By Yangden
Yangden is the charge nurse for the palliative care service at Jigme Dorji Wangchuck National Referral Hospital in Thimphu, Bhutan. She and her colleagues, with support from HVO volunteers, established the first palliative care service in Bhutan. They are working to expand services to other hospitals by training more health care workers from every district in Bhutan.
The Inception:
The Home-based Palliative Care service in Thimphu is an initiative of the Jigme Dorji Wangchuck National Referral Hospital (JDWNRH) under the leadership of President Lhab Dorji. In 2017-2018, JDWNRH recorded an upsurge of cancer cases. To address the suffering associated with cancer and the profound pain endured by patients and their loved ones, hospital management envisioned starting a Home-Based Palliative Care Service to support cancer patients and their families around Thimphu. This was also to achieve the optimum utilization of the limited resources available. The much-awaited service was officially launched in March 2018.
The service aims to re-instill a sense of beauty, purpose, and value for people affected with life limiting illnesses. It seeks to empower patients in the comfort of their homes with control over the care they receive and to enable them to maximize the time spent with their loved ones as they traverse the most harrowing journey in life. In line with the cultural and social norms of Bhutan, the Home-Based Palliative Care Program endeavors to honor every Bhutanese at the end of their lives with compassionate care and the best possible support.
Milestones in Development:
The journey began in February 2018 with the submission of a proposal to the Ministry of Health. From March to June 2018, the program entered a pilot phase, with three dedicated nurses (Yangden, Nima Lhamo Sherpa, and Ambika Luitel) at the helm, initially supported by a surgical oncologist (Dr. Tashi Dendup) and a nurse anesthetist (Dr. Singay). The successful completion of the pilot phase culminated in the submission of a comprehensive report to the Ministry of Health, outlining the feasibility and effectiveness of the Home-Based Palliative Care Service.
December 2018 proved to be a pivotal moment when a high-level committee meeting presided over by Her Royal Highness Ashi Kesang Wangmo Wangchuck convened at the Ministry of Health. This meeting sought and secured crucial approval for the official implementation of the Palliative Care Service. Moving ahead to September-December 2020, a collaboration with the WHO Collaborating Centre at the Institute of Palliative Medicine (WHO CC IPM) unfolded. Under the guidance of WHO, this partnership resulted in the creation of a comprehensive training manual on Bhutanese palliative care for health workers. This training manual has been the main source of reference for developing national palliative care guidelines and for the chapter on palliative care in the National Standard Treatment Guidelines.
The palliative care nurses have been involved in developing the national palliative care guidelines, which are now being finalized. They are also responsible for training district healthcare workers on the foundations of palliative care training and providing clinical observation opportunities in their unit after the foundation course.
The Team:
Immediately after COVID in early 2022, a fourth nurse joined the team. A fifth was added in September 2024, bringing the total to five palliative nurses working for the palliative unit.
In February 2024, the team was joined by Bhutan’s first palliative physician. The team is also supported by a nurse anesthetist who joins visits once a week to address complex pain management. The team also seeks support from physiotherapists when there are cases requiring their expertise and assistance.
They schedule home visits every day from Mondays to Saturdays with the following care provisions:
- Registration of people who require palliative and end of life care
- Assessment of patients’ needs and preferences
- Plans for care and counseling
- Support for people as they journey the last days of life
- Pain and symptom management
- Nursing procedures, and practical care that improves comfort and quality of life
- Assessment and assistance of socio-economic need
- Spiritual support to prepare the family for anticipatory bereavement
- Assistive devices such as oxygen concentrators, air mattress, diapers, and nutritional supplements
- Death certificates
- Continued education program for nurses
- Networking and collaboration with relevant stakeholders
- Telephone consultation
- Out-patient and in-patient department consultation services with palliative physician
To date, the palliative care unit has offered its service to 875 patients and is currently serving 153 patients. Out of 722 deaths, 422 have been home deaths and 300 have been hospital deaths.
Challenges:
Embarking on the journey to launch the palliative care service meant starting from scratch as we faced constraints of essential resources such as office space, transportation, and a telephone system. After thorough exploration, we had to request a male changing room at the Central Sterilization Department (CSSD) where we functioned until 2021.
We moved to the Kidu Medical Center in January 2022, where we have a larger office space which we share with the dialysis unit. With regard to service, we first started with two visits per week, which we increased to three to four visits a week with disruption during the national lockdown in the COVID period. Once the team acquired two designated vehicles, we could finally make daily home visits from Mondays to Saturdays.
Support:
Despite the challenges, we also received gracious support from the Royal Family of Bhutan. Her Majesty the Queen Mother Ashi Tshering Pem Wangchuck and Her Royal Highness Princess (HRH) Kezang Wangmo Wangchuck have generously made monetary donations to purchase vehicles for the palliative team to conduct home visits. A hearse was also purchased by the hospital with the royal donation.
A significant milestone in palliative care is the Hospice Project envisioned by Her Majesty the Royal Grandmother Gyalyum Kesang Choden Wangchuck and supported by Her Royal Highness Ashi Kesang Wangmo Wangchuck and Her Serene Highness Ashi Kesang Choden T. The project seeks to build a facility where patients at the end of life can receive the best possible care that allows them their dignity and comfort.
The location of the hospice facility has been identified as Simtokha, Thimphu, Bhutan where the road construction has been completed as of now. The stakeholders meeting chaired by HSH Ashi Kesang Choden T, with the Minister of Health, the President of the National Medical Service and relevant officials has been convened for the hospice construction at the Minister’s Chamber.
Networking with Health Volunteer Overseas (HVO) USA:
Collaboration with external agencies like HVO has provided the nurses with guidance and support for training and service improvement.
With HVO, we started an in-person, case-based learning exchange prior to the pandemic. HVO volunteers came several times a year for one to three months at a time to continue training and assist in the development of oncology patient care. As a part of the program, the volunteers helped the newly started palliative care service, which, at the time, was focused only on cancer patients. In the absence of a doctor on the team, the nurses requested the volunteers begin with case-based teaching/learning catering to the needs of cancer patients in their homes. This was an effort to define the goals of the palliative care service and to help implement changes that meet the objectives of palliative care in Bhutan. To continue the development of our expertise in palliative care during COVID lock downs, we switched from an in-person training model of case-based learning to a virtual training model through WhatsApp calls. Then, we moved the weekly calls to Zoom for case-based learning which takes place every Thursday morning for one hour, something we are still doing to this day. HVO also donated a laptop for us to conduct Zoom meetings.
The subjects of the Zoom meetings are not only limited to case discussions, but have also expanded to program development activities such as updating SOPs, developing referral criteria, developing our end of life brochure, and updating palliative care forms. Now the nurses in the palliative care unit have requested that HVO provide them with sessions on research topics, abstract writing, and data analysis, as they lack the skills and knowledge on research activities, which is crucial to publishing their work and seeking necessary recognition and support to further develop the palliative care service in Bhutan.
Last year in March 2024, HVO offered funding through the Wyss Scholarship for two nurses to attend a clinical attachment in Singapore at Assisi Hospice for two weeks.
Hopes and Expectations:
Despite beginning with limited resources, the program has been growing steadily since its inception. While the progress so far is commendable, there is a pressing need for further action. It is important to develop a national strategy and national action plan. Experience has shown that the possible way forward will be through policy guidelines, awareness building across various sections of the society, further international collaboration, increasing access and affordability of essential medicines, regional education, and increasing staffing and skill levels.
We look forward to achieving the following as we grow:
- Publishing our own data
- Learning to carry out research activities and make our own publications
- Continuing to learn and advance our knowledge to further improve our services
- Training health workers from ten more districts and have a set of national health policies inclusive of palliative care
- Improved access to palliative care
- Improved multi-disciplinary team approach
This HVO project is recruiting physicians or nurse practitioners specializing in medical oncology or pediatric palliative care, as well as pharmacists with expertise in chemotherapy, to complete both virtual and in-person assignments. In-person placements are a minimum of one month. Volunteers assist local teams with program development and mentorship. For more information, contact Lauren Franklin at l.franklin@hvousa.org.