This is the second of a three-part series. Part 3 will appear on December 23. \t Where There is Life, There is Hope Cultural and religious beliefs define many of us, and the decisions we make. It plays an especially important role in healthcare where it can impact the physician-patient relationship and the treatment options that are selected. From traditional and holistic treatments to the greatest advances in modern medicine including vaccinations, what a patient wants and is willing to endure from a treatment perspective often finds its roots in his traditional beliefs. The attitude, “when there is life, there is hope,” is especially powerful and strong in terms of end of life care, palliative care, the specialty centered on management of the incurable illness, which is a relatively new area of healthcare. Treating the symptoms of the terminally ill patient and his family, and even providing care aimed primarily at comfort care in patients with prolonged chronic illness may appear to contradict the goals of medicine. The treatment options available to physicians and patients have grown exponentially over the years, aided by new technology, new medications, and fueled by the concept that “you can put a price on life.” Thus we have chemotherapy cancer treatments costing tens of thousands of dollars per month which fail to prolong life and often prolong suffering, and unresponsive, comatose patients sustained on breathing machines and artificial feedings with no realistic hope of a recovery. Western medicine has wrestled with the question of “futile care” and moral, religious, medico-legal and economic aspects. Within the USA, only several states have enacted laws that may protect physicians as they decide to withhold care that is considered hopeless and wasteful. Opinions on this topic run high and emotional amongst healthcare providers as well as patients, family and clergy. In the developing countries that I visited, the concept is even less clearly addressed; religious and educational factors play a strong role in the acceptance of comfort care over continued efforts at care for cure. In Hanoi, Vietnam I spoke with Dr. Bach Duong, one of the first palliative care physicians in Vietnam, and a key physician in the movement to bring palliative care to the country. Dr. Duong described similarities to palliative care in the USA; in Vietnam there is an emphasis on providing comfort care and pain management to patients with chronic conditions and in need of pain management. The concept of DNR orders (Do Not Resuscitate) is less accepted. She explained that patients may refuse care. Every patient, however, regardless of age and medical condition is otherwise to be treated until they pass away. The physician cannot deny treatment, and if your heart stops, the doctors will attempt to bring you back. Advance directives and “living wills” are not common, and palliative care in Vietnam is primarily comfort care and pain management, often related to chronic conditions and severe illnesses such as cancer. Similarly, palliative care also is a new and growing aspect of medicine in Nigeria. Similar to Vietnam, there is no DNR, and little in the way of advance directives and patients making decisions and requests in advance. In speaking with Dr. Lillian Ekpo, in her clinic in Lagos, Nigeria, she explained quite simply that to most people in Nigeria “life is hope.” Simply breathing and having a heartbeat, despite the odds, means that one can get better, and one can have hope. Nigeria is a fairly religious country, with most of the population split between Christianity and Islam. To live one more day, regardless of pain or even if the efforts are futile, is still one more day on earth for that person and his family. There is still hope. As a result, this is more of a social and religious than an ethical issue, with the idea of life truly priceless and less consideration over mental and physical function. Unlike the other places I traveled to, Russia has one of the most most advanced healthcare systems and some of the oldest medical research universities, yet palliative care is not a focus there. When I visited St. Petersburg, Russia, I noted that there is no DNR for patients, and palliative care is largely non-existent. The government has a stronger hand in healthcare, especially topics that are debated in the US. They allow research in stem cells but topics like medical marijuana or euthanasia are not even open for discussion. Russia boasts some of the most stoic people on the planet, with many patients not going to the doctor until they absolutely have to. The idea of “giving up on life” is something that is largely inconceivable, and palliative care is viewed that way. Views vary through religious differences, and I witnessed this as I visited countries with largely Buddhist populations like Myanmar, Thailand, and Vietnam. Here again, the idea of “giving up” is the way that election for palliative care over curative care is seen, and this often conflicts with and contradicts the religious beliefs. The United States and parts of Western Europe seem to be at the forefront of the issue of end of life care, DNRs, and the decisions an individual can make towards his own end-of-life treatment. In countries such as the United States, an individual can decide to have a DNR, and can decide what is or is not done, spelled out before and in the event he is incapacitated. Additionally, family members may be named as health care proxies, the assigned decision makers for the care of the patient who loses capacity to make those decisions. Outside of Western Europe and the United States, in many cases there are few decisions families can make in terms of what type of end-of-life care they can accept or decline. The decisions will more strongly be for treatment methods and how invasive they are (and are often cost determined). Traditional and alternative medical treatments and “spiritual healing” become a big part of end-of-life care in many countries. Again, as discussed in the first part of this article, on “The Band-Aid Treatment,” understanding and relating to people of different cultures and understanding their beliefs and how they affect treatment options plays a big role. Education, financial means, the religious beliefs of the patients and families, and the views and convictions held by the treating physician strongly influence the direction of treatment at this stage. While more options and opportunities for many healthcare decisions and end-of-life decisions exist in the United States and Western Europe, for palliative care and pain management especially, there is still globally a significant growth of prescribing pain medication and in pain management. While the primary effects are better quality of life by managing the pain, the effects of the increased prescription of pain medication and potential addictions and negative impact is still being explored and studied. In this, too, the relationship between how different cultures value the idea of life and the impact of hope and spirituality play a significant role in all healthcare decisions, as well as the increasing prescriptions, as lack of other alternatives may exist. The idea and definition of life, and how different cultures and societies value the idea of life and the hope that comes with it play a central role in the acceptance of end-of-life care and palliative care. At this time, patients and families generally have control of these decisions and physicians serve to advise. Recognizing the impact on resources, economic and otherwise, it may be that government and health insurance providers may soon have a say in defining futile care and restricting the “rights and decisions” currently exercised by patients and their families in regard care of the terminally ill and end of life treatments. With contributions from Frederic E. Wien, MD, FACP Assistant Clinical Professor, The Mount Sinai School of Medicine, New York; Assistant Clinical Professor, St George’s University School of Medicine, Grenada; Diplomat ABIM Geriatrics, and Palliative Care & Hospice. Image credit: Rakka via flickr.