Photo taken in Kolkata, India
Every country and culture has some insight to contribute to the human experience. We can all benefit from expanding our minds to explore the creative ways other cultures handle health care and death. Even if we do not take on every aspect, idea exchange can allow us to think more creatively, outside the box and to recognize the importance of every human life on a global scale.
Below is just a small snapshot of the takeaways from each of the countries I visited.
Below is just a small snapshot of the takeaways from each of the countries I visited.
Pittsburgh, PA USA |
Hamilton, Canada |
Belo Horizonte, Brazil |
In Pittsburgh, the aging population makes end of life care very important and certainly a growing field. The hospice movement has been developing with really wonderful, well rounded services to provide wonderful in home care allowing people to remain in comfort there rather than at the hospital. Within the hospital, palliative teams are growing in major research hospitals, engaging physicians, physicians assistants, ethicists, nurses and social workers in holistic care discussions.
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The 3 Wishes Project conducted in the ICU in Hamilton has humanized health care in the clinical setting. It is a beautiful and well rounded initiative, engaging the clinical team in care on a more personal level, allowing for greater fulfillment and better care for both patients and their families.
(Cook, Deborah, Marilyn Swinton, Feli Toledo, France Clarke, Trudy Rose, Tracey Hand-Breckenridge, Anne Boyle, Anne Woods, Nicole Zytaruk, Diane Heels-Ansdell, and Robert Sheppard. "Personalizing Death in the Intensive Care Unit: The 3 Wishes Project." Annals of Internal Medicine Ann Intern Med 163.4 (2015): 271) |
Though sometimes lacking in resources as well as the barrier of disparity, the Brazilian culture in which the sense of touch is of great importance is reflected in the health care system. The ability for physicians to physically assess their patients in order to understand their patients' needs and gain an authentic sense of trust and understanding is one of its huge assets.
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Wolverhampton, UK |
Cork, Ireland |
Brussels, Belgium |
The UK is the founder of the hospice movement through the influence of Dame Cecily Saunders, a nurse who began the first hospice in 1967 in London, and truly is at the forefront of so much in regards to quality, compassionate end of life care. The shift in the health care system that a "good death" is considered a "good outcome" is groundbreaking in terms of allocating the needed resources to the care for the dying. It allows for the well rounded, palliative quality of care that people receive in hospice care to be given in the hospital setting as well when appropriate.
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Ireland's hospice movement and holistic services are truly remarkable. Their diversity of services, in-patient units, home care teams, day care services, fundraising and volunteerism engages the whole community in care for the dying, thus addressing stigma around hospice care as well as sharing responsibility and making it more manageable.
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Being at the center of Europe and hub of the EU, the hospital system here engaged a great deal in education for students around the world. There was a large focus on the improvement of health care throughout Europe and the world based on best practices, particularly in the ICU as rounds were covered by doctors and fellows from Brazil, Canada, France, Greece, Spain, Ireland and Belgium. A great draw for these fellows was the systematic manner in which each person was assessed to standardize and make care more thorough.
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Zurich, Switzerland |
Rome, Italy |
Stockholm, Sweden |
In Switzerland lies the headquarters of the World Health Organization, which helps to regulate and promote best practices around the world. One of its greatest contributions to care for the dying comes from Elizabeth Kubler-Ross who wrote "On Death and Dying" (1969) a seminal book in the literature on dying and coping with grief.
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Rome, Italy is home to the catacombs whose history displays the great cultural significance in beliefs in the afterlife. The catacombs dating back 2000 years display symbols marking new life, forgiveness and resurrection; clear Christian symbols reflecting an almost celebratory look at death, moving into heaven, the land of the living. On a contrasting note, many catacombs are located below what were once the Greek Necropolises, otherwise known as the cities of the dead, where pagans were historically buried. Thus displaying the great contrasting views in death's meaning even 2000 years ago.
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Sweden's health care system focuses a great deal on skill and specialization. Their palliative care hospital was very cohesive, there was a great deal of collaboration and attention to detail in terms of medications, knowing the family dynamics, ethical issues and being aware of comfort levels and space. The palliative in patient units were well designed to give a sense of peacefulness and comfort, with separate rooms to have private discussions with the families as well as open spaces for patients to form community, if so desired. They also are the first to have Silviasysters who are nurses who specialize in dementia care.
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Brno, Czech Republic |
Krakow, Poland |
Jerusalem, Israel |
Acute care in the Czech Republic is excellent, it is the chronic care which becomes a problem due to lack of resources. Though there is no specialty in palliative care, the principles are still applied in the ICU. There is a particular method of having end of life discussions with patient and family members through introducing the topics with care over a series of days so as not to overwhelm and to give the families time to process and make proper decisions. Speech therapists are excellent resources for assisting in systematically determining the competency of a patient.
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Auschwitz lies just outside Kraków, Poland. It is where the Nazis exterminated millions of people, mostly Jews. Approximately 1.6 million people visit this site every year but the reflection becomes: what have we learned from this? That the Holocaust was just some a bad occurrence? Or that this was a degradation of human dignity on a massive scale based on one group of people deeming themselves to be superior to another group of people? Furthermore, how does this translate into how we value human dignity through our treatment of others today... In families, communities, countries and internationally... In education or health care systems? Do we simply continue to undermine human worth in less explicit ways?
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In Israel, palliative care is just beginning, however in depth analysis into ethical issues on a country wide and international scale are not. On a practical level, unlike other western countries, the religious and spiritual needs are so ingrained in the community, the responsibility of meeting those needs does not fall to the health care system. In terms of withdrawal of treatment such a ventilators, Halacha Law (http://98.131.138.124/articles/BrachaLeAvraham/sprung.asp)
is in place giving strict guidelines regarding these decisions, generally stating that the removal of a life sustaining treatment is equivalent to murder, which places greater discussion on whether or not to start someone on extensive treatments. On an international level the ETHICUS (see med professionals page) studies being conducted here study end of life best practices around the world and are at the forefront of academia in this field. |
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Dassa-Zoume, Benin |
Johannesburg, South Africa |
Kolkata, India |
In Benin, there is no specialty in palliative, geriatric or hospice care. When a person approaches the end of life, usually the family helps to take care of the person, sometimes a traditional healer is called in with different herbs and medicinal therapies. The life expectancy is around 60 according to WHO data. (http://www.who.int/countries/ben/en/) However, the great communal culture as well as great faith culture which mixes traditional and world religions is reflected in the great joy displayed at funerals, the supportive nature of villages and communities and a lack of fear of death due to its normality in the societies.
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The palliative hospice in Joburg displayed a great deal of focus on holistic care and individualized services by providing inpatient and outpatient options, maintaining its own pharmacy, counseling services, innovative social entrepreneurial programs, volunteer programs and continuing education workshops and classes for the staff and the community. The disparities created by a long history of social injustices from imperialism and apartheid still have their effects on culture and thus the health care system which must be addressed by the hospice. In the wealthier areas, cancer is the usual illness dealt with by the hospice, while in the poorer, historically Black areas, it is HIV/AIDS due to stigma and fear.
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Kolkata truly is where the "poorest of the poor" are located in India. Blessed Mother Teresa first established her homes for the destitute and dying here in 1952. Due to its location and the people it serves, the primary purpose is to acknowledge the dignity of each person who enters by allowing them to die clean, in shelter and in peace. The Missionaries do the best that they can with the basic resources that they are given. Volunteers come from all over the world to serve alongside the Missionaries of Charity to take care of the people who are brought in off the streets, those who have been completely forgotten or shunned by society for whatever reason, to give them a place to die other than the streets of the slums.
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Bayombong, Philippines |
Okayama, Japan |
Sydney, Australia |
In the Philippines, the newly established hospice systems struggle against lack of resources, difficulties in access due to geography, a largely rural and spread out population and disorganized infrastructure. However, the hospice services that are present reflect the warm and personable culture of the Philippines as nurses enter into homes, not just to distribute medicines and do physical assessments but to truly spend time with the patients and know them on a personal level. There is also a very strong identity in faith for the majority of Filipinos and this unapologetic nature of their beliefs allows for a greater ability to discuss one's fears with one's family, discuss priorities and find meaning in life and death and establish trusting relationships with their care givers.
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The hyper organized culture of Japan is reflected in the neighborhood structures which assign specific tasks to specific members of the communities which includes looking out for the elderly. Generally, the Japanese live to be very old with life expectancy 87y for women (http://www.who.int/countries/jpn/en/) and generally remain in good health. Though nursing homes are becoming much more common, the historic culture of revering the wisdom of one's elders and ancestors is still a part of the culture and as of now, people still take care of their aging relatives. However, there is also a culture of shame and stigma which prevent certain topics, such as death, being openly discussed. In addition, the lack of openness, is reflected in a lack of social services such as counseling and furthermore, the highest suicide rate in the world.
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Australia's palliative care hospital displays a great value of multidisciplinary care, research and education. There is a focus on investing in the staff through reflections and discussions on care for the dying on a personal level, supporting the staff in times of difficulty, providing talks on ethics and other disciplines to enhance the respect and understanding of one's colleagues and hence a cohesion of teams. If not absolute cohesion, a realistic look at problems and how to fix them occurs to keep the patient and his or her family always at the center of care. A commitment to research in all aspects of care is displayed in a very active research department and there is a great deal of collaboration with neighboring hospitals to provide a continuum of care as well as consult in areas of expertise such as renal or palliative care.
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Portland, Oregon USA
Oregon Health Science University is one of top hospitals for health care research, particularly in cancer treatments. The state of Oregon, however, was also the first state in the US to legalize euthanasia, giving people the "right to die" in 1994 (see med professional page). After over 20 years with this policy, it has generally become an accepted part of the hospital culture here as was evidenced by a series of lectures at an academic institution speaking to the Death With Dignity Act from solely the pro point of view, interesting as this view is certainly not shared throughout the entire United States.
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Not shown here are France, Germany, Austria and Palestine as I spent very brief amounts of time in these countries and not enough to engage deeply into the aspects of death and dying in these environments.
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