End-of-Life Care in Latin America

The GCI team recently published an extensive review article on “End-of-Life Care in Latin America,” led by Dr. Enrique Soto-Perez-de-Celis and published in the Journal of Global Oncology. The paper outlined the current state of end-of-life care practices and legislation in Latin America and noted deficiencies of health systems and areas for improvement throughout the region.

End-of-life care is an important aspect of cancer control and essential to providing quality patient care. The end of life is a difficult and painful time for patients and families, as they struggle with the terminal stages of disease, medical bills, and preparing for the future. Additionally, with the great cancer burden seen in low- and middle-income countries (LMICs) and the large expenditures associated with end-of-life care, health systems in Latin America are struggling to address the needs of patients and the hospitals that serve them. Throughout the region, we see large inequalities in access to palliative care services and pain medication, as well as insufficient clinical infrastructure, patient and family education, and legislation to protect patients’ rights. Thus, it is important to increase training and capacity in Latin America in order to respond to the growing and dire need for high-quality end-of-life care for cancer patients.

Here are some key facts from the paper:

• In Latin America alone, more than one million new cancer cases and 600,000 cancer deaths occur each year.
• 78% of the adults worldwide who need end-of-life care live in LMICs.
• While 13 countries in Latin America have a national cancer program that includes palliative care within the program’s framework, only four countries (Uruguay, Mexico, Colombia, and Panama) have dedicated national palliative care laws.
• Only six countries in the region have specific legislation regarding advanced directives (ADs), which are legal documents that allow patients to express their wishes about their end-of-life care before they become too ill to do so.
• Mexico is one such country that has AD legislation; however, utilization of ADs is low, with only 3,000 AD documents signed in all of Mexico between 2008 and 2014.
• Within countries, palliative care is often limited to privileged, urban centers.
• Less than 15% of physicians working in palliative care in the region have received palliative-specific education as part of their training.
• Only 2.1% of global palliative care publications come from Latin America.
• Latin America consumes nearly 13 times less than the global average of morphine per capita, due to issues of availability and affordability.
• The median price for oral morphine is 5.8 times higher in LMICs than in wealthier countries.
• The price of one month of injectable morphine is several times the minimum wage in Mexico, where it is not provided by the public health system.
• Cultural aspects of end-of-life care in Latin America — including family decision-making and spiritual support — are also important to consider, but research on these topics is scarce.

These shortcomings negatively affect patient care and health system performance. Integrated and well-functioning palliative care services will improve patient quality of life, reduce the economic burden of costly advanced disease care, and allow the shifting of resources to more primary and secondary cancer prevention.

Dr. Soto-Perez-de-Celis and his team conclude by suggesting that Latin American countries:

• commit to conducting research and reporting more palliative care data
• design and follow palliative care plans
• integrate end-of-life care into national health policies
• make ADs legal and accessible
• increase education and training of the health care workforce
• improve access to pain medication
• emphasize cultural sensitivity in the approach to end-of-life care

These are not small tasks, and their fulfillment will take time and effort, but they will undoubtedly allow countries throughout Latin America to provide comprehensive, high-quality, and compassionate end-of-life care for cancer patients.

Levels of palliative care development in Latin America