Increasingly equal treatment for the terminally ill
In Finland, not everyone has access to high-quality palliative and end-of-life care.
“Unfortunately, the level of care depends on where the patient lives. Furthermore, certain patient groups are left outside adequate palliative care,” says Professor of Palliative Medicine Reino Pöyhiä.
The professorship in palliative medicine at the University of Eastern Finland is one of the three of its kind in Finland, and Pöyhiä started in the part-time post at the beginning of March. He also works as Chief Physician in the Palliative Centre of Mikkeli Central Hospital, which is part of the South Savo Social and Health Care Authority, Essote.
Palliative care refers to symptomatic and comprehensive care of a terminally ill patient, seeking to alleviate suffering and to ensure a good quality of life. The need for palliative care increases especially when a chronic disease progresses, as well as at towards the end of life. Palliative care administered in the last days or weeks of a patient’s life is referred to as end-of-life care.
According to a WHO estimate, more than 40% of patients whose death is impending require palliative care. In Finland, approximately 30,000 patients annually are estimated to need palliative care at the end of their life, and the number of people needing palliative care already before is even higher. Unfortunately, only 12% of the palliative care need is covered internationally.
“Symptoms commonly suffered by patients whose death is impending include pain, shortness of breath, and nausea. In addition, social needs and existential questions that most people feel the need to address must also be considered in end of life care,” Pöyhiä says.
There is great variation in the availability of, and competence in, palliative care across Finland. According to a recommendation and a model published by the Ministry of Social Affairs and Health (MSAH) in 2019, comprehensive palliative care service chains should be built throughout the country, from the basic level of social welfare and health care to the intensive special level, which is the responsibility of palliative centres operating within university hospitals. In addition, all hospital districts are to open palliative centres that have outpatient clinics, end-of-life wards and hospital-at-home activities, among other things.
“Efforts are definitely needed to convince the new wellbeing services counties to commit to the implementation of the MSAH model of palliative care, and guarantee the sustainability of care,” says Pöyhiä, who is in charge of launching a palliative centre within Essote.
Palliative care can also be supportive treatment, for example, alongside active treatment of cancer.
“A study published in the NEJM journal ten years ago provided important evidence on its effectiveness. Lung cancer patients who received early palliative care as a supportive treatment had less depression and fewer aggressive treatments at the end of their life, and yet they lived a little longer than patients in the control group. Similar results have since been obtained from other studies as well.”
A large proportion of those in need of palliative care are diagnosed with cancer.
“There is, however, a large number of patients with heart and lung issues whose need for palliative care is poorly recognised. Instead of giving these patients as efficient alleviating treatment as possible at home, they will be undergoing unnecessary and burdensome treatments, examinations and hospital visits. Comprehensive care also includes talking about death, which many physicians and nurses still find difficult.”
In Finland, the identified skills gap in palliative and end-of-life care is sought to be bridged by social welfare and health care training. For a long time, physicians have been offered special competence training in palliative medicine, and a similar training was recently also launched for nurses. The University of Eastern Finland is among the first universities to introduce palliative medicine to basic medical studies as a module of its own.
“In 2020, there were 183 physicians in Finland who have completed this special competence training, and the estimated need in the upcoming years is 307. The figure is already among the highest in the world in terms of the population size, but the need and supply do not meet because competence is centralised to large urban areas.”
Pöyhiä’s research examines, e.g., pain management and sedation, teaching methods in palliative medicine, how spiritual and mental needs are addressed in palliative care, and hospital-at-home activities, on which he has also edited a textbook. According to Pöyhiä, it is possible to provide hospital-level care increasingly at home, where most people want to spend the final stages of their life.
“The hospital-at-home is, of course, much more than just palliative care, for example, it is a key service for pneumonia patients who need intravenous antibiotics. Thinking out-of-the-box, hospitals could be reserved for surgeries and intensive care only, and other care could be provided at home.”
“Palliative care pharmacotherapy still involves many unexplored issues, such as the mechanisms of action and behaviour of drugs in a body damaged by disease. Drugs that have been tested on healthy individuals may function differently towards the end of life,” Pöyhiä points out.
He has also studied self-administered sedatives in connection with, for example, a painful or frightening procedure. During the procedure, the patient can self-adjust the dose of the anaesthetic, which studies have proven to be an effective and safe method. Less anaesthetic is used when the patient is in charge of the dose.
“In order to develop our education, we have recently studied the attitudes of students towards death and end-of-life care. This will help teachers to support students where support is needed.”
The research group is also developing tools for measuring spiritual well-being in palliative care. There are partners in, e.g., Tanzania, where Pöyhiä originally ended up through the Finnish Christian Medical Society to support the development of palliative care.
“This has been a mutual learning experience, and we could learn from Tanzania’s communality in particular. In many African countries, palliative care is relatively advanced. With scarce resources for diagnosing and treating diseases, the least people can do is to offer good end-of-life care and make sure that the dying person is not left alone.”
Reino Pöyhiä
- Professor of Palliative Medicine, University of Eastern Finland (part-time, 30%), 1 March 2022 –
- Lic. Med., University of Kuopio, 1986
- MD, Anaesthesiology Specialist, University of Helsinki, 1994
- Title of Docent in Palliative Medicine, University of Turku 2013
- Title of Docent in Anaesthesiology, University of Kuopio 2005 and University of Helsinki 2008
- Special Competence in Pain Management, Palliative Medicine, Cardiac Anaesthesia, and Medical Teacher
Key roles
- Chief Physician, Palliative Centre of the South Savo Social and Health Care Authority, 2020–
- Medical Director, Kauniala Hospital 2016–2020
- Head of Department, Anaesthesia Unit, HUS Meilahti Hospital 2008–2016
- Chief Physician, Uppsala University Hospital, Palliative Centre, 2015
- Head of Department, Pain Clinic, Jorvi Hospital, 2007–2008
- Visiting Associate Professor, McGill University, Canada, 1998–2000
For further information, please contact:
Professor Reino Pöyhiä, reino.poyhia (a) essote.fi, tel. +358 404 3599514
