Palliative care in Lithuania

I first went to Lithuania in September 2004. From this initial visit came our twinning link with Kauno Slaugos Ligoninė (KSL). 

There are pockets of palliative care across the country. The focus is almost entirely on cancer and I suspect that this is unlikely to change until services have developed, maintained and funded to take a broader perspective on end of life care. In Lithuania, palliative care can be provided in an institution, a day centre or at the patient’s home. 

The British Embassy in Vilnius has been very supportive of the British Lithuanian Society and of the development of palliative care in Lithuania. Indeed, volunteer training was supported by the Embassy and this training event was formally opened by the British Ambassador.

The Tiltas Trust is in effect the charitable arm of the British Lithuanian Society. It has funded the translation into Lithuanian of MacMillan literature on palliative care topics and has provided travel fellowships for members of the Lithuanian Palliative Care Association to which the hospice movement in Northern Ireland where there is also a large Lithuanian Community.

Centro Poliklinika

My first visit was to the Centro Poliklinika (polyclinic), a public health non-profit institution that provides primary and secondary outpatient and inpatient care. Within the Lithuanian system care is provided at three levels: primary care, including GPs, Gynaecology, Surgeons, dentists, psychiatry, and paediatricians; secondary care, comprising specialist medical care including cardiology, endocrinology, neurology, as well as district hospitals, and tertiary care, represented by University Hospitals.

Palliative care for children and adults falls under primary care. The clinic also provides palliative care for children and adults as a primary level of healthcare.

Currently the polyclinic has a central diagnostic and administration centre with 5 branches in the city.  For palliative care, the head of service has 17 nurses, of which 1 provides care for a home based palliative care patient 10 hours per day. There is 1 nurse assistant in this team, which also comprises 1 social worker and 1 palliative care physician. There are some 100 patients currently on the palliative care list. 

Referrals for palliative care are made by the family doctor. The team is licensed for palliative care. Palliative care services are paid for on a tariff basis.

The Vilnius Polyclinic is planning an e-home nursing system so that results of tests at home are transmitted to the doctor’s office and the analysis and results are feedback wirelessly. There are also plans to convert one of the clinic branches to provide a hospice. The hospice is planned to be on the 3^rd floor from which patients would have a view of the city and access to a roof garden.

Hospice of the Blessed Father Michael Sopocko- Vilnius

I was also invited to visit the first purpose-built hospice in Lithuania, opened in Vilnius on 6 June 2012. The new hospice is dedicated to the Blessed Father Michael Sopocko and built on the site of a ruined Vincentian convent, donated by Cardinal Backis, the Archbishop of Vilnius to the Sisters of Divine Mercy.  The project was entrusted to Sister Michaela Rak, a Polish nun who has had a great deal of experience, having managed the Hospice of St Camillus in Gorzon Wieklopolski in Poland.

The new hospice will accept both adults and children, predominantly, if not exclusively, focusing on those with a terminal cancer diagnosis.  Building on the home care service, there will be 16 beds in multiple occupancy rooms with shared en-suites. Care will be free of charge, and will be delivered by professionals and religious devotees. Currently there are some 70 volunteers. Admission to the hospice would be on the basis of self-referral.

The focus of the care contrasts with that delivered in my home country, the UK. The emphasis appears to be on the needs of the dying and their preparation for death with dignity and love, whereas in the UK, the focus is on quality of life. This is reflective of the different cultures in the two countries. Lithuania is a predominantly Catholic country and this hospice has been developed and built by the Catholic Church. It istherefore not surprising that religion is central to their philosophy of the delivery of palliative care, albeit in a hospice setting.

There are firm plans for two other hospices (as opposed to hospital-based palliative care services) in the country: one in Klaipeda and a second hospice in Vilnius. There is also a fourth hospice being considered in the Alytus region but this is only at an investigatory stage.

Altys

In Alytus I met Eimentas Balaika, director of the organization Teviskas Namai, who has plans to build a hospice in the Alytus region.

Mr Balaika provides volunteer visiting services to adult palliative care patients in their homes, in hospital and in rehabilitation centres. There are some 100 expressions of interest from potential volunteers and about 20 who are active. 

Kauno Slaugos Ligonine (KSL)

Perhaps because I am familiar with the building, the most dramatic evidence of progress has been the refurbishment of the Kauno Slaugos Ligoninė. At KSL, I also met staff from the Kaunas Palliative Practice Centre, the first in the country to be granted a licence to practice. 

The team use a model of the multi-disciplinary team approach to patient care with everyone qualified on the new palliative care course. The team covers central Kaunas. It is important to note that KSL is not a hospice per se, but admits and cares for terminally ill patients.

Garliava

Dr. Asta Sileikiene runs a GP practice in Garliava on the outskirts of Kaunas. Deeply passionate about palliative care, she and her team have attended the training course. Her practice has over 9000 patients and runs independently of the local polyclinic. The practice maintains an excellent staff and a warm, friendly and professional approach to its work. A consultant orthopaedic surgeon provides consultations on a pro bono basis. 

Klaipeda

The drive to Klaipeda (a round trip that day over nearly 700 miles!) went via the scared site, the Hill of Crosses ( Kryziu kalnas).The crosses have been erected as votive offerings and the site has become a symbol of suffering, hope and undefeated faith. This underlines the importance of the Catholic faith in Lithuania. In my opinion, it is impossible to understand the culture of the country in the context of end-of-life and palliative care unless we take careful note of the centrality of Catholicism in Lithuania.

In Klaipeda I was taken to see the site of a new hospice development. Brother Benidiktas of the Order of St Francis of Assisi was the lynchpin of this development. On a site adjacent to the hospital, a stunningly simple yet amazingly beautiful church has been built.  Beside it, a monastery is being constructed as well as the hospice. 

Also in Klaipeda, but in the town centre, I visited a small day care clinic run by a doctor and 2 nurses.  It was in a small rented house. There was one room with 2 beds that were used for patient care, both morning and afternoon – 4 patients per day. There was also a small clinic room where patients were seen on an out-patient basis. There are plans to find a new building in due course to expand the size and scope of services

It was interesting to note that palliative care in Lithuania now has a body of law to support it. I was often told about how care had to be delivered in accordance with the law. As a democracy, still emerging from Soviet occupation, progress to establish and regulate new institutions and practice is clearly important to Lithuania.

There is a tariff for palliative care services which is protected by law, and while the sums involved are clearly inadequate, the principle has been established. On my first visit to KSL, I was told how once funding was exhausted after a few months, patients had to leave the hospital if families could not afford to keep them. This is no longer the case. 

I am forced to consider how much better end-of-life care could be provided across the country with better coordination and exchange of information. The pressure must be kept on the Ministry of Health to allow, facilitate and fund the networks and associations so that there can be a coordinated approach to providing palliative care in Lithuania.

The concept of charity as we understand it in the UK remains an uncertain concept in Lithuania outside of its religious context. My impression was that while the church plays an important part in the encouragement and organisation of care, for all practical purposes it is the state which sets the tariff and which provides healthcare. Charitable bodes are beginning to emerge and there seems to be a nascent volunteer culture.  That said, my belief is that it will take time for this to grow and become an established part of society.

I was completely unaware of the existence of the State Commission of the Lithuanian Language. The Commission is responsible to the Seimas (parliament) for language policy and for the regulation of the language. Unlike the Accadamie Française, whose recommendations carry no legal force, the decisions of the Commission are legally enforceable. While the word hospisas is commonly used, adapted in the Lithuanian tradition, it has no official recognition as a Lithuanian word. 

The need for palliative care has been well established and the first hospice has been built, with more planned for the near future. There is a long way to go to develop a full hospice movement and perhaps once hospice and end-of-life care is an integral part of Lithuanian life, clinical practice and culture, the Commission will gladly allow the official adoption of the word meaning ‘Hospice’.