Partner Institutions in Nepal

Dr. Pradeep Vaidya with patient in the patients own home as a community service of Hospice Nepal.

1. Hospice Nepal

Within the past few years, there’s been a significant shift in attitudes about terminal cancer in Nepal, and a growing awareness of the need for palliative care. Hospice Nepal is at the forefront of a movement within countries with limited resources to give greater attention to the needs of those cancer patients for whom there is no cure.

Established in 2000, Nepal’s first Hospice Nepal, was created to help ease the suffering of cancer patients and to give comfort to their families in a cheerful and homelike setting. The hospice is directed by Dr. Pradeep Vaidya, a professor at Tribhuvan University Teaching Hospital in Kathmandu and a surgeon by training.

“Before 2000, we would tell patients, “We cannot do anything more. Please go home.’ That is what was so heartbreaking. Terminal patients would have to go home and die in pain, with no doctors to treat them.”

Family member helping patient in Bhaktapur Cancer Hospital.

Hospice Nepal was the brainchild of three physicians and a local businessman with a genius for fundraising. They opened a facility with ten beds and a small staff devoted to helping improve the quality of life for the dying patient and the family members, who play such a critical role in care-giving. In Nepal, physicians share much of the responsibility for palliative care with nurses, social workers and community volunteers who embrace the notion that everyone has a right to die free of pain.

“The whole system in Nepal has changed,” Dr. Vaidya declares. “There was a time when palliative care was considered unimportant, even in the hospitals. Patients and families had only their doctor to rely on, and he or she was busy with patients with a possibility of cure. Most hospitals now have separate palliative care units, where a dedicated nursing staff looks after patients. This team approach has decreased the physicians’ workload, and the families are happier to have the undivided attention of a nurse who becomes almost a member of the family.”

Hospice Nepal now proposes to build a new hospice facility with 25 beds and an educational and training center. Plans are underway, too, to expand community outreach into the outlying districts to aid terminal patients who, because of family obligations, cannot stay in Kathmandu. By sponsoring a palliative care training workshop for physicians in outlying districts, as was done in March 2007, Hospice Nepal hopes to encourage the development of local networks of palliative care nurses and community health volunteers who can make home visits. These visits provide comfort to patients, instruct family members who are caring for them, and satisfy government concerns that morphine is being administered properly.

“The pivotal moment for us came in 2002 when INCTR came to Nepal and wanted us to do something about palliative care in hospitals,” recalls Dr. Vaidya, whose staff would often travel by bicycle to visit terminal patients at home. “INCTR has given training to me and our nursing staff. They provided a van for us to use in our Community Hospice program. When we give our presentations about the importance of palliative care, people understand that we are here to help bring dignity to dying.”

2. Bhaktapur Hospital

Nepal faces the same challenges typical of countries with limited resources and too many patients with advanced-stage cancers. What is different, says Dr. Sudip Shrestha, a medical oncologist at Bhaktapur Hospital in Kathmandu, is that his country has a group of people who believe that palliative care is important and who are working together and individually to develop and expand palliative care.

“We want to deliver palliative care to the door of the people who need it,” he says. “That is our ultimate goal.”

For that to happen, he says, morphine must become more widely available all over the country — not just in hospitals or hospices but also in the context of home based programs. In Nepal, nearly 86% of the population lives in rural areas—and most of them have unrealistic fears regarding opioids. Compounding the problem, very few inpatient beds in the capital city of Kathmandu are designated for palliative care.

Dr. Shrestha coordinates palliative care at Bhaktapur Hospital, Nepal’s second-largest cancer hospital. The charitable hospital was established in 1998 with 44 beds. Four years later, the hospital began integrating palliative care in the treatment of all patients diagnosed with cancer. INCTR has selected his hospital as one of four facilities within the Kathmandu valley targeted for its program designed to increase capacity in palliative care, thereby improving access to those in need.

“Palliative treatment is needed not only for advanced cases, but also for patients in the earlier stages of cancer,” Dr. Shrestha notes. “All patients and their families need to know how to cope with the disease and how to deal with family needs at the same time.”

In a family-centered society such as Nepal’s, family members make decisions on behalf of their ailing loved ones and often don’t want doctors to relay the poor prognosis to the patient. That information is better shared by a beloved husband or a favorite daughter. Then again, sometimes it is the patient who instructs her caregivers how she wishes to die.

Dr. Shrestha recalls a young Christian woman who, at age 32 had developed breast cancer. The young patient underwent surgery, but the cancer had already spread.

“We managed her pain with morphine and told her she could go home,” recalls Dr. Shrestha. “She knew she was dying, but she was afraid that her Hindu family would not respect her wishes for a Christian death. When the time came, she called her family member and her nurses together, she asked her brother to read a Hindu prayer, she lay down with her Bible scriptures, and she passed away very contentedly. That she could die pain-free, and with dignity, keeps us going.”

At Bhaktapur, while there is no single palliative care specialist, a core group of caregivers is responsible for patients and family needs. Palliative care nursing staff, although not permitted to write prescriptions, coordinate each case in collaboration with the oncologists and social workers, and work closely with the family.

A sister hospice in the state of Idaho, United States, provides some support Bhaktapur’s palliative care unit, and the Nepal Cancer Relief Society is a huge ally. INCTR/NNCTR is also an active partner in the effort to develop a well-organized palliative care system in which all health care professionals play a part.

“We don’t yet have awareness at the government level, but there is so much enthusiasm for palliative care that we are now building hospices near Kathmandu. We have a bright future.”

Marcia Landskroener for INCTR