Second Breath Moldova - Completed Projects

Previous projects: • Project “Second Breath” – development of home and community based care services in Moldova, creation of gerontological center for medical and social rehabilitation of older persons, OSI, 1998; • Trainings for the volunteer development in the field of medical and social rehabilitation of the elderly, Soros Foundation Moldova, 1999; • National Conference “Life Quality of the Elderly and Development National Standards of Care”; OSI, 2000; • Organizing the meeting “Development of the National Network of NGOs working with and for older people”, HAI; 2000 • Continuation of the activity of the project “Second Breath”; duration – 1year 6 months, 2001-2002; OSI, 2001 • Training of the National Network of NGOs working with and for the elderly in Moldova, HAI, Charity Know How, July 2001 • Publishing the Policy booklet Moldova “Nothing about us – without us”, HAI, LGI, 2001 • Informational center for terminal patients and their relatives, Soros Foundation Moldova, 2002-2003 • Reintegration of older people in Moldovan society – TACIS, IBPP program, project Nr. 136, 2003-2004 • Project “Living with Hope” for palliative care of people infected with HIV/AIDS and creating self-help groups, SFM, 2004-2005 • Professor Luczak’s visit in Moldova, holding an International Seminar on Palliative care, SFM, Chisinau, June 2004.

	PROJECT “Second Breath” The primary goal in the project is the creation of the home & community based care system in Moldova for increasing longevity and maximal socialization of the elderly, development of the National Network of NGOs working with and for the elderly, the development of a partnership with HAI, London. Another important goal of our project was the propaganda of the ideas of palliative care in Moldova.

	STRUCTURE OF SERVICES Day Care: 9:00-16:00, 5 days a week, social rehabilitation, social worker (programs for stimulation of mental activity, creative therapy, games, contests). Home Care: daily 3-4 hours for a client; caregiver’s work 2-3 times per week; consultation of the service coordinator 2 times per week. Hospice at Home: permanent service of 10-15clients at home at the same time. *Meals on Wheals:* 5 days a week. Daily 1-2-3 hours. Caregiver 3 times per week. Observation of the service coordinator.

	DAY CARE CENTER Holds medical & social rehabilitation for the people over 65 who are using public transportation. Activity program of the Day care center 1) Physical exercises for people over 60 years; daily; Mental activity development – 3 times per week 2) Creative therapy – 2 times per week 3) Musical therapy (singing) 2 times per week

	4) Lectures – social & medical issues Medical topics: -Nutrition in the old age – 1 time per week -Elderly people and illnesses – 1 time per week 5) Games (Bingo) – 1 time per week 6) Joint TV watching 7) Joint birthdays’ celebration, festive dates 8) Breakfasts & Dinners 9) Medical consultations (neurologists, eye-doctor, physician)

	10) “Warm House” program – represents a link between clients of the Day care center and elderly people who are not going out for a long time. It’s held 1-2 times per week for 15 persons (communication, joint nutrition, singing, dancing). 11)“Open House” program – as a rule organized on a special occasion, holiday. 40-50 people get together in a warm atmosphere, singing, reciting poems, etc.

	HOSPICE AT HOME SERVICE Usually 30 clients are served. The majority has breast cancer of the 4th stage, lung cancer of the 4th stage, rectum cancer of the 4th stage. There are patients with the Alzheimer’s Disease and decompensated liver cirrhosis. Sample program of the Hospice service activity: 1) conversations and spiritual relief 2) help in personal hygiene 3) cleaning 4) laundry 5) curative physical exercises 6) light massage 7) prophylaxis and decubetus cure 8) bandaging 9) enema 10) injections 11) droppers

	A permanent work with patients and their families is being held. A new program “Round Table” for the families of the dead and dying persons has been started. Here they exchange and share their thoughts and emotions, thus rendering moral support to each other. HOME CARE PROGRAMME Home Care programme is being held for 40 persons. There are rendered 2-3 visits at home, and when necessary more visits in a week during one month. A number of standards are used in the work: The rights of a client receiving help and duties of caregiver are equally respected and fulfilled according to the Bill of Rights in the care; Co-ordinator of the Home Care service selects prospective clients using the scale of daily life activities; For every client a personal register is started and an individual programme is selected; The dignity and independence of a client are respected.

	The Home Care service includes medical consultations as well and free of charge treatment in case of necessity. The main achievement of this project was the development of the volunteering among elderly and the changes of their social role. At the end let’s mention the words of one of our old volunteers, Tatyana Ryabova: “Our visits are awaited with eagerness. We, too, are always happy to see the older people we visit. Before, nobody cared for us in society, but now, our capabilities, knowledge and experience are being put to good use. We really feel that we have become younger”.

	Informational center for terminal patients and their relatives The Informational and Consultative Center (ICC) was founded in January 2003. It is open from 9.00 to 14.00 for 5 days per week. There are held consultations by the psychologist, physician and nurse. There was created a team of a family doctor and a nurse, who along the consultations at the ICC hold consultations at home.

	The relatives of the patients are mostly concerned about the stress as the result of the sufferings of the relative and the permanent care of the terminal patient. The relatives mostly need psychological support and as well as explanations about the suffering which are beard by their sick relatives.

	The most frequent questions asked by the relatives are the following: - How to feed the patient and what to give him/her to eat? - How to prevent the decubitus? - How to do an enema? - What to do with the pain? -Asking the nurse to teach them to make injections. The patients are mainly interested in: - How to live and how to fight with such a disease? - Is it possible to ease theirs and their relatives’ lives?

	The main diagnosis of the patients: uterus cancer intestinal cancer esophagus cancer lungs cancer liver cancer strokes diabetes with complications cancer of the urinal bladder lymphosarcoma brain cancer pancreas cancer

	Project “Living with Hope” for palliative care of people infected with HIV/AIDS and creating self-help groups 1. General Development of home care services and creating a model of palliative care for HIV infected people and AIDS in Balti. 2. Problem AIDS began to spread in Moldova since 1997-1998. In comparison with other countries the spreading is rather slow. The causes of HIV infection in 2003 are, 70% - drug addicts, 16% - heterosexual contacts, 4,6% - prostitution. By January 1, 2004 in Balti were registered 612 HIV infected people, out of which 598 are drug addicts. During the year 2003 there were registered 38 new cases of HIV infection.

	3. Aims and Objectives of the Project I. Making a research of the living conditions of the ones infected with HIV and AIDS who live at home with their families with the help of an elaborated questionnaire and a direct interview. II. Appreciating the number of the people who need palliative care at home. III. Creating a multidisciplinary team of palliative care for those infected with HIV and AIDS. IV. Training the team members. V. Creating some basic principles of the palliative care at home program for the HIV infected and AIDS patients. VI. Creating a working program for the relatives of HIV infected and AIDS patients. VII. Editing a brochure “Models of palliative care at home for HIV infected and AIDS patients”.

	4. Methods of implementation • Creating a team having its own specifics. In the team there will be included: a doctor, 2 nurses, a narcologist, an infection disease doctor (AIDS Center), a lawyer, a priest, a psychologist, a social worker, a group of volunteers (10-20). • The program of work at home: - individual work with the patient at home, that will be done by any member of the family according to the patient’s needs (physical exercise, psychological relaxation, consultation by the social worker, individual visit by the priest, etc). - Psychological and social support to the patients and their relatives, creative and musical therapy, art. - The program of care according to the Chart of care with further signing of a contract. The Chart of care includes: help in the individual hygiene, cleaning, buying products, cooking, feeding, medical manipulations in case of necessity (injections, IVs, bed sores prophylaxes, enema).

	- Programs of treatment prophylaxis (vitamin therapy, antibiotics, bandaging). - Selecting and directing to ARV therapy of the patients who need this kind of therapy. - Trainings of the personnel in palliative care at home, - Trainings for those infected with HIV about the AIDS prophylaxis and ways of life in case of HIV infection - Creating self-help groups among the infected people. - Organizing programs such as “Warm House” with participation of friends, the team members, and other infected persons according to the wish of the host patient. - Programs of holiday celebration with cooking by the patients themselves. - Programs of regular meetings of the relatives of the HIV infected and AIDS patients having the aim of training and psychological and social rehabilitation. - Reflecting the given activities in mass-media

Educational Programs • Scientific-practical conference “Introduction in Gerontology and Gerontological Nursing”; Balti, 1999 • Trainings for volunteers in the network of social workers and nurses on medical and • social rehabilitation of older persons in Judetul (region) Balti; 2000 • Training for the older persons “Healthy and Pathological Age”; 2001 • Training on home care for caregivers (older volunteers); 2001 • Training “Care for Dying Person” for volunteers and relatives of hospice clients; • National Conference for volunteers in Hospice and Home Care services (dedicated to the International Year of Volunteers), July 2001, Chisinau; • Round table “Palliative care and Hospice services”, June 2001, Balti, Interdisciplinary for family doctors, nurses and social workers; • Seminar on “Standards in Palliative care”, September 11 2001, Chisinau • Training for National Network of NGOs working with and for the elderly. Joint work with HelpAge International, London, July 2001, Chisinau • National Conference “Introduction into Palliative Care and Hospice Services”, September, 2001-2002. There was produced a Memorandum of the Conference. • Round tables “Basic Principles in Palliative Care”, Balti, Cahul, 2002 • National Conference “The International Action Plan on Ageing and the Situation of the Elderly in Republic of Molfova” for social workers and representatives of the Ministry of Labour and Social Protection, Balti, Chisinau, August, 2002, • Interdisciplinary Training on Palliative Care for 60 people, Balti, May 2003, • The International Seminar on PC and Hospice with Professor Jacek Luczak, Chisinau, June 2004. There was produced a Resolution of the Seminar. • Training for nurses and doctors on PC, Edinet, July 2004

PUBLICATIONS: • Informative brochure “About Hospice”; 1998 • Manual-guide for doctors, nurses, social workers “Introduction in Gerontology and Gerontological Nursing”; 1999 • Guide for volunteers “Important Steps While Accepting the Volunteer Activity in Medical and Social Assistance to the Older Persons”; 2000 • “Life Quality of the Elderly and Development National Standards of Care”; 2000 • Policy Booklet Older People and Decision-making in East and Central Europe, together with LGI and HAI, UK. 2001 • Guide for volunteers in Hospice services. (translation into Romanian of the materials of Louisville University); 2003 • “Living with Hope” Palliative Care, 2003 • “The life in a Family Where one of the Members has an Incurable Disease” (Recommendations for relatives), 2003 • Poster-calendar “Philosophy of PC”, 2003 • Leaflet “Flying from Darkness into Light surrounded by Love”, 2003 • Poster calendar on the activities of the project “Reintegration of older people into Moldovan society”, 2004. • Good Practice Manual on the activities of the project “Reintegration of older people into Moldovan society”, 2004.

The Memorandum of the National Conference “Introduction in Palliative Care and Hospice Services”, 20-21 September 2002, hotel “Turist”, Chisinau The main objective of the Memorandum is to obtain palliative care for terminally ill patients. Ethics does not allow suffering. “The society that does not care for its dying people has a vicious philosophy”, Cecily Saunders, the founder of hospice services, London. 1. National policy. To introduce palliative care among the priorities of the health systems of Republic of Moldova. The financial, physical and emotional needs must be adequately compensated by the state. 2. Training. There must be included courses of methods in palliative care in the educational programs of students from medical universities and colleges. It is necessary to elaborate training standards on PC for medical students. Trainings in palliative care Centers from abroad (for example, “Casa Sperantei”, Brasov; Polish Fund of Hospice) are important. 3. The state must provide the accessibility of morphine for terminal patients. The need of the opioids must be calculated depending on the number of the trained professionals, annual reports and the estimates from the experts from the International Bureau of Drug Control (Vienna). 4. Specialized Palliative care services. Creating of such a service as the Polish National Committee of Palliative Care is important both for the terminally ill patients and for their families. 5. Information. There should be included the concept of effective and simple methods of stopping suffering among population, doctors, political activists. Recommendations: It is necessary to coordinate the efforts thus is needed to create a National Society of Palliative care in Moldova. Any person interested in palliative care may become a member. This organization must form an active network, be a primary initiator of changes in the government, inform the society about palliative care and collaborate with mass media.

The resolution of the Seminar “Palliative Care in Republic of Moldova”, Chisinau, June 17-18, 2004 In Republic of Moldova (RM) about 6000 people die from cancer every year and about 20 000 people die from other chronic and progressive diseases including AIDS and tuberculosis. These people suffer pain, dyspnea and other symptoms that are present in advanced stages of a terminal disease. Thus their desperate families suffer too. Palliative care/hospice offers to the terminally ill people care and treatment free of charge to alleviate pain and other symptoms and also supports psychologically and spiritually the patients and their families. In connection with the above said, we want to mention that the access to the basic strong opioids – morphine is not satisfactory: 1. Oral morphine, a golden standard of WHO for strong and moderate pain management in cancer, needs to be introduced in the pain treatment urgently. 2. The limited quantity of injectable morphine in RM causes big problems to the dying patients and its substitution with other opioids like Omnopan and Promedol – are not recommended by WHO. 3. The quantity of administrated morphine – 10 ampoules per prescription, prescribed by the family doctor, is not sufficient for the majority of patients (according to WHO normatives). Moreover the relatives of the patients are put to some humiliating process to return the empty ampoules to the local medical institutions. 4. Taking into consideration the above mentioned facts, we ask to create a working group having the aim to change and improve the legislation of RM about opioids administration according to the recommendations by WHO and the experience of other countries with old traditions in palliative care. The working group will be composed by the representatives from the Ministry of Health, National Drug control Center, other interested organizations, including NGOs. 5. Elaborating national standards of PC according the recommendations by WHO is a matter of urgency in Moldova. Due to the restricted policies the dying patients rarely die in hospitals, the majority die at home in great sufferings. About 87% from these categories die without an adequate care. In RM there were founded 3 nongovernmental Hospices (Chisinau, Balti, Zubresti) and other nursing initiatives having the aim to alleviate suffering and to improve the quality of life of the dying. These organizations offer free of charge palliative care to the patients. The services which are offered by professionals in PC are not included in the National Program of Medical Insurance. It is a matter of urgency to change the governmental policies, that need to contain PC/Hospice in the National Program of Medical Insurance financially covered by CNAM. The support and the collaboration with the Ministry of Health is very important and should be done through the Council in PC composed by representatives from the Ministry of Health and interested people who will be able to reach the above mentioned objectives. On behalf of the participants of the Seminar, Irina Baicalov, director, Gerontological Association, “Second Breath”, the organizer of of the Seminar Jacek Luczak, professor, the president of ECEPT, director of the Hospice “Palium” from Poznan, the Chief the Chair and Department of Palliative Medicine, Poznan University of Medical Sciences