PALLIATIVE CARE DURING MILITARY CONFLICTS AS A HUMANITARIAN IMPERATIVE

I. Introduction

1. The Diversion of Clinical Resources During Military Conflicts
During times of military conflict, medical attention is conventionally directed towards triaged interventions that support life-saving wartime casualties. However, it is also critical that we do not lose sight of the essential needs of those who require hospice or other palliative care, and whose needs are often eclipsed by the exigencies of combat; inadvertently neglected by lack of access to healthcare personnel, medical facilities, and treatment resources; and involuntarily emotionally abandoned by familial deployment to militarized zones or wartime casualties. Accordingly, it is imperative that curricula incorporate principled and pragmatic approaches to address these issues so that healthcare professionals and military personnel are prepared to address needs on emergent bases.

2. Illustration:  The Full-Scale Invasion in Ukraine 
The full-scale invasion in Ukraine vividly illustrates the dire need for palliative and hospice care resources for those who not only suffer from combat-related injuries, but who also suffer from illnesses that are not necessarily the proximate cause of the military conflict. For example, as the invasion began, “roughly 80 percent of oncologists fled the country even as thousands of cancer patients remained” [1], and healthcare facilities suffered absences as “colleagues … became soldiers” [2]. Despite resiliency [3], Russian attacks on Ukraine’s healthcare infrastructure such as facilities, warehouses, and transport systems disrupted supply chains and humanitarian aid routes, restricted mobility, and caused mass displacement, which encumbered access to potable water, sanitation, hygiene, food security, shelter, and security, all of which complicated the evacuation of civilians and crowded shelters which bred infection and COVID [4,5,6,7]. The impact has been especially harsh for those with chronic diseases such as diabetes, cancer, cardiovascular disease, tuberculosis and other respiratory diseases, HIV, and cognitive, psychological, and neurological conditions, as well as for those with disabilities [4,5,6].

Moreover, the healthcare systems of geographically proximate countries to which forcibly displaced persons flee are likewise burdened, and the health of their populations are likewise imperiled [7]. During war, an influx of displaced persons burden healthcare resources in surrounding areas [8], whose medical needs may be exacerbated by infection; malnutrition; lack of local language fluency; disparate cultural expectations about medical care; lack of financial resources; and profound psychological trauma.  As but one example, in the months following the 2022 invasion, Poland saw a four-fold increase in chickenpox cases relative to the prior year when it accepted more than four million Ukrainian refugees [4,8]. In addition to a rise in communicable diseases, there appears to be a clear nexus between cancer and military operations, as war impedes diagnosis and treatment of cancer; chemical, nuclear, biological, and radiological hazards may be carcinogenic; war diverts resources from protracted cancer treatments; and diagnosis and treatment of combat-related injuries may expose pre-existing tumors [4,5,6,7,9]. Not surprisingly, mental health disorders are reportedly higher amongst those who live in or flee war zones [5,6,7,10]. 

Tragically, military conflict inevitably divides families, separating patients from sources of solace and care when they are most vulnerable. For healthcare professionals, the stark ethical dichotomy leads to moral distress: disaster or mass casualty triage prioritizes the greatest good for the greatest number of casualties but conflicts with normative clinical care, which prioritizes individual patient-centered attention based on autonomously derived goals of care. It is critical that educational and training institutions educate about these issues so that prospective healthcare professionals are prepared to administer both acute and palliative care in ethically appropriate triaged and sufficiently resourced ways before the perils and lack of predictability about military conflict arise.

II. The Role of Palliative Care in Patient Care 

Hospice care provides a type of palliative care, which in some regions such as the United States is rendered when a person’s life expectancy is six months or less and when curative or life-prolonging therapy is no longer indicated [11]. “The role of palliative care at the end of life is to relieve the suffering of patients and their families by the comprehensive assessment and treatment of physical, psychosocial, and spiritual symptoms patients experience” [11]. Palliative care is designed to provide relief from pain and other symptoms, affirm life, envisage dying as a normal process, neither hasten nor postpone death, attend to the patient’s psychological and spiritual beliefs, help the patient live as actively as he wishes until death and enhance his quality of life as feasible, and support the patient’s family during the patient’s illness and comfort the family and friends during bereavement [11,12]. In contrast to hospice care, palliative care is rendered throughout the patient’s illness regardless of life expectancy prognostications, in conjunction with and separate from curative therapeutic interventions.

But as needs for multifaceted, expanded, and familial-inclusive team care increase, the prospects for such care decrease in times of war which exacerbates barriers to the provision of palliative care, which include lack of resources, policies, and funding; and insufficient supplies of opioids and other analgesics [13]. Furthermore, in conflict situations, healthcare for civilians is primarily focused on trauma care, infectious diseases, and maternal and child health [13]. Families and friends, who would otherwise be integrated into the palliative care plan, may be separated from the patient, and thus deprived from providing and receiving consolation or possibly of even being apprised of their loved one’s condition.

III. Recommendations to Mitigate the Problem 

Tragically, in times of war, suffering comes in even more forms, urgently and gruesomely, contemporaneously because of combat and because of illness. The clamor and cacophony of combat may compete with the plaints of pain from illness, but they are no less harrowing. 

The essence of humanitarianism is the alleviation of human suffering. Although attention on palliative care in humanitarian crisis contexts has been increasing, in large part due to collaborations with ethics research groups, palliative care organizations, and the World Health Organization [14], significant needs remain unmet. Illustrative of the need for greater focus on this care is one recent study’s confirmation that “[r]esearch on end-of-life experiences among refugees is sorely lacking” [15]. 

As needs-driven approaches are ascertained and refined, there are many ways these needs can be addressed through multifaceted, collaborative, and interdisciplinary interventions:

1. National Initiatives

• Enact legislation that incorporates palliative care into the healthcare system and fund it accordingly.
  
  

2.  Educational and Training Initiatives for Military and Healthcare Personnel 

• Establish palliative care as a recognized medical specialty or sub-specialty and incorporate its training in military school curricula and in medical, nursing, and other healthcare curricula and in mandatory continuing pedagogy.
  
  
• Train military personnel to ensure preparedness to administer palliative care in combat zone settings when curative or stabilization efforts are unavailing or futile.       
  
  
• Train and enlist culturally-sensitive translators for intake, consultation, and charting, and be judicious about the timing of charting and ensure accurate communications about legal rights, notwithstanding the need to obtain basic demographic, diagnostic, and medical history information for clinical and family reunification purposes, to promote trust amongst those who may harbor suspicions about governmental misuse of information.
  
  
• Train and engage community caregivers and other volunteers [13], when family and friends are unavailable.
  
  
• Build educational fora and establish international collaborations to share knowledge to address gaps in the provision of health services [16].
  
  

3. Ethical Clinical Care Intitiatives

• Establish a professional code of conduct for the principled clinical administration of palliative care.
  
  
• Ensure that palliative care is rendered equitably without discrimination based on race, ethnicity, religion, age, sex, sexual orientation, gender identity, disability, socioeconomic status, or other inappropriate criteria.
  
  

4.  International Collaboration

• Harmonize international legislative, regulatory, and licensure schemes to expedite the mobility and deployment of personnel and resources to provide hospice and palliative care, including psychological support, to military casualties and to those at end of life and with severely life-limiting or chronic diseases in combat zones and host countries, as well to those who have been forcibly displaced and those who have been left behind or who have chosen to remain and who need ongoing medical attention and preventative care.
  
  
• Coordinate effective international assistance to ensure that countries sheltering refugees have adequate resources and infrastructure to meet the needs of refugees and also to meet the needs of their own populations.  
  
  
• Coordinate effective and transparent disease surveillance and reporting systems, outbreak investigations, case management, and response capabilities.
  
  
• Ensure internationally-sanctioned and supported humanitarian corridors for the safe transport of healthcare personnel, first responders and medications, vaccines, food, and other essential supplies.
  
  
• Enlist the collaboration of border control authorities to sensitively mitigate health risks and to counter discrimination of refugees [17].
  
  

5.   Re-Integration Plans

• Seek to maintain cultural, religious, and other ties to the refugees’ countries while displaced persons are in host countries if they so wish to help them adjust to the displacement and to ease re-entry once the conflict ends.
  
  
• Develop discharge plans, including for the eventual re-settlement or return to the country of origin after the conflict ends, for ongoing treatment [12], and for family reunification.
  
  

IV. Conclusions

It is incumbent on healthcare providers, the military, and the world at large to integrate palliative care into the practice of medicine generally, including by assiduously ensuring that the perils and exigencies of war do not distract from the provision of such care to ill persons. Failure to provide palliative care to forcibly displaced persons, to those who remain behind, to the populations of host countries, and to those in battle is a breach of the ethical duty of care that violates the ethos of medicine and humanitarianism, that exacerbates suffering, and that is a menace to personal dignity.

What of the potential argument that resources may be too scarce in some crises to provide palliation to some in lieu of aggressive life-saving treatment to others? Some commentators retort that limited resources should not be expended on futile interventions, that curative care may be possible contemporaneously with palliative care, and that many palliative care interventions require neither cost nor resources; holding the hand of a patient, whispering words of comfort, or singing softly may help bring a great deal of comfort. Of course, funding for personnel, training, medication, equipment, facilities, and infrastructure, as well as a commitment to the systemic foundations for the administration of palliative and hospice care is essential.

Ultimately, we must recognise that investment in our global community is an investment in our own health.

References: 
1. B. Newport, Chemotherapy in Ukraine continues, despite the challenges of war, Direct Relief (May 21, 2023). Available at:   https://www.directrelief.org/2023/05/chemotherapy-in-ukraine-continues-despite-the-challenges-of-war/ (citing Stan Polozov of Mission Kharkiv). 

2. O. Riga O, J. Marston Palliative care during humanitarian crisis: An Inside view from Ukraine, Indian Association of Palliative Care (Nov. 10, 2023). Available at https://www.palliativecare.in/palliative-care-during-humanitarian-crisis-an-inside-view-from-ukraine/. 

3. Press Release, New WHO assessment reveals resilience of Ukraine’s primary health care system amid the war, World Health Organization (Oct. 12, 2023) .Available at  https://www.who.int/europe/news/item/12-10-2023-new-who-assessment-reveals-resilience-of-ukraine-s-primary-health-care-system-amid-the-war. 

4. N. Smith, As Conflict strains health system, needs continue in Ukraine: Maternal and newborn health, mental health needs, and chronic disease care are among top concerns, Direct Relief (July 8, 2022). Available at https://www.directrelief.org/2022/07/as-conflict-strains-health-system-needs-continue-in-ukraine/.  

5. A. Pandey, D.R. Wells, V. Stupnytskyi, et al. Disease burden among Ukrainians forcibly displaced by the 2022 Russian invasion. Proc Natl Acad Sci USA (Feb. 21,2023);120(8):e2215424120 doi: 10.1073/pnas.2215424120. 

6. T. Lewis, How the war in Ukraine is Causing Indirect Deaths: Crowded shelters and destroyed health care facilities will likely exacerbate COVID, TB, and other diseases, Scientific American (Mar. 29, 2022). Available at https://www.scientificamerican.com/article/how-the-war-in-ukraine-is-causing-indirect-deaths/.

7. K. Lewtak, K. Kanecki, P. Tyszko, et al. Hospitalizations of Ukrainian migrants and refugees in Poland in the time of the Russia-Ukraine Conflict. Int J Environ Res Public Health (Oct. 19, 2022):1335 doi: 10.3390/ijerph192013350.

8. M. Püsküllüoglu, A. Grela-Wojewoda, G. Szczubialka, et al. Cancer care for Ukrainian refugees during the first 6 weeks of 2022 Russian invasion – An experience of a cancer reference centre in Poland. European Journal of Cancer, vol. 178, 234–242.  

9. C. Caglevic, C. Rolfo, The Armed conflict and the impact on patients with cancer in Ukraine: Urgent considerations. JCO Global Oncology no. 8 (2022) e2200123 doi: 10.1200/GO.22.00123.

10. O. Lushcha, M. Velykodna, S. Bolma, et al, Prevalence of stress, anxiety, and symptoms of post-traumatic stress disorder among Ukrainians after the first year of Russian invasion: a nationwide cross-sectional study, Lancet, 36:Jan.2024, 100773, https://doi.org/10.1016/j.lanepe.2023.100773.

11. R.B. Rome, H.H. Luminais, D.A. Bourgeois, et al. The role of palliative care at the end of life. Ochsner J. 2011 Winter; 11(4):348-52. 

12. S.R. Connor (ed.), Worldwide Hospice Palliative Care Alliance, Global Atlas of Palliative Care, 2d ed. London( 2020). Available at http://www.thewhpca.org/resources/global-atlas-on-end-of-life-care. 

13. PallCare, Palliative care: All is unfair in love and war, European Association for Palliative Care (June 20, 2018).  Available at https://eapcnet.wordpress.com/2018/06/20/palliative-care-all-is-unfair-in-love-and-war/.

14. E. Nouvet M. Sivaram, K.Bezanson, et al. Palliative care in humanitarian crises: a review of the literature. Int J Humanitarian Action 3, 5 (2018). Available at https://doi.org/10.1186/s41018-018-0033-8.

15. F. Madi, H, Ismail, F. M. Fouad, et al. Death, dying, and end-of-life experiences among refugees: A Scoping review, Journal of Palliative Care (2019);34(2):139-144 doi:10.1177/0825859718812770.

16. European Stroke Organisation, ESO Statement on the War in Ukraine. (2024) Available at https://eso-stroke.org/2024-eso-statement-on-the-war-in-ukraine/.

17. Y. Ioffe, I. Abubakar, R. Issa, et al. Meeting the health challenges of displaced populations from Ukraine. Lancet (Mar. 26, 2022);399(10331):1206-1208. doi: 10.1016/S0140-6736(22)00477-9. 

Author: Madeleine Schachter
Author Affiliations: Weill Cornell Medicine; Albert Einstein College of Medicine and 
non-profit organizations Hospices of Hope and Children of Heroes Ukraine
Author Contact Email: MAS3005@med.cornell.edu

Date: 03/18/2024