Palliative Care in CubaNancy English PhD, APRN, CS, CHPN Nov 5, 2019
I was able to visit Cuba just after this country opened its borders to the United States in 2016. I remember being so excited about not the typical things many Americans would be — smoking cigars or drinking mojitos — but rather being able to have a first-hand introduction to one of the best healthcare delivery systems in the world. I’m was not traveling alone. On this journey, I have the honor of traveling with six other adventurous women led by Dr. Joan O’Connell, Health Economist and Professor at the School of Public Health.
Early one Monday morning, our entertaining driver, Samberto, arrived in a shiny 1972 Lada — a blocky car native to Russia — and we were on our way to the School of Public Health. There, we were introduced to Cuba’s public health system and how it cares for the needs of more than 11 million residents. After a 30-minute commute to the School, which sits on the outskirts of Havana, we arrived grateful for the tropical breeze.
At the school, we learned that Cuba’s model of care is based on disease prevention and health maintenance for all Cubans. At the heart of this massive system is the Primary Health Care Team. All phases of healthcare — from birth to death — are coordinated at the local level through these teams and their community-based office and free to all citizens. This structure is hard to imagine, but over the next few days, we visited these clinics and witnessed first-hand how the doctors and nurses care for their communities. Throughout Cuba, clinics are placed according to the village or district’s health needs and population distribution. The goal is to place a clinic within 1 KM of the district or village residents. Staffing for each of the clinics is approximately 6 physicians/1000 population. (Cf. USA 2.4 physicians/1000 populations) The clinics are open 24/7 and operate as a walk-in clinic or with an appointment.
The Cuban system has a very defined method of triaging patient needs. When a patient presents to the Primary Health Care clinic and the problem is assessed to be out of the scope of practice for the clinic, the patient is transferred to a Poli-clinic. Poli-clinics are full-service outpatient clinics that provide laboratory service, X-rays, pharmacy, specialist physicians and a short stay Intensive Care/Observation unit. If more intensive services are required, patients are transferred via special transportation to the regions Central Hospital.
I was fortunate to be able to speak with the educators at the Central Hospital in the region I was visiting. I was particularly interested in how the very seriously ill and dying are cared for in a Cuban Health Care System. The three nurse professors I spoke with immediately replied, “Oh, you are referring to palliative care”! One professor began to explain how pain management is approached as well as other symptoms. What she shared was very similar to our approach in the US. The difference is regardless of where the patient is on the trajectory of illness, treatment of pain and symptoms are the priority goals of care. I then asked, is there a point when you suggest to the family that the chemotherapy or other disease-related care are no longer helpful and recommend stopping chemotherapy or further treatments for the disease? This question did not seem to be understood by the nursing professors. I reworded the question several ways and was hoping that it was not lost in translation because they looked at me as if I was very naïve to ask such a question. The three professors all replied that the family and the patient decide about the care they want. They emphasized that the patient is at home under expert care of nurses and doctors at their primary health care clinic when hospitalization is no longer needed. All care is coordinated with the patients’ primary providers. Home visits can be as often as is needed until the patient dies.
I also asked about spiritual care and again I was met with blank looks. They replied the family could call their priest or spiritual caregiver at any time. After the conversation ended, I realized that under a socialist health care system, where resources are scarce, that stopping treatment and allowing a natural death does not seem to be an issue. It seems that death and life are considered as part of the natural cycle. Could it be that the need to discuss ‘death’ and Do Not Resuscitate orders are discussed in a cultural context? This piqued my curiosity and will be a subject I hope to pursue when I visit again.
It was such an honor to have a small glimpse into a community health care system where issues and problems are assessed according to the emerging needs of the patient and the community. It was also refreshing to see how available primary health care was for all citizens and that it was free to patients.
For more about Cuban Health Care, a must viewing is the film, “Salud” and can be accessed free at http://saludthefilm.net/awards/
Questions or Comments please write, Nancy.firstname.lastname@example.org