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EurasiaNet.org
April 24 2014
Armenians Struggle for the Right to Die without Pain
April 23, 2014 - 1:42pm, by Gayane Abrahamyan
Tablets and bottles of medicine lie scattered on a shelf in the
one-room medical clinic of Chiva, a village about 120 kilometers south
of Yerevan. Opiates, legal for dying patients but nearly impossible to
obtain, are not to be found in such rural clinics. (Photo: Dean C.K.
Cox)
For Heghine Simonian, the memories of her 27-year-old daughter's
suffering are still raw. She can hear her daughter's pleas for relief
from the pain caused by terminal-stage breast cancer, yet no help was
available -- for the simple reason she lacked access to painkillers.
Alleviating the suffering of the terminally ill often is difficult, if
not impossible in Armenia. Although eligible patients are entitled to
free, state-subsidized opioid painkillers, the process for acquiring
them can prove so complicated and time-consuming that patients often
die before they receive the medication.
A lack of clear, time-efficient procedures is a big part of the
problem. No law on palliative care exists. Under current practices, a
medical commission and, then, local police officials must approve each
morphine prescription. The medical commissions themselves are a
cumbersome arrangement; since they comprise the patient's attending
physician, the head of the local clinic or hospital where the patient
is receiving treatment, as well as two other qualified doctors, it's
not always easy to convene a commission in a timely manner and then
get members to agree on a course of action.
"Before a commission would come to the regional center hospital,
before they would prescribe morphine, my daughter passed away in
intolerable pain," said Simonian, wiping her eyes. "My heart breaks
every time I recall the imploring look in her eyes. And because I felt
helpless, unable to stop that pain, I felt like dying with her."
For rural Armenians like Simonian, a 64-year-old homemaker from the
northern hamlet of Akhtala, the process for obtaining permission to
administer painkillers to a terminally ill patient must begin with a
costly and time-consuming trip to the nearest administrative center.
Medical commissions tend to wait until they have received applications
from a several patients before meeting to decide whether or not to
authorize the use of painkillers. The delays involved in the process
can be -- quite literally - agonizing for patients.
To dodge the hassle involved in convening a medical commission, many
doctors try to persuade "their patients that they do not need
painkillers, that they cause addiction; overlooking the fact that it's
given to people in the advanced stage of their disease, on the verge
of death," noted oncologist Dr. Hrant Karapetian, director of
palliative-care services at Yerevan's National Oncology Center.
Lack of knowledge about palliative care can complicate matters.
Armenian medical schools do not provide instruction about palliative
medicine, so doctors often do not know how to evaluate a patient's
level of pain, or to prescribe an appropriate dose of morphine, noted
Dr. Stephen Connor, a clinical psychologist and longtime American
hospice-palliative-care advocate who has worked in Armenia as a
consultant for the Open Society Institute's International Palliative
Care Initiative. [Editor's Note: The Open Society Foundation-Armenia,
a part of the Soros Foundations network, conducts research and
advocacy on palliative-care issues in Armenia. EurasiaNet.org operates
under the auspices of the New York-based Open Society Foundations, a
separate entity in the Soros network].
"Often that's where the problems start," Connor noted.
Uninformed doctors make decisions for uninformed families of the
dying, agreed Dr. Karapetian. "Often, [family members] do not know
that cancer patients do not have to suffer pain. They can get
painkillers, yet every day thousands are simply suffering."
Since 2011, financial support from the Global Fund to Fight AIDS,
Tuberculosis and Malaria has provided for four pilot palliative-care
projects in public hospitals in Yerevan and the regional towns of
Ararat and Vanadzor. But the impact of these projects appears limited.
Research by the Open Society Foundations-Armenia suggests that not
even 10 percent of the registered 18,000 hospital patients with
terminal diagnoses get access to painkillers as part of end-of-life
care.
Those families who decide to persevere with trying to get morphine for
a dying loved one must go through a "big ceremony," commented
Hovhannes Madoian, an HIV/AIDS-awareness activist with the
non-governmental organization Real World, Real People.
"One member of the family has to dedicate two days a week to that
process," he elaborated. "It is not just going and getting. It is
about getting several signatures, knocking at a few doors, and if the
patient lives in a region, that becomes a time-consuming and costly
procedure because they have to get to the nearest town to get the
drugs."
Obtaining sufficient dosages poses an additional challenge. The usual
permitted prescription -- three ampoules of morphine per day - has an
effect for only about 12 hours, Dr. Karapetian said.
One Yerevan resident told EurasiaNet.org that he spent two days
fighting to increase the prescribed amount of painkillers for his
39-year old wife, who is dying from lung cancer. The man only gave his
first name, Manvel, since his children do not yet know about their
mother's diagnosis. "Her physician prescribed a higher dose [of
morphine], but the chief doctor [at the hospital] would not allow it,
for no reason, and only after going to lawyers for help and getting
Healthcare Ministry employees involved was I able to get the
painkillers," said Manvel.
Frustrated by seemingly unnecessary obstacles, some Armenians suspect
medical personnel of selling what should be free morphine on the black
market. One local, privately owned company, Arpharmacia, supplies the
drug to the Ministry of Healthcare.
An official from the national police's anti-drug-trafficking office
claims that illegal peddling of morphine is a rare occurrence. "There
might be two to three cases per year, when medical morphine appears on
the black market," said Lt. Col. Artur Minasian. In general, he
continued, a doctor's refusal to increase a morphine dosage has more
to do with trying "to avoid the headache" involved with securing
official permission for the prescription.
Suren Krmoian, chief of staff at the Ministry of Healthcare, conceded
that dying patients' access to painkillers is problematic, but
maintained that a bill expected to be submitted by the government this
year would improve the situation. Under intended changes, only a
patient's doctor and another physician employed at the clinic where
the patient is registered would need to authorize the use of morphine,
Krmoian said.
Palliative-care advocates do not expect an imminent breakthrough, but
believe that public awareness of the problem, at least, is increasing.
"The progress is slow, but the will is obvious," noted Dr. Connor.
Editor's note:
Gayane Abrahamyan is a freelance reporter and editor in Yerevan.
http://www.eurasianet.org/node/68300
From: A. Papazian
April 24 2014
Armenians Struggle for the Right to Die without Pain
April 23, 2014 - 1:42pm, by Gayane Abrahamyan
Tablets and bottles of medicine lie scattered on a shelf in the
one-room medical clinic of Chiva, a village about 120 kilometers south
of Yerevan. Opiates, legal for dying patients but nearly impossible to
obtain, are not to be found in such rural clinics. (Photo: Dean C.K.
Cox)
For Heghine Simonian, the memories of her 27-year-old daughter's
suffering are still raw. She can hear her daughter's pleas for relief
from the pain caused by terminal-stage breast cancer, yet no help was
available -- for the simple reason she lacked access to painkillers.
Alleviating the suffering of the terminally ill often is difficult, if
not impossible in Armenia. Although eligible patients are entitled to
free, state-subsidized opioid painkillers, the process for acquiring
them can prove so complicated and time-consuming that patients often
die before they receive the medication.
A lack of clear, time-efficient procedures is a big part of the
problem. No law on palliative care exists. Under current practices, a
medical commission and, then, local police officials must approve each
morphine prescription. The medical commissions themselves are a
cumbersome arrangement; since they comprise the patient's attending
physician, the head of the local clinic or hospital where the patient
is receiving treatment, as well as two other qualified doctors, it's
not always easy to convene a commission in a timely manner and then
get members to agree on a course of action.
"Before a commission would come to the regional center hospital,
before they would prescribe morphine, my daughter passed away in
intolerable pain," said Simonian, wiping her eyes. "My heart breaks
every time I recall the imploring look in her eyes. And because I felt
helpless, unable to stop that pain, I felt like dying with her."
For rural Armenians like Simonian, a 64-year-old homemaker from the
northern hamlet of Akhtala, the process for obtaining permission to
administer painkillers to a terminally ill patient must begin with a
costly and time-consuming trip to the nearest administrative center.
Medical commissions tend to wait until they have received applications
from a several patients before meeting to decide whether or not to
authorize the use of painkillers. The delays involved in the process
can be -- quite literally - agonizing for patients.
To dodge the hassle involved in convening a medical commission, many
doctors try to persuade "their patients that they do not need
painkillers, that they cause addiction; overlooking the fact that it's
given to people in the advanced stage of their disease, on the verge
of death," noted oncologist Dr. Hrant Karapetian, director of
palliative-care services at Yerevan's National Oncology Center.
Lack of knowledge about palliative care can complicate matters.
Armenian medical schools do not provide instruction about palliative
medicine, so doctors often do not know how to evaluate a patient's
level of pain, or to prescribe an appropriate dose of morphine, noted
Dr. Stephen Connor, a clinical psychologist and longtime American
hospice-palliative-care advocate who has worked in Armenia as a
consultant for the Open Society Institute's International Palliative
Care Initiative. [Editor's Note: The Open Society Foundation-Armenia,
a part of the Soros Foundations network, conducts research and
advocacy on palliative-care issues in Armenia. EurasiaNet.org operates
under the auspices of the New York-based Open Society Foundations, a
separate entity in the Soros network].
"Often that's where the problems start," Connor noted.
Uninformed doctors make decisions for uninformed families of the
dying, agreed Dr. Karapetian. "Often, [family members] do not know
that cancer patients do not have to suffer pain. They can get
painkillers, yet every day thousands are simply suffering."
Since 2011, financial support from the Global Fund to Fight AIDS,
Tuberculosis and Malaria has provided for four pilot palliative-care
projects in public hospitals in Yerevan and the regional towns of
Ararat and Vanadzor. But the impact of these projects appears limited.
Research by the Open Society Foundations-Armenia suggests that not
even 10 percent of the registered 18,000 hospital patients with
terminal diagnoses get access to painkillers as part of end-of-life
care.
Those families who decide to persevere with trying to get morphine for
a dying loved one must go through a "big ceremony," commented
Hovhannes Madoian, an HIV/AIDS-awareness activist with the
non-governmental organization Real World, Real People.
"One member of the family has to dedicate two days a week to that
process," he elaborated. "It is not just going and getting. It is
about getting several signatures, knocking at a few doors, and if the
patient lives in a region, that becomes a time-consuming and costly
procedure because they have to get to the nearest town to get the
drugs."
Obtaining sufficient dosages poses an additional challenge. The usual
permitted prescription -- three ampoules of morphine per day - has an
effect for only about 12 hours, Dr. Karapetian said.
One Yerevan resident told EurasiaNet.org that he spent two days
fighting to increase the prescribed amount of painkillers for his
39-year old wife, who is dying from lung cancer. The man only gave his
first name, Manvel, since his children do not yet know about their
mother's diagnosis. "Her physician prescribed a higher dose [of
morphine], but the chief doctor [at the hospital] would not allow it,
for no reason, and only after going to lawyers for help and getting
Healthcare Ministry employees involved was I able to get the
painkillers," said Manvel.
Frustrated by seemingly unnecessary obstacles, some Armenians suspect
medical personnel of selling what should be free morphine on the black
market. One local, privately owned company, Arpharmacia, supplies the
drug to the Ministry of Healthcare.
An official from the national police's anti-drug-trafficking office
claims that illegal peddling of morphine is a rare occurrence. "There
might be two to three cases per year, when medical morphine appears on
the black market," said Lt. Col. Artur Minasian. In general, he
continued, a doctor's refusal to increase a morphine dosage has more
to do with trying "to avoid the headache" involved with securing
official permission for the prescription.
Suren Krmoian, chief of staff at the Ministry of Healthcare, conceded
that dying patients' access to painkillers is problematic, but
maintained that a bill expected to be submitted by the government this
year would improve the situation. Under intended changes, only a
patient's doctor and another physician employed at the clinic where
the patient is registered would need to authorize the use of morphine,
Krmoian said.
Palliative-care advocates do not expect an imminent breakthrough, but
believe that public awareness of the problem, at least, is increasing.
"The progress is slow, but the will is obvious," noted Dr. Connor.
Editor's note:
Gayane Abrahamyan is a freelance reporter and editor in Yerevan.
http://www.eurasianet.org/node/68300
From: A. Papazian