminars, with 2 additional afternoons spent in large hospitals. Our educational program coincided with the Cuban World Day for Hospice and Palliative Care. The course was taught with the assistance of Ms. Jennifer Kwakwa, a specialist palliative care nurse from the UK who has an academic post at Peninsula Medical School and a clinical post at the Grand Cayman Hospice Service. The aim of our combined presence was to provide an understanding of the philosophy of palliative care, along with some clinical guidance with examples and to provide a framework on which to begin to build an evidence based program. To ensure that indigenous perspectives were recognised, lectures were also given by Cuban psychologists, paediatricians and oncologists.
The Policlinic course was well attended by a group of multi-professionals including doctors, nurses, social workers, psychologists and medical students. All teaching materials were translated into Spanish prior to the commencement of the programme each day; continuous translation facilitated full participation by all those present.
Particular gravitas was attached to the lectures we delivered at the Miguel Enriquez Hospital and Enrique Cabrera Hospital. At the first hospital, the lecture was hosted by the Medical Director and Head of the Medical School and was attended by about 200 doctors and nurses. At the second hospital, the head of each clinical specialty and approximately 50 doctors and nurses attended. During the receptions for us following each lecture there was a strong and lively debate about the potential for palliative care growth in Havana.
A number of dominant issues were raised by each audience. First was the slow cultural shift in Cuba to disclose to patients a diagnosis and prognosis. There is a strong tradition of not telling a patient about a diagnosis of an incurable malignancy, and furthermore, families require that doctors do not break bad news to patients.
It was clear to us, as well as to the attendees, that palliative care cannot satisfactorily exist solely in either hospital or community, and that integration across both was necessary as they develop in parallel.
It is also clear that there is a growing recognition of the benefits of palliative care in Cuba. Cubans also recognize the need to work with their own cultural and political traditions in order to develop and apply a palliative care model in their country. For example, where resources are limited, teaching focuses on the potential for palliative care to exist outside of the traditional hospice building. Only through self determination and collaboration, when requested, can Cubans succeed in integrating palliative care across clinical settings. There is certainly a role for the international palliative care community to help where they can. Open and honest end of life communication and care can only take place once there is a cultural shift from the present. There are certainly opportunities for the international palliative care community to assist in the development of educational resources for the training nurses and medical students.
A significant development at the end of the week was a collaborative planning session to develop an evidence based program for palliative care. This will be assisted by the recent translation and validation of a Spanish Palliative Outcome Scale (POS) in Argentina, which is planned for use in Cuba.
Clearly the course generated a greater awareness and interest in palliative care provision in Cuba. While further developments can only be achieved from within the Cuban healthcare system, it is important for international palliative care to be ready and willing to respond appropriately when requested to do so. We should ensure that those who are pioneering palliative care within Cuba are included in our global efforts and that they also have access to advocacy and education resources. The Latin American Palliative Care Association may offer the greatest potential to provide such help, particularly since Cuba already offers clinical education to many students from the region. Another important development could be the successful establishment of a Cuban National Palliative Care Association.
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