Also from Dr. Serpil Osezgin Ocek -- A regional report -- Turkey

I am an Anesthesiologist and Reanimation specialist living and working in Turkey. More than 74 million people live in Turkey but unfortunately, there is no palliative care specialisation in Turkey. The medical oncology units and departments of algology in major hospitals provide pain control and symptom relief. Oncologists and pain specialists in hospitals report that they are actively working to establish palliative care. Most of the interested oncologists and pain specialists work in relatively few university hospitals. In 2003, Yasemin Oguz co-authored a paper in which they reported that end of life care services continue to be markedly inadequate. In particular, she and her colleagues highlighted the lack of nursing and financial support for families who care for their older, terminally ill relatives at home-- this increases the likelihood of a hospital admission. Oguz et al. noted the issues surrounding the use of opioids and these points were reiterated by Serdar Erdine (2005) who suggested that too often the end of life is likely to be painful and lonely in hospital.

Narcotics are often available to meet the needs of dying patients with chronic pain. Many private pharmacies however shun the bureaucracy and the potential liability that goes with dispensing "green" prescriptions (addictive or abusable drugs) and "red" prescriptions (narcotics). Our hospitals and their staffs are not organised or trained to provide palliative care. In 7 university hospitals and 9 state hospitals in our three largest cities, not one hospital has a policy on end of life care, pain management or DNR (do not resuscitate) orders.

There is a lack of education of our health care personnel, and we lack a range of strong opioids because only slow release morphine, transdermal fentanyl and tradamol are available. The fear of psychological or physical addiction to strong opioids is prevalent as is the unwillingness of some doctors to prescribe strong opioids. Therefore, the use of opioids in Turkey is limited.

Inevitably there are great problems with the approaches of physicians to patients during the course of cancer and particularly during the end stage.

After becoming aware of this situation, I opened a private Pain-free Life Centre in 2000 in order to deal with the management of pain in end-stage cancer patients. I admitted cases from my colleagues who could not manage cancer patients with complications and insufferable pain. I tried to find solutions to their problems of pain and other complications. I encountered a variety of cases on a daily basis that we were able to bring satisfaction by answering their questions and providing comfort.

When I first opened my practice I had to pretend to be a psychologist, dietician, physiotherapist and a grief therapist while taking care of them in hospital or at their home during their last stages. All the patients were very happy and content with my services. I was able to provide intensive care in their homes by being available at all times, 24/7.

Dealing with death openly is considered taboo in Turkey and as a community we exhibit thanatophobic attitutes towards present and potential death phenomena. Commonly observed thanatophobic attitutes of healthcare providers, especially doctors, facilitate isolating the patients in a condition of despair and exhaustion. Usually patients lose themselves during the last moments on the journey to death. I try to enable my patients and their relatives to spend their last days in maximum comfort and as free from the depression that is often caused by the death denying attitudes of health care providers, particularly physicians. As the population ages, all physicians are confronted with increasing numbers of dying patients. This is stressful for them and they need to care for themselves emotionally and learn to deal with the fatigue associated with compassionate care. I have noted considerable changes in my own thinking about death during the ten years since starting the Center for Painless Living. My challenge is to find effective ways to share my experiences and knowledge with others in order to improve end of life care wherever I can.

Dr.Serpil OZSEZGIN OCEK