Enhancing End-of-Life Care in Low and Middle-Income Countries: The Role of the SPICT-Low Income Setting Tool

A Journal Correspondence

We read the article “How do Primary Care Clinicians Approach Hospital Admission Decisions for People in the Final Year of Life?” by Davies et al. (2024) [2] with great interest. Although that review considered studies mainly from high-income countries, we found many parallels between its findings and our experiences in a rural teaching hospital in Kenya. In many LMICs, conversations around death are often avoided and the treatment preferences of terminally ill patients are rarely considered [8]. Doctors and nurses frequently conceal terminal diagnoses from patients, hence alienating them from the decision-making process [1]. Besides, some family members prefer hospital admissions over home-based care to avoid actively experiencing the death process and its social, emotional, and financial implications [3]. Therefore, terminal patients are frequently subjected to nonbeneficial hospital stays with a lack of personalized care in often overcrowded wards.

The economic challenges in many developing countries are a major hindrance to home-based care for patients with complex needs. Unlike many developed countries, hospital care can sometimes be cheaper for Kenyan families insured by the Social Health Insurance Fund (SHIF), which caters for most basic hospital expenses for as low as 3 US dollars monthly [6]. Although this may promote systemic wastage, admitting terminal patients offsets recurrent costs, including medications, meals, and transport, to and from hospitals for these caregivers. Consequently, the threshold for admitting patients is notably low, and from our experience, many terminally ill patients are neglected in the wards eventually developing avoidable physical and psychological complications.

While the paper highlights clinician inexperience as a major challenge among the gatekeepers of hospital admissions in several developed countries, LMIC hospitals are frequently staffed by clinical officers and junior doctors with significantly less training in end-of-life care [9]. As a result, identifying palliative patients and initiating conversations on advanced directives and home-based care is even more challenging. So, we implemented the Supportive and Palliative Care Indicator Tool (SPICT-low-income setting) in Chogoria Mission Hospital in Kenya which has been integrated into the electronic health records system to allow junior clinicians to identify terminally ill patients and link them to the necessary care, which often includes holistic and home-based interventions [5]. Having tested that SPICT is feasible to use as a screening tool in a busy general hospital in Africa, our next step may be to train workers in the local health centers and dispensaries to identify patients with palliative care needs that might be addressed in the community rather than admitted routinely to the hospital.

In conclusion, reducing unnecessary admissions for terminal patients remains a major challenge in LMICs. While some economic and cultural challenges may not be easy to mitigate, more effort should be directed toward training clinicians to identify end-of-life patients and initiate discussions on home-based care. Additionally, the healthcare funding model in these countries should incorporate the promotion of community-oriented care for end-of-life patients with complex needs [7].

Authors:

Ian Basil Kibet, Mteeve Brian Amugune, and Grace Macharia

Affiliations:

Kabarak University & Kirinyaga University

Funder statement:

No funding was received for this correspondence.

Corresponding author:

Ian Basil Kibet, PCEA Chogoria Hospital, Chogoria Town, Kenya.

ianbasil@kabarak.ac.ke

List of abbreviations: LMICs: Lower and Middle-Income Countries, SHIF: Social Health Insurance Fund, SPICT: Supportive and Palliative Care Indicator Tool.

Acknowledgments: We would like to express our gratitude to the staff at Chogoria Mission Hospital for their dedication and support in implementing the Supportive and Palliative Care Indicator Tool (SPICT). Their commitment has been instrumental in improving the identification and care of palliative patients. We also thank the University of Edinburgh, Kabarak University and Kirinyaga University for their continued support in our writing endeavors. Lastly, we appreciate the insights provided by Davies et al. (2024), which inspired our reflections on end-of-life care practices in lower and middle-income countries.

Author contributions: IBK wrote the first manuscript. MBA edited the written manuscript with input from all authors. All authors provided critical feedback and helped shape the final manuscript.

DECLARATIONS

Competing interests: The authors declare that they have no competing interests.

Ethical Considerations: This correspondence did not involve interactions with human or animal participants; therefore, ethical approval was not required.

Funding Information: No funding was received for this correspondence.

Disclaimer: The views expressed in this correspondence are those of the authors and do not necessarily reflect the opinions or policies of their affiliated institutions.

Key Words

End-of-Life Care, Palliative Care, Hospitalization, Terminal Illness, Health Services Accessibility, Clinical Decision-Making, Home-Based Care, Low and Middle-Income Countries, Health Insurance, Kenya

Reference

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