The launch by Dr Chris Fearne of the National Palliative Care Strategy for Malta last week is something which has been in the pipelines and which I welcome enthusiastically. Those who read this column know how many times I write on end of life care, and it goes without saying that I am very pleased that the little we all contribute has not only been acknowledged but also implemented.
The objectives of the strategy aim at encouraging people to talk more openly about the needs and care of the dying and to encourage ‘conversations about their wishes and preferences’. When applied to patients of course this translates into Advance Care Planning, which, as opposed to Advance Directives does not require legal documentation but only being noted in the patient’s file and implemented and therefore subject to change at any time the patient wishes. Secondly the plan aims to improve education on palliative care (which, incidentally, is not only about pain relief) throughout the health care profession and of course the public. Many assume that if one is a nurse or specialist working in hospital palliative care can always be given. This is not the case for all and studies we have conducted actually show that many health care professionals, including consultant, would like to see more educational programmes implemented into undergraduate and specialist courses, and in other forms of training.
The main objective of course is to see that patients and their families and carers receive the support that they need. The plan recommends therefore that a ‘competence framework’ is formed which delineates the knowledge each level of care requires. I was pleased to notice that there is to be collaboration between existing palliative care services, the university of Malta, professional bodies and NGOs, including hospice and (also mentioned during the meeting and taken note of) patient NGOs who work a lot with their members.
Indeed the publication mentions the ‘Consensus Document’ which I had coordinated between the Faculties of Medicine& Surgery, Laws, and Theology, during the Erasmus+ project EndCare (Google: EndCare Project. L-Universita’ ta’ Malta) was quoted. The fact that this document is validated reinforces the content, namely that pain relief can be given, even if it hastens death by a few days – something which is morally accepted and which many do not know about (perhaps reading what the catechism says on euthanasia can help!).
It is not the first time that people think that it was the morphine, and not the cancer that killed their dying relative – a factor which contributes greatly to the fact that pain relief is given more cautiously in many places and that sometimes we see dying people in pain or discomfort. It also validates that we can legitimately remove futile and extraordinary treatment and indeed move towards a palliative approach.
Dr Fearne had shown a great interest in this at the time we presented the project and had mentioned that doctor need to be covered by the law in this regard. The faculty of laws asserted that all is legitimate but clarification of the law (as is the case on what has been incorrectly dubbed as the current ‘abortion’ act) is always useful. Who wants to go to court anyway, even if they know they did nothing wrong.
So indeed, a great ‘well-done’ to the team, and to Dr. Annalise Buttigieg, who is said to have spent the COVID period compiling the document whilst taking care also of her new-born.
Of interest were some of the facts presented and the comments coming from the panel chaired by Dr Anthony Gatt. To start with the former, Ms Annabelle Magro Conti, the Nursing Officer in charge of the Palliative Care Unit (PCU) and SAMOC – the Sir Anthony Mamo Oncology Centre – said that the very term ‘palliative care’ can raise concerns and anxiety. Indeed as explained by Mr Walter Busuttil, palliative care is not only for cancer, but also for elderly and other chronic, and sometimes terminal conditions, such as neurological diseases.
In this regard the Bjorn Formosa’s ALS Foundation was mentioned. I see at first hand every day how the elderly need palliation with the handicaps they develop from chronic conditions, falls, and change in body function. We all need to die someday, as emphasised by the DPM, and it would be nice to know that we do our best so that when the need is approaching people can live in the most comfortable manner and have the necessary services available. Most of all none of us want to die in pain or continue with the burden of some treatment which is futile or simply too much for us.
An important fact was explained by Dr Walter Busuttil (Director General) is that in Malta we have 16 beds in the PCU and will have 16 beds at the new Hospice (a collaboration between the Hospice movement, the government and the Curia). He and others had pointed out that this number was too low. In fact, it turns out, that those involved in palliative care, most notably of course, the Hospice movement, wish that one moves away from beds in hospitals and hospices but focusses more on delivery of care at home, where the patient is more comfortable, and of course, ‘at home’, surrounded by one’s environment and family, and not in a clinical setting.
But as Dr Jurgen Abela pointed out, putting all the necessary equipment at home needs resources and teamwork. This is of course a the ten-year plan and I am sure that the enthusiasm that people working in palliative care show, especially in motivating those who provide the resources, along with a cooperative Ministry and Department of Health, such training and team work will be provided. Of significance is member of the opposition Dr Stephen Spiteri’s support for the strategy and the professions involved. Why this is not given as much media coverage as the current Bill under fire is beyond media ethics’ comprehension.
One needs to mention that we need to educate the public of what it is all about. Rather than ponder about euthanasia, we need to disseminate knowledge about what is not euthanasia (such as the administration of high doses of morphine and other pain relief, mentioned above). This is not only the responsibility of the government or the hospital but of those who can reach the public.
My suggestion to the Strategy is to formally ask the Curia to formally ask priests to speak more positively about death and to educate the public on the relevant paragraphs of pain relief and extraordinary care removal (found in the Catechism), when discussing end of life and euthanasia. It is important to distinguish between what is and what is not euthanasia is we want to avoid the latter. For more specific patient populations, NGOs can target their members and their families (hich I am sure they already do). However there needs to be a formal system of dissemination of this kind of information which I hope that this Strategy will implement and find funding for. Public dissemination, debate and discourse can be expensive, but in this case it is worth while.
Pierre Mallia is Professor of Family Medicine and Patients’ Rights and teaches University of Malta. He Chairs the Bioethics Research Programme of the Faculty of Medicine and Surgery. He also chairs the Bioethics Consultative Committee.
This article is his personal opinion and does not represent the opinion of any committee or board he serves on.
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