Lebanese Nurses Outlooks on Palliative Care in Lebanon

Lebanon is a country in Western Asia. It is bordered by Syria to the north and east Israel to the south and the Mediterranean Sea from the west. Lebanon's location at the crossroads between the east and the west made its capital Beirut to be known as “the Paris of the Middle East” and the country was compared to Switzerland. Before the Lebanese Civil War (1975–1990), Lebanon was known as the hospital of the Middle East due to the quality of health care available in terms of human and physical resources. The outbreak of the destructive civil war (1975) has put an end to the prosperity in the health care sector. More attention was given to causalities and emergency needs. Little interest was given to chronic conditions prevailing among the population. At the end of the war, there were extensive efforts to rebuild national infrastructure including the health care sector [1].


Introduction
Lebanon is a country in Western Asia. It is bordered by Syria to the north and east Israel to the south and the Mediterranean Sea from the west. Lebanon's location at the crossroads between the east and the west made its capital Beirut to be known as "the Paris of the Middle East" and the country was compared to Switzerland. Before the Lebanese Civil War (1975)(1976)(1977)(1978)(1979)(1980)(1981)(1982)(1983)(1984)(1985)(1986)(1987)(1988)(1989)(1990), Lebanon was known as the hospital of the Middle East due to the quality of health care available in terms of human and physical resources. The outbreak of the destructive civil war (1975) has put an end to the prosperity in the health care sector. More attention was given to causalities and emergency needs. Little interest was given to chronic conditions prevailing among the population. At the end of the war, there were extensive efforts to rebuild national infrastructure including the health care sector [1].
In Lebanon the health care sector is mainly based on fee for service, and predominant medical model of hospital based, with an extensive exploratory and interventional approach, depending worryingly on technology [1] with minimal human contact. This prevailing culture in the health care sector made the Ministry of Health introduce palliative care as a patient right in the first article of the law on" patient rights and informed consent" [2].

Palliative care in Lebanon
Palliative care idea was first presented in Lebanon in 1995 through joined efforts between the Lebanese Ministry of Health and WHO. In order to further endorse this concept the Lebanese Ministry of health issued a ministerial decree launching the National palliative care committee [3] with key people in the health field including nurses with the directive of developing national plans for research, education, practice and policy related to Palliative care [4]. The interprofessional Lebanese national palliative care committee adopted the WHO definition of Palliative care which stipulates that palliative care is an approach that "improves the quality of life of patients and their families facing the problems associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychological and spiritual" [5]. The focus of the committee is on four arms: Education; Practice, Research and public Policy.
Palliative care is becoming a growing need for individual's journey with illness. Historically palliative care knowledge matured from experience with cancer population. However, the awareness and acknowledgment that palliative care can be of usefulness to individuals suffering from other chronic conditions has been rising quickly. The world's population continues to grow and many countries including Lebanon will see increases in their older age cohorts [6]. This entails that the number of individuals who will experience illness, either chronic or life-threatening conditions will live longer with their lifelimiting illness because of the advances in science and technology is anticipated to raise significantly [7]. In Lebanon, it is estimated that that overall cancer for males and females will reach 361 and 312 for cancer cases per 100,000 respectively by 2020 [8]. Also an increase is expected for both male and females, knowing that by 2025 the elderly population aged over 60 years will constitute around 10% of the total population [9].

Lebanese nurses and palliative care
Nurses are the biggest workforce in health care worldwide and are consequently in influential position to impact the quality of palliative care delivery throughout the course of illness [10]. Similarly in Lebanon, nurses are always at the front side and in direct contact with patients and their families.
According to the latest statistics published by the Lebanese Order of nurses [11] there are 12522 practicing nurses in Lebanon. 46.76% have a university degree, others have a technical degree.84.26% work in hospitals and others work in different places such as medical and insurance companies, schools and long term facilities etc.. It is worth noting that in order to be able to play an instrumental role in palliative care nurses need to be backed by education and a favourable "milieu" for practice. This article will shed light on the palliative care knowledge and practice environment provided for Lebanese nurses to practice palliative care.

Nursing education and palliative care
In Lebanon, the main core of nursing education and practice is focused on holistic care and support for the sick individual and family. Palliative care education is integrated in undergraduate nursing curricula but in a very reluctant approach. In some particular university hospitals staff continuing education about palliative care is being selectively offered [12,13].
Nurse's graduate with a trivial knowledge about palliative care and with minimal skills about managing interpersonal issues and minor knowledge for helping a person diagnosed with a disease navigate and his /her family through the numerous decisions they have to make. Moreover this situation put nurses working on oncology units under a lot of stress and pressure which increase the risk of job turnover as reported by an as yet unpublished study. nurses reported that palliative care destroys hope and leads to despair and depression. Oncology Nurses were the least likely to regard living with dignity and respect as one outcome of palliative care. In conclusion the study recommended the formalization of palliative care education in Lebanon.
Recently, the national palliative care committee mandated that a one credit course on palliative care and pain be integrated in undergraduate nursing curricula. Questions related to palliative care, pain and end of life to be added to all official examinations for nurses [9] hoping that this approach might improve the knowledge and practice of nurses in providing palliative care. Still more work needs to be done at the graduate level education [9].

Clinical practice and palliative care
The practice of palliative care is still in its infancy stages in Lebanon despite the continuous efforts that were initiated in 1995 until present [9]. The Lebanese Ministry of Public Health took the lead on the physical arm of palliative care: it introduced new narcotics on the market; it extended the renewal time of narcotics from 15 to 30 days and made palliative care as a new recognized specialty for physicians [4]. Universities took the lead for education and research but implementation is still in a basic form [9]. Practice is still the main concern similarly to many Middle East countries [13]. Two main leading hospitals in the capital introduced palliative care as a model but the implementation still needs more institutionalization and framing within the health care system. It is worth noting that within the Lebanese health care system financial support for palliative care remains the main challenge for proper application.
No data are available regarding the public's interpretation of palliative care. What is the understanding of palliative care within the Lebanese population? Is it directly associated with end of life care? More studies are needed in this regard. Efforts are being directed towards media and politicians awareness [9]. It is worth noting that the Ministry of Public health is starting to incorporate palliative care within the national policy through several initiatives [4,9] such as the new narcotic policy and the creation of the national committee.
Providing symptoms management, patient teaching and emotional assistance for the patient and family are theoretically key responsibility of Lebanese nurses. Results of an unpublished study yet on oncology nurses experiences in Lebanon nurses reported that they care for patients and families in different settings and conditions which put them at times in difficult position especially when dealing with life threatening situations due to major restrictions related inadequate academic preparation, truth telling and pain management established processes.
It is worth noting that nurses in Lebanon are not allowed to discuss the diagnosis and prognosis or even to practice truth telling especially with cancer patients due to the prevailing paternalistic approach that is dominated by family members and physicians [15]. Families of Lebanese cancer patients always demand high-tech treatment to prolong life at any value, including the price of their suffering. Physical and psychological sufferings become acceptable as a price to pay for a futile gain. Lebanese physicians who are working in a fee for service culture most of the times are following parents' wish in prolonging life and providing aggressive treatment even when palliative care is needed. In an as yet unpublished study assessing the Lebanese oncology nurses' experiences oncology nurses reported being disturbed by lack of truthful communication with patients and by witnessing unjustified cancer treatment. They described the approach as "fearful" and unjustifiable.
They all asked for changing the work environment. The results of the study endorse the need for implementing the palliative care culture. Similarly Huijer, Dimassi and Aboud [16] In another study about the lived experience of parents of children admitted to the pediatric intensive care unit in Lebanon [17] parents highlighted the need for a more friendly and comprehensive environment. They also raised the demand for being involved in the care which demonstrates the need for psychological and spiritual attention. The results support the idea that palliative care is not only confined to cancer patients but it is needed in every life threatening condition as stipulated by the WHO definition [5].

Conclusion
Nurses initially as the primary link between the patient and the family and the other health care professionals can play a vital role in the endorsement, implementation and improvement of palliative care for patients and families. It is worth noting that in order to facilitate this role for nurses to play education about palliative care and a favourable atmosphere for practice are needed. Moreover, In order for palliative care services to be broadly spread, become affordable and socially acceptable in Lebanon, education of the population, health care professionals and key leaders is highly recommended.