In Jordan, specialist palliative care services are offered by two organisations: the Al Malath Foundation for Humanistic Care and the King Hussein Cancer Centre. Supportive care is offered at Al Basheer Hospital (Table 1).

Table 1: Palliative care provision in Jordan 2005

These organisations are based in the capital city, Amman, providing 4 services; a home hospice team for adults and children, a hospital and home hospice team for adults and hospital based supportive care for adults. Pain and symptom relief for cancer patients is also provided in some oncology units in other general hospitals in Amman and Irbid.

The Al Malath Foundation for Humanistic Care runs one service in Amman; the home hospice team Al Malath Hospice. The team supports 4 volunteer nurses who work alone, in their own time, in other areas of Jordan. Since 1994 (the year following the establishment of the hospice) admissions have steadily increased (Table 2).

Table 2: Al Malath Foundation – change in admissions and home visits over years 1994, 2000, 2004.³

About 80 % (in 1994) to 63 % (in 2004) of patients admitted to the home hospice have been supported to die in their own home. Of this number some families requested that their relative be admitted to hospital in the 24 hours before death. For various medical and psycho-social reasons around 20-30 % of home hospice patients die in hospital having been admitted weeks or some days prior to death.

As records show (see Table 3), the majority of patients have cancer but also, over the years, the Hospice has cared for a small number of patients with other illnesses at the end of life. In the early years nurses were most likely to refer to the Hospice. Increasingly physicians are encouraged to refer patients.⁴ A proportion of patients are self-referring, through family or friends.

Table 3: Al Malath Foundation - percentage of children and adult patients, diagnosis and referrals over the years 1994, 2000, 2004⁵

The hospice provides a 24 hour on-call service and the home care team will continue to support their patients if requested after admission to hospital. The Foundation has an equipment loan service, for example providing hospital beds, wheelchairs, bathing and toilet aids, and oxygen cylinders free of charge - with an option to make a donation. Financial help is offered from a special fund in cases of hardship and there is also a ‘special last wishes’ fund which can provide for a personal request by the patient towards the end of their life. Examples include funding the cost of a special trip away, and the making of a commemorative video of the patient for his or her children.

The King Hussein Cancer Centre (KHCC) is a government hospital dedicated to treatment of adults and children with cancer. Patients are referred for treatment from all over Jordan. Since October 2004 the hospital has offered 2 key palliative care services – hospital support and home care for adults with cancer - delivered by the multi-professional hospice team including director, physicians, nurses, psychologists, physiotherapist, social worker and nutritionist. The team cares for patients in the following settings:

• patients admitted onto the wards
• patients attending the out patients department
• patients at home if they are resident in the western areas of Amman within a 6 km range of the hospital

Telephone support is available for KHCC patients and their families living in other areas of the country. There are plans to extend home care services into other areas of the country via the recently reformed community healthcare system. An eight bed in patient unit at KHCC is due to open in 2005 (Table 4).

Table 4: Key palliative care services in development, and since 2004, being offered by the home hospice team to King Hussein Cancer Centre patients.

Referrals are made by either the patient’s primary physician or via the oncology unit based at KHCC.⁶ The criterion for admission for either palliative support at hospital or hospice care at home is based on the patient’s decision about resuscitation:

‘Do not resuscitate’ (DNR)

Home care palliative services are offered to all those patients at the end of life who have decided they do not want resuscitation, even if they are re-admitted to hospital.

‘Resuscitate’ (non DNR)

Palliative support is offered to patients at the end of life who choose to stay in hospital and in spite of a poor prognosis wish to be resuscitated, for example, in the event of sudden collapse.

In May 2005, there were 6 patients in home care (DNR) and 10 being offered hospital palliative support (non DNR). Around 17 - 20 patients are admitted to the hospice service per month, with capacity to admit 30 patients per month.⁷

Hospital oncology units There are three major oncology units in government funded hospitals in Amman which will offer pain and symptom relief to cancer patients at the end of life. Civilian patients can access supportive care and since 2004 specialist pain and symptom management in the oncology unit at the government Al Basheer Hospital. The Jordan University Hospital offers pain and symptom relief. Army patients can access relief through the Royal Medical Services at the military hospital King Hussein Medical Centre . Other hospitals able to provide pain and symptom relief at end of life include two in Amman; the Islamic Hospital (run by the Islamic Centre Charity Society);⁸ the privately funded Speciality Hospital; and in Irbid at the King Abdullah University Hospital(KAUH) and by referral from KAUH at the Health Centre of Jordan University of Science and Technology (JUST). These units and hospitals are part of the Jordan Pain Relief and Palliative Care Initiative supported by WHO and the Center for Palliative Care Studies at San Diego Hospice, CA.⁹

Patients may ask to be referred or self-refer to the specialist palliative care services at Al Malath or KHCC. Patients at the end of life resident outside Amman, who have left the major oncology units to return to their homes, can access basic pain and symptom relief either from their primary physician or in local hospitals.

There are no reports of any government funded specific palliative care services for patients at the end of life with other illnesses, including HIV/AIDS. There are plans by government to provide insurance for patients to receive end of life care if they have neurological illnesses, such as Alzheimer’s disease. As of 2005, patients and their families pay private nursing agencies to provide ‘aid nurses’ for patients with other illnesses at the end of life.¹⁰