In 2004 Professor Jacek Luczak, MD
Traveled to: Moldova

Background

After three physicians from Hospice Angelus in Moldova finished their training in Poznan’s Hospice Palium Palliative Care Resource & Training Center, Professor Luczak visited the Republic of Moldova (RM) for the first time in May 2003. During his stay he met several palliative and hospice care individuals as well as delegates of Ministry of Health. Encouraged by Dr Irina Baikalov, the director of Second Breath Hospice in Balti to visit Moldova again, Professor Luczak applied and received an IAHPC Traveling Fellowship grant.

Aims of the visit:

• To identify the current epidemiological situation, the Palliative Care needs and determine the current status of hospice programs and share experiences and knowledge on PC principles, policy, education, cancer pain management and morphine availability
• To gather PC leaders, professionals including oncologists, AIDS specialist, nurses and volunteers with the delegates of Ministry of Health and the Agency for Drug Control to discuss the urgent problems and obstacles in developing palliative care in RM.

SUMMARY OF VISIT

June 14

First, a visit to Hospice “Zubresti-North Carolina” and then a home visit to an 83 year old patient with breast cancer. The Hospice provides home care hospice program for adults, children and adolescents with cancer and nonmalignant diseases started three years ago. Currently the team provides home care free of charge for patients from Zubresti and the neighboring villages (about 10,000 inhabitants). Patients are visited daily or every second day and during weekends. The Hospice director presented a summary of the development of the Hospice and the project of the creation a 20 bed Hospice with the financial support from North Carolina USA. The hospice is planned to open in October 2004 as the first inpatient unit in Moldova.

June 15

Visit to Balti, where a meeting with the team from the “Second Breath” took place. Many problems were discussed, such as death rates from cancer in Balti and in Moldova, opioid administration and principles of pain management. Due to a limitation on the amount allowed for prescription (10 ampoules per week), patients from Balti can’t receive the necessary dosage of morphine. Some commercial preparations of potent analgesics are available, but too expensive. In addition, family members are obliged to take back to the policlinic the empty ampoules of used morphine!

June 16

1. Visit to the Medical University in Chisinau
Here a meeting took place with Ion Ababii, the Rector of the University, Mr. Vovc, the chief of the International Relations Department, and Mr. Chicu, the vice director of the University. There were issues discussed related to possible cooperation between the Medical University from Chisinau and K. Marcinkowski University of Medical Sciences in Poznan. As a result of this meeting, an additional one took place at the University with several professors and academic teachers from interested in PC.

2. Visit to the Oncological Institute
A meeting was organized with the vice-director of the Institute, Dr. Cernat who gave an overview about the activities of the Oncological Institute and the importance of oncologists in PC. Patients suffering pain can be admitted to hospital for symptom control. There are plans to set up by the Institute of Oncology with four inpatient hospice units in Moldova.

3. Meeting in Soros Foundation Moldova Center (SFM).
Professor Luczak met with the director of the Public Health Program, Valeriu Sava and the assistant of the PC program Angelina Ursu. There was also a discussion about the right to die in dignity and in peace.

4. Meeting with Mr. Gherman, Minister of Health of Moldova.
Professor Luczak was accompanied by Polish Ambassador Piotr Marciniak and his deputy, Igor Bugai and the interpreter. Mr. Gherman was accompanied by the vice-minister, Mr. Vovc and Rodica, the responsible person for International Relations.
Professor Luczak spoke about the visits to the existing Hospices in Moldova, the importance of changing the restrictive policy of opioid prescription in Moldova and the effectiveness of oral Morphine. Mr. Gherman agreed on the importance of PC. Also, he talked about making oral morphine available in Moldova, and in setting up a Palliative Care Task Force Group attached to the MOH. He also emphasized the importance of HIV/AIDS infected people and the care they receive and role of nurse initiatives and nursing education.

June 17-18

During these two days, the seminar “Palliative Care” took place in Chisinau. The meeting was organized by “Second Breath”, Soros Foundation Moldova, ECEPT and chaired by Irina Baicalov and Professor Luczak

The meeting was planned for 30 participants but 45 participants registered, including medical students!

Workshops were an important part of the Seminar. The workshop on dying focused on the unmasked face of dying and death and included with the sharing of a very painful experience by a young bereaving widower.

Participants of workshop on opioid availability and PC policy development leaded by Maria Ivancov worked out the recommendation and steps in developing of palliative care.

Important steps in developing PC in Republic of Moldova

Education in PC

1. Elaborating nationally agreed guidelines of cancer pain management and PC
2. Elaborating methodological recommendations for the medical workers and patients/relatives
3. Including the PC program in the Educational Curricula
4. Introducing PC programs in the curricula of the Chairs for Doctors’ Perfection
5. Rising Public awareness on cancer pain management and important role of hospice and palliative care services especially in end of life care

PC Policy Development

1. Recognizing palliative medicine and PC as a separate compartment of medicine
2. Introducing PC in the State Health System
3. Introducing the PC services in the unique program of medical insurance
4. Allowing NGOs to implement PC services
5. Introducing PC in the National Program of Combating Cancer
6. Development of PC according the WHO recommendations
7. Preparing medical, social workers on PC and team work.
8. Supporting the initiatives of civil society in PC

Improving opioid availability

1. Allowing the GP who take care of the patient to prescribe opioids
2. Making oral morphine available– an important recommendation by WHO
3. Eliminating the requirement of having the patient’s relatives retunr the empty ampoules of morphine
4. Allowing to prescribe up to 10g of oral morphine or the equivalent of injectable morphine-4 g
5. Simplifying the prescription process
6. Changing the legislation on regulation allowing every physician to prescribe opioids

Evaluation of the Seminar:

This was the first time in Moldova that a Seminar in PC was organized with the participation of an international expert, the Polish Embassy, professors from Medical State University, Ministry of Health, Oncological Institute, representatives from Medical colleges from Moldova, Drug Control Committee, NGOs and people who deal with PC/Hospice in Moldova.
The participants of the Seminar showed a great interest in studying the problems and development of PC in Moldova. As a group discussion the participants elaborated some recommendations on development of PC in Moldova, it was a task that was a beginning of their joint collaboration.
The Resolution/Recommendations of the Seminar were given to the Ministry of Health through the Polish Embassy. The event was featured in the National mass media – TV, radio, newspapers, as it was organized a Press Conference at the end of Seminar.

Due to the restricted policies the dying patients rarely die in hospitals, the majority die at home in great sufferings. About 87% from these categories die at home without an adequate care.
In RM there 3 nongovernmental Hospices (Chisinau, Balti, Zubresti) and other nursing initiatives having the aim to alleviate suffering and improve the quality of life of the dying were founded. These organizations offer palliative care to the patients free of charge. The services which are offered by professionals in PC are not included in the National Program of Medical Insurance. It is a matter of urgency to change the governmental policies that need to contain PC/Hospice in the National Program of Medical Insurance financially covered by CNAM.
The support and the collaboration with the Ministry of Health is very important and should be done through the Council in PC composed by representatives from the Ministry of Health and interested people who will be able to reach the above mentioned objectives.

Creating qualitative PC services in Moldova through:
- A National Committee on PC with the representatives of the Ministry of Health, Medical University, Polish Embassy, NGOs that deal with PC;
- Elaborating Standards on PC, where the focus will be on pain management for dying patients;
- Development of Educational programs at a state level in Medical University and Colleges and post graduate programs;
- Public awareness on development of PC and the problems of dying patients in Moldova; better understanding and public sensibility on these problems;
- Protection of the rights of the dying in Moldova. (see also Recommendation agreed by Workshop Participants :Important steps in developing PC in RM)

June 18
Prof. Luczak’s last day ended with visit to Hospice Angelus Moldova. He met the team, discussed their achievements (rising number of patients cared, lots of training and education also abroad (St Christopher’ Hospice, International Seminars in Palliative Care in Gdansk, Poland) and their project to set up an training center at the hospice (they taught GP and family nurses in PC and would like to extend the program).The main problem are funds for renovation of the old building (headquarter of the hospice) and for new one in-patient hospice and lack of policy enabled the hospice doctors to prescribe medicines including opioids.

Author Comments:
As someone involved in supporting development of hospice/palliative care in Moldova, I found this grant by IAHPC an important step forward.
The main goals of the visit were realized, but there are still many things to do to improve the care of dying. Activities of the hospice leaders must be supported by the government, the prescription policy must be changed, and implementation of oral morphine is urgently needed.
Formation of the Palliative Care Task Force Group as an advising body attached to the Ministry of Health and cooperation with the University of Medical Sciences can be helpful in further development.
We made recently arrangements to provide a doctor and a nurse from hospice Zubresti with training in our hospice (Poznan, Poland) this July and an oncologist from Chisinau Oncological Institute in November. In the future cooperation with our Moldovan colleagues we will be continuously supported by Polish Embassy.

Click on photo to view larger image
Preparation of the Palliative Care Resolution	Participants in the Palliative Care Seminar	Opening of the seminar: Dr. Irina Baikalov and Mr. Piotr Marciniak, the Polish Ambassador in Moldova
	Moldova 2004
Professor Luczak with participants in a Workshop on Death and Bereavement		Future in patient facility at Hospice Zubresti

Submitted by: Professor Jacek Luczak, MD