Pattern of referral of noncancer patients to palliative care in the eastern province of saudi arabia.

AIM: The palliative care (PC) needs of patients with noncancer life-threatening illnesses are comparable to that of cancer patients. This report describes the contribution of noncancer patients to the population of PC patients in a tertiary care hospital in the Eastern Province of Saudi Arabia.
MATERIALS AND METHODS: This is a retrospective review of the "palliative care inpatient database" of 21 months.
RESULTS: From 474 patients, 20 (4.2%) had a noncancer diagnosis. The main reason for the referral of noncancer patients was pain control. The most prevalent diagnoses were sickle cell disease (SCD) in 6 (30%) patients and peripheral arterial disease (PAD) in 5 (25%).
CONCLUSIONS: These findings suggest that the PC needs of noncancer patients are largely unmet in our region. Further efforts are necessary to advance noncancer PC in Saudi Arabia. The PC needs of patients with SCD and PAD need to be addressed in future research.

INTRODUCTION

Palliative care (PC) in Saudi Arabia is in the stage of localized provision, where it is represented by few hospital-based PC programs in major cities.

Dammam is the capital city of the Eastern Province of Saudi Arabia where the only available PC service is located at King Fahad Specialist Hospital-Dammam (KFSH-D), a 640-bed tertiary referral hospital.

Although patients with life-threatening illnesses other than cancer have PC needs comparable to those of patients with cancer, these needs are largely unmet due to many barriers.

In this report, we describe the pattern of inpatient noncancer referrals to our program. This may provide guidance for the future development of PC in our region.

MATERIALS AND METHODS

The PC program of KFSH-D was established in 2007 and serves cancer as well as noncancer patients through an eight-bed inpatient unit, a hospital-wide consultation service, an outpatient clinic (four per week), and community care through the home health care program of KFSH-D.

The source of data is the “palliative care inpatient database.” The database was initiated in 2009 and includes data about inpatients looked after by the PC team as a primary care giver or as a consulting service. The following data were retrieved from the database: age, gender, primary diagnosis, referring specialty, and the admission outcome.

All inpatients admitted by or referred to the PC service from April 2009 to December 2010 were included in this retrospective review.

The study was approved by the institutional review board of KFSH-D.

RESULTS

During the specified period, the PC team cared for 474 patients out of a total of 727 admissions.

Twenty patients (4.2%) had a noncancer diagnosis. Characteristics of noncancer patients are shown in Table 1. Sickle cell disease (SCD) and peripheral arterial disease (PAD) accounted for more than half of these patients (55%).

Table 1

Characteristics of 20 noncancer patients referred to palliative care

Fifteen (75%) of noncancer patients were referred mainly for pain control.

The majority (454, 95.8%) were cancer patients. The most common primary cancer diagnoses were breast in 81 (17.8%) patients, colorectal in 54 (11.9%), hematological in 45 (9.9%), and lung in 42 (9.3%).

DISCUSSION AND CONCLUSION

Only 4% of inpatients looked after by the PC service at KFSH-D had a noncancer diagnosis. This percentage is much lower than the estimated percentage of noncancer patients among those who are in need for PC in an acute care hospital setting.[1-3] In a survey to identify inpatients with terminal life-threatening disease in a French university hospital, 53% of identified patients had a noncancer diagnosis.[1] Another survey in a British acute care hospital found that noncancer patients represented 45% of inpatients identified to have PC needs and/or be terminally ill.[2] Similarly, noncancer diagnosis accounted for 47% of inpatients who were expected to die within 6 months or considered terminally ill but not imminently dying in a general hospital in the United States.[3]

The low rate of noncancer referral to PC was reported in a previous study conducted in the Central Province of Saudi Arabia where only 2% of inpatients referred to PC had a noncancer diagnosis.[4] Inadequate noncancer PC is a problem that should be addressed at a national level in Saudi Arabia.

Being a major tertiary care facility in our region, KFSH-D is expected to care for noncancer patients in need for PC like those with end-stage neurological, hepatic, and renal diseases. Unfortunately, for the time being, the exact number of these patients and their contribution to the true PC population are not known. There is an ongoing effort to develop effective survey methods to identify patients in need for PC in the hospital setting.[5] The implementation of such survey tools, increasing awareness on noncancer patients’ PC needs, research, and other measures are needed to improve noncancer PC in Saudi Arabia.

The scope of noncancer PC differs from a region to another. For example, in the United States, the common diagnoses of noncancer patients receiving PC are advanced cardiovascular, respiratory, and neurological diseases.[6] On the other hand, in Sub-Saharan Africa, with high HIV/AIDS mortality, noncancer PC is directed mainly to terminally ill HIV/AIDS patients.[7]

In our setting, patients with SCD or PAD represented more than half of noncancer patients referred to PC. Although this may not truly represent the population of noncancer patients in need for PC in our region, the PC needs of patients with SCD and PAD need attention.[89]

The most common diagnosis among noncancer patients referred to our PC program is SCD. This is not surprising because the prevalence of SCD in the Eastern Province of Saudi Arabia is among the highest worldwide.[1011] SCD is a debilitating disease with a negative impact on different aspects of quality of life.[12] In addition to the suffering resulting from pain and other physical symptoms, patients with SCD are at risk to experience other aspects of suffering including social, psychological, and spiritual suffering.[8] The detrimental effect of SCD on the quality of life is not limited to affected patients and extends to their caregivers.[13] The treatment of SCD is usually palliative,[14] and a significant proportion of SCD and their caregivers may benefit from the holistic PC approach. However, the palliative and end-of-life care needs of patients with advanced SCD are largely unmet.[8] Few reports addressed the need for PC provision for patients with SCD.[815-18]

In her response to a review article about the management of SCD, Seton-Jones criticized the review for ignoring the palliative and end-of-life care needs of patients with SCD. She mentioned that PC should be, at least, integrated into the care of patients with severe SCD to deliver better end-of-life care.[8] Benjamin and Wilkie et al. suggested a multidisciplinary PC approach throughout the disease trajectory which may start at diagnosis of SCD.[1618]

A quarter of patients referred to PC in our setting had PAD and were referred mainly for pain management. The PC needs of patients with PAD are even less addressed in comparison to SCD. Due to cardiovascular, respiratory, renal, and other comorbidities, a subgroup of patients with PAD is not a candidate for surgical interventions and a realistic approach of care for them is PC.[19] The multidimensional suffering and prognosis of patients with advanced PAD is comparable to that of a group of advanced cancer patients.[9] There is a need to identify poor prognosis PAD patients earlier during the course of their disease and integrate PC into their care to relieve their physical, social, psychological, and spiritual suffering.[9]

Research is needed to identify the PC needs of patients suffering due to noncancer life-threatening illnesses prevalent in our region like SCD and to develop suitable PC delivery models.