Malta must aim higher than offering the minimum palliative care, the Medical Association of Malta said. For one thing, in Malta there are only two officially appointed palliative care specialists, one consultant and one resident specialist, when the World Health Organisations recommends 12 for a country the size of Malta.

On the association's website, MAM president Patrick Sammut said the WHO Essential Medicines List for Palliative Care is designed as a minimum standard, a basic framework to help low- and middle-income countries provide relief for terminally ill patients. It includes 22 medications. While this list is important, it should not be mistaken for a comprehensive standard in a high-income European country like Malta.

Malta currently ranks 26th out of 35 in the 2023 Euro Health Consumer Index, and prides itself on achieving high standards in hospital care, primary care, and longevity. In this context, limiting Malta's palliative care provision to the WHO's essential list would fall significantly short of both public expectation and clinical need, Sammut wrote.

"We must aim higher. Countries like the UK, France, and Germany have expanded palliative care formularies that include over 50 medications to manage complex pain, breathlessness, agitation, seizures, and terminal secretions. Malta should strive for similar gold standards in this area, ensuring compassionate, evidence-based care for all terminal patients not just some".

Recently, a detailed list of over 30 additional medications that are commonly used in the UK and EU for advanced palliative care - but currently missing from Malta's government formulary - was submitted to the Ministry for Health, Sammut wrote. Constructive discussions are ongoing with the authorities, and this momentum is welcomed by the medical community.

However, the key issue is not just availability, but accessibility, Sammut wrote.

Accessibility Issues in Malta's Palliative Care

1. Accessibility by condition or diagnosis:
Malta's palliative care medication provision remains focused predominantly on cancer patients. Yet cancer accounts for only about 25% of all patients who require palliative care. Other conditions often involve suffering that is equally - if not more - prolonged and distressing. These include:

• Heart failure
• Chronic obstructive pulmonary disease (COPD) and respiratory failure
• End-stage liver disease
• Neurodegenerative conditionssuch asAmyotrophic Lateral Sclerosis (ALS)andadvanced dementia

2. Accessibility by location:
Several key palliative care medications can only be accessed in hospitals or in hospice settings. This makes it difficult or impossible for patients living at home -especially those in rural areas or with mobility limitations - to receive appropriate symptom control. A genuinely patient-centred approach requires these medications to be readily available in the community, including through home care services and pharmacies.

3. Accessibility through specialist prescribing:
Palliative care is not only about medication it is about specialist knowledge, holistic care, and compassionate decision-making. Palliative care specialists are trained to assess symptoms dynamically and adjust treatments based on evolving needs.

Malta currently has only two officially appointed palliative care specialists one consultant and one resident specialist. They are supported by a handful of general practitioners with a special interest in the field. This is far below what is internationally recommended, Sammut wrote.

According to WHO and European Association for Palliative Care guidelines, a country of Malta's population (just over half a million) requires a minimum of 12 full-time palliative care consultants to adequately serve hospitals, hospices, community services, and non-oncology patients.

This severe shortfall means that many patients are left without the expert input they need, which places further strain on hospital doctors and family physicians who may lack the necessary training.

The recent national discussion around euthanasia has, ironically, brought attention to the gaps in palliative care that should have been addressed first. Malta has not yet reached the standards required to claim a robust or fair system of end-of-life care.

The Medical Association of Malta (MAM) is not merely raising concerns, it is offering solutions and proposing a roadmap forward, Sammut wrote. We urge policy-makers and health administrators to take this opportunity to work alongside clinicians to define and achieve high standards.

To truly honour the dignity of every person at the end of life, we must be able to look them in the eye and say: we have done everything modern medicine can offer to relieve your suffering.

Only then can we have meaningful discussions about end-of-life choices, Sammut said.