Review Article Open Access
Palliative Care in the United Arab Emirates, a Desperate Need
Humaid O Al-Shamsi, Mona Tareen3
1Department of Oncology, University of Sharjah, Sharjah, United Arab Emirates
2Emirates Oncology Association, Dubai, United Arab Emirates
3American Hospital, Dubai, United Arab Emirates
*Corresponding author: Humaid O Al-Shamsi, MD, MRCP (UK), FRCP(C), FACP, University of Sharjah, Sharjah, United Arab Emirates. Tel: +971506315388; E-mail: @
Received: August 10, 2018; Accepted: August 16, 2018; Published: August 20, 2018
Citation: Al-Shamsi HO, Tareen M (2018) Palliative Care in the United Arab Emirates, a Desperate Need. Palliat Med Care 5(3): 1-4. DOI: 10.15226/2374-8362/5/3/00161
AbstractTop
The enormous burden of life-threatening illnesses including cancer is associated with physical and psychosocial suffering explains the illustrious and desperate need for palliative care in developing countries. Despite the demonstrated and proven benefit of palliative care in developed countries , current provision of effective and well structured palliative care in developing countries including the United Arab Emirates (UAE) is at best very limited. Access to essential pain medicines in developing countries, particularly oral opioids, for pain control is extremely limited and far below the global mean. Cancer patients in the UAE are having major difficulties in accessing palliative care services due to the limited palliative care facilities and trained physicians and other palliative health support workers in this field. There is a general lack of government policies that recognize palliative care as an essential component of the current health care system and there is inadequate training for both health care providers and the general public about palliative care. We recommend establishing palliative care program within a public health strategy as part of a national cancer control plan, as recommended by the World Health Organization (WHO), which offers the best approach for translating knowledge and skills into evidence‐based, cost-effective interventions that can reach everyone in need of palliative care in the UAE.

Keywords: Palliative Care; Health Research; Policy; Cancer; Barriers; Communications; Developing countries
Introduction
As cancer rates climb in the developing world, an urgent need for palliative care services has emerged, outpacing even the need for cancer treatments, since most cancer is diagnosed at a late stage in the developing countries due to lack of structured screening program[1]. In 1990, the World Health Organization (WHO) defined palliative care for the first time as “ the active total care of patients whose disease is not responsive to curative treatment and that control of pain, of other symptoms and of psychological, social and spiritual problems is paramount ”[2]. The goal of care is achievement of the best possible quality of life for both the patients and their families [2]. The WHO currently defines the palliative care public health model as having three basic components: policy, education, and drug availability [3]. In developing countries, attention to palliative care has been minimal, since public health programs have focused largely on preventing and treating infectious diseases and malnutrition. Studies have shown that only about 6% of all palliative care services are located in Asia and Africa [1].

Cancer has only recently emerged as a public health problem in the developing world, Because access to health care can be minimal and diagnostic services poor, most cancer is diagnosed at late stages of the disease, making palliative care an immediate need [1]. Patients with advance terminal cancer should be provided with efficient pain and symptom management with the aim to improve their quality of life [4]. Contemporary current medical knowledge is sufficient to control the suffering of most of the millions of terminally patients in the world if applied appropriately [5]. Beside symptoms control, early implantation of palliative care has been shown to improve survival and quality of life in advanced cancer patients [6-8]. It has been also shown that palliative care consultation teams cut hospital costs for terminal palliative cases [9]. This is achieved by multidisciplinary approach with the involvement of various support staff such as social workers, psychiatrists, dieticians, physiotherapists, speech and language therapists, clinical pharmacists, home health care nurses and physicians, and pain management physicians. This multidisciplinary approach reduces the physical psychological and social suffering of the cancer patients and their families[4]. This paper will discuss palliative care in UAE in general with special emphasis on cancer palliative care. This is the first published paper that discusses and addresses the issue of palliative care in the UAE in depth.
Brief synopsis about the UAE
The United Arab Emirates (UAE) is a relatively young country established in December 1971 and located in the southeast of the Arabian Peninsula. It is a federation of seven emirates (states); Abu Dhabi (which serves as the capital), Dubai, Sharjah, Ajman, Fujairah, Ras al-Khaimah and Umm al-Quwain (the last 5 emirates are known all together as the Northern Emirates). The population of the UAE has almost tripled between the 1990 and 2005 due to large inward migration [10] with estimated population of 9.2 millions in 2013 (population estimates: 287,000 in 1971, 4.1 million in 2005, 8.3 million in 2010) [11], The majority of the population in 2013 (7.8 million) are expatriates from around the world specially Asia, only 1.4 million (15.2%) are Emirati (UAE) citizens. This multinational population with varying degree of education, religious and cultural backgrounds may pose a challenge for public health strategies [10]. The UAE has the world’s third-largest conventional oil reserves, and its fifthlargest natural gas reserves [12]. The UAE’s 2015 GDP per capita ranked in the 95th percentile globally [13]. The UAE is classified by the United Nation as a developing country [14]. The UAE health system was ranked twenty-seventh in the world by the World Health Organization [15]. The health services in the UAE are covered by government funded health insurances, private insurance or self pay [16], The current UAE’s immigrations rules mandate compulsory basic insurance for all expatriates, UAE citizens all have government funded health insurance and they vary on their coverage based on the emirate of residence. In the UAE, approximately 4,500 new cases of cancer are reported in a year [17]. Cancer is the third leading cause of death in UAE after diseases of the circulatory system and injuries. A total of 758 deaths from cancer occurred in 2014, equivalent to a crude mortality rate of 8.34 deaths per 100,000 [18].
Current Status of the Palliative Care in the UAE
The palliative care in the UAE is very limited and only available in two hospitals in the UAE. The two hospitals are Tawam hospital in Al-Ain city which is a government funded tertiary cancer center in the UAE and the American hospital in Dubai which is a private hospital that provides a comprehensive cancer treatment including palliative care. Due to the limited services of palliative care in the UAE, the palliative care in the UAE has been classified by the WHO as “Group 3 countries” which identified as isolated palliative care provision in the country. This group of countries is characterised by: the development of palliative care activism that is patchy in scope and not well supported; sourcing of funding that is often heavily donor dependent (which is not the case in the UAE); limited availability of morphine and opioids; and a small number of hospice-palliative care services that are often homebased in nature and relatively limited to the size of the population [3].

The first and only comprehensive government funded palliative care program in the UAE was established in Tawam hospital in 2007 as a consultation service and was developed into a complete division within the oncology department providing outpatient clinics and inpatient consultations with a dedicated inpatient unit. The number of outpatient visits and inpatient consultations in this Palliative Care program has been increasing at a steady rate over the last decade, official data from the palliative care program is not available publicly [4]. Palliative care service at the American hospital which is a leading private hospital in Dubai is an outpatient based palliative care clinic with inpatients consultation service.

The palliative care service at American Hospital in Dubai started in 2014 December, providing inpatient level of care as a palliative Hospitalist in conjunction with the oncology and radiation oncology team. The service is currently restricted to oncology given lack of understanding the value of palliative non hospice services for non oncology patients, for example end stage Dementia, pulmonary fibrosis and end stage congestive heart failure. The current volume is around 4320 new palliative consult a year. As per Center to Advance Palliative Care, calculator for expected volume and projection in cost savings would be US$ 3,274 per case admitted. In our opinion even with the availability of palliative care service it remains underutilized.

For both main palliative centers in the UAE (Tawam Hospital and also the American hospital), There is a desperate need for addition of counselors, care coordinators as well as nursing staff especially trained in palliative medicine to help with grief support and alleviate existential suffering [19].There is a need for the integration of palliative medicine into standard oncologic practices as evident in ASCO clinical guidelines [20].

Of note there is no government or private hospice in the UAE , yet there are multiple private for profit palliative care providers lead by palliative nurses mainly in Dubai and Abu Dhabi providing palliative care services and in home end of life care. Of note many insurance policies in the UAE specifically exclude palliative services; these services are generally expensive and more than average patients’ abilities to afford. These services also are not regulated or audited in any formal way so we cannot make any clear comments about their activities, competencies or how much these services are contributing to the palliative care landscape in the UAE. There is a need for an umbrella organization to governor and ensure these services are providing an evidence based , up to date and safe level of palliative care for the palliative care patients in the UAE.
Pain Medications
Developing countries consume only about 9% of the world’s morphine, even though they account for 83% of the world’s population. Meanwhile, only 10 countries consume 91% of the world’s morphine, according to the Pain Policy Studies Group at the University of Wisconsin [1].

Extensive research in the field of pain management at the end stage of cancer and last week of life showed that 35% describe the pain as severe or intolerable [21]. Pain control and management at the end of life is the right of the patient and the duty of the health care providers. The WHO states that patients have a right to have their pain treated and controlled adequately based on clear guidelines and recommendations [22]. Adequate pain relief can be achieved in 70% to 90% of patients when treatment guidelines are followed [22]. Unfortunately, the availability of effective therapy has not eliminated the problem of ineffective cancer pain management. Ineffective cancer pain management can results from health care provider, patient/family, and health system-related barriers [23]. Health care provider-related barriers include poor assessment of patient’s pain, inadequate training and education on management of cancer pain, inadequate time and resources to address cancer pain, greater attention toward cancer treatment rather than pain management, and poor knowledge and fear of opioids over use [23-25]. Patient/family related barriers include fear of addiction and dependence, fear that complaining of pain could distract the treatment process, belief that cancer could not be treated and nothing could be done, inability to express pain to nurses, and lack of adherence to treatment regimens [23,25]. In the 3-step analgesic ladder, the use of morphine for cancer pain management has not been the gold standard approach although opioids continue to be the mainstay of pain treatment, morphine is relatively cheap, and it is the most widely available opioid analgesic. The median consumption of opioids in the United Arab Emirates is 3.02 % as compared to other in the region 3.27%(excluding methadone) [26].

The per capita global consumption of morphine in the UAE was 0.3824 , this is a very low rate when compared with global mean of the per capita global consumption of morphine which was ta 5.93. The UAE consumption is very low compared with developed countries like Canada 52.05, USA 28.96 and UK 19.99. In Asian developing countries, UAE was still low compared with other Asian countries like Malaysia 0.84 but higher than other developing countries like Indonesia 0.01 and Myanmar 0.05 [13].

One of the major barriers for prescribing opioid in our opinion is the widespread over-regulation of opioid use in the UAE. For example only consultant physicians are permitted to give 30 days’ supply of narcotics, while general physicians or physicians in training are permitted to give 7 days’ supply only. Another example for over regulations, in the emirate of Abu Dhabi, a narcotic can be prescribed only by a physician licensed by the local health authority for an in-patient and must be written on the approved narcotic prescription form. Private sector prescriptions for out-patient narcotic supply are not usually allowed. However, exceptions will be considered following a request from from the medical director of that private health facility [27]. These strong bureaucracies involved in terms of procurement and dispensing of opioids are very common in developing countries and have been addressed in previous studies as one of the main barriers in pain control in these countries [28]. These measures are certainly a step to avoid opioid and narcotic abuse, protect the public and control the prescription of narcotics but this process in our view is very critical barrier especially in a busy clinic were these special controlled drugs prescriptions pads are locked in a secure area and only accessed when there is a need to prescribe controlled drugs, This process is very time consuming and can take between 30-45 mins to prepare a single opioid prescription. One of the suggestions to facilitate this process is by using a special serial numbered prescription pads that carries the physician name and facility and this pad will be linked to the physician and will be used by him/her only. This may improve the ease of accessing prescription pads and opioid prescription across the UAE for patients with pain.

Another major barrier is that many essential opioids are not registered with the regulatory health authorities in the UAE and if a specific medication is needed and not registered with the regulatory health authorities where the hospital fall under this regulatory authority, then this unavailable medication has to be ordered from abroad through a special request and approval from the regulatory health authority where the hospital is located in a process that may take 2-3 months. Example for that includes Hydromorphone, where hydromorphone which is about eight times stronger than morphine is neither registered with Dubai Health Authorities or UAE Ministry of Health [29]. Oxycodone is another example that is not registered with Dubai health authority. Methadone which is very important tool in refractory pain management in cancer and non cancer pain is only registered for detoxification of opioids dependency. The drug is not registered as pain medication tool and it is difficult to obtain for pain management as it is highly regulated and only released for detoxification of opioids dependency from pharmacies.

Another critical component in our opinion is inadequate training and education on management of cancer pain by health care providers. The authors acknowledge from their experience in the UAE there is a fear of prescribing opioids, and if they were prescribed are most likely prescribed in a suboptimal doses and frequencies. Patient Controlled Analgesia (PCA) use is very limited in outside hospital setting and there are medicolegal barriers pertaining to discharging patients on an infusion “Potentially Deadly Drug”. With the appropriate steps which includes reviewing and revising the existing policies with the stakeholders and health authorities, educating the physicians about the basic skills of pain management through workshops, conferences and small group educational sessions. Recommending a list of palliative medications for pain and also other palliative symptoms management as mandatory medications on each health authority’s formulary.
Research
Palliative care research shares most of the obstacles common to health research in the developing world. Additional obstacles include a lack of consideration of palliative care as part of cancer control strategies and the low political acceptability of such care because it involves the use of opioid analgesics and may be perceived by health care stockholders as futile and less important than active treatment of cancer itself. Coordinated research efforts through active networking between physicians, health authorities and governmental bodies would increase the visibility of the discipline, provide answers relevant to the local contexts, and assist in expanding palliative care services across the developing world including the UAE [5].
Conclusion
The UAE has made strident efforts to advance health care for it is citizens and residents. Palliative care and supportive services are very limited in the UAE. Cancer patients in the UAE are having major difficulties in accessing palliative care due to limited palliative care facilities and qualified palliative physicians and nurses. Currently there is no cancer hospice in the UAE. We recommend establishing palliative care program within a public health strategy as part of a national cancer control plan, as recommended by the World Health Organization (WHO), which offers the best approach for translating knowledge and skills into evidence‐based, cost‐effective interventions that can reach everyone in need of palliative care in the UAE.
ReferencesTop
  1. Crane K. Palliative Care Gains Ground in Developing Countries. JNCI. Journal of the National Cancer Institute. 2010; 102(21): 1613-1615. DOI: 10.1093/jnci/djq445
  2. Cancer pain relief and palliative care. Report of a WHO Expert Committee. World Health Organ Tech Rep Ser. 1990; 804: 1-75.
  3. WHOWdopchwwicpdeDa. 2018.
  4. Jaloudi M, Kanbar J, James DM, et al. An Overview of Cancer Care in Societies in Transition: Global Perspectives-UAE Experience, in Silbermann M (ed): Cancer Care in Countries and Societies in Transition: Individualized Care in Focus. Cham, Springer International Publishing. 2016.
  5. Pampallona S, Bollini P. Palliative care in developing countries: why research is needed. J Pain Palliat Care Pharmacother. 2003; 17(3-4): 171-182.
  6. Connor SR, Pyenson B, Fitch K, Spence C, Iwasaki K. Comparing hospice and non hospice patient survival among patients who die within a three-year window. J Pain Symptom Manage. 2007; 33(3):238-246. DOI: 10.1016/j.jpainsymman.2006.10.010
  7. Salins N, Ramanjulu R, Patra L, Deodhar J, Muckaden MA. Integration of Early Specialist Palliative Care in Cancer Care and Patient Related Outcomes: A Critical Review of Evidence. Indian J Palliat Care. 2016; 22(3): 252-257. DOI: 10.4103/0973-1075.185028
  8. Temel JS, Greer JA, Muzikansky A, Gallagher ER, Admane S, Jackson VA. et al., Early palliative care for patients with metastatic non-small-cell lung cancer. N Engl J Med. 2010; 363(8): 733-742. DOI: 10.1056/NEJMoa1000678
  9. Morrison RS, Dietrich J, Ladwig S, Quill T, Sacco J, Tangeman J, et al., Palliative care consultation teams cut hospital costs for Medicaid beneficiaries. Health Aff (Millwood). 2011; 30(30): 454-463. DOI: 10.1377/hlthaff.2010.0929
  10. Blair I, Sharif AA. Population structure and the burden of disease in the United Arab Emirates. J Epidemiol Glob Health. 2012; 2(2): 61-71. DOI: 10.1016/j.jegh.2012.04.002
  11. United Arab Emirates National Bureau of Statistics. Global Health Data Exchange. 2013.
  12. Magazine Tf: The rising Northern Emirates, special report, 2016.
  13. John I. UAE's per capita GDP stays high. Khaleej Times. 2016.
  14. Country classification by the Department of Economic and Social Affairs of the United Nations Secretariat. 2017;
  15. Blair I, Sharif A: Health and health systems performance in the United Arab Emirates. World Hosp Health Serv.2013; 49(4): 12-17.
  16. Hamidi S, Shaban S, Mahate AA, Younis MZ. Health insurance reform and the development of health insurance plans: the case of the Emirate of Abu Dhabi, UAE. J Health Care Finance. 2014; 40(3): 47-66.
  17. The Official Portal of the UAE Government C. 2018.
  18. EMIRATES CIIUA, NATIONAL AROTU-, 2014 CR.
  19. Osman H, Shrestha S, Temin S, Ali ZV, Cleary JF. Palliative Care in the Global Setting: ASCO Resource-Stratified Practice Guideline Summary. J Oncol Pract. 2018; 14(7): 431-436. DOI: 10.1200/JOP.18.00087
  20. Ferrell BR, Temel JS, Temin S,  Alesi ER, Balboni TA, Basch EM, et al., Integration of Palliative Care Into Standard Oncology Care: ASCO Clinical Practice Guideline Update. J Clin Oncol. 2017; 35(1): 36-112. DOI: 10.1200/JCO.2016.70.1474    
  21. Ventafridda V, Ripamonti C, De Conno F, Tamburini M, Cassileth BR. Symptom prevalence and control during cancer patients' last days of life. J Palliat Care.1990; 6(3): 7-11
  22. Carlson CL. Effectiveness of the World Health Organization cancer pain relief guidelines: an integrative review. J Pain Res.2016; 9: 515-534. DOI: 10.2147/JPR.S97759
  23. Bashayreh A. Opioidphobia and Cancer Pain Management. Journal of Pediatric Hematology/Oncology. 2011; 33: 60-61. DOI: 10.1097/MPH.0b013e3182122059
  24. Hilden JM, Emanuel EJ, Fairclough DL, Link MP, Foley KM, Clarridge BC, et al., Attitudes and practices among pediatric oncologists regarding end-of-life care: results of the 1998 American Society of Clinical Oncology survey. J Clin Oncol. 2001; 19(1): 205-212. DOI:10.1200/JCO.2001.19.1.205
  25. Oliver DP, Wittenberg-Lyles E, Demiris G, Washington K, Porock D, Day M. Barriers to pain management: caregiver perceptions and pain talk by hospice interdisciplinary teams. J Pain Symptom Manage. 2008; 36(4): 374-382. DOI: 10.1016/j.jpainsymman.2007
  26. Osman H, Rihan A, Garralda E, Rhee Y J, Pons JJ, Lima DL, et al., Atlas of Palliative Care in the Eastern Mediterranean Region. Houston. 2017; IAHPC Press.
  27. Drugs and controlled medicines  hwgaei-a-sh-a-fd-a-c-m, Accessed August 17th 2018
  28. Saini S, Bhatnagar S. Cancer Pain Management in Developing Countries. Indian J Palliat Care. 2016; 22(4): 373-377. DOI: 10.4103/0973-1075.191742
  29. List of Registered Controlled Medicines (SCD CaCN, 2018 uo-hwhaHLafhMDtAAt:
 
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