Assist Professor Angsuma Aphichato – Faculty of Nursing, Songklanagarind Hospital, Prince of Songkla University, Hat Yai:
interviewed by Michael Wright, 8 March 2007. Length of interview: 11 minutes.

Angsuma Aphichato explains the importance of the spiritual dimension of health care as understood within the Buddhist tradition. A prominent feature of this tradition is meditation and the state of mindfulness. This is important, she says, as patients come towards the end of their lives and recognise that everyone has to face the four conditions of birth, illness, ageing and dying. Consequently, she speaks of the role played by the monks of a nearby temple who visit regularly to conduct meditation sessions for patients, relatives and staff. Angsuma explains how these sessions help patients to address their suffering and create a sense of peacefulness at the end of life.

Assoc Prof Earmporn Thongkrajai – dean, Faculty of Nursing, Khon Kaen University, Khon Kaen:
interviewed by Michael Wright, 6 March 2007. Length of interview (with Pulsuk Siripul): 14 minutes.

Earmporn Thongkrajai speaks of her background as a researcher, teacher and professional nurse and outlines her present, wide-ranging duties as dean of the nursing faculty. She tells how her interest in palliative care dates from the time when she first experienced the death of a patient and saw at first hand the interconnecting physical, psychosocial and spiritual issues that accompanied the event. She acknowledges the part played by medicine within a holistic approach to care, but places this care in the context of a Buddhist worldview that recognises death as an integral part of life, a natural process that warrants acceptance rather than denial. She goes on to explain the Buddhist concepts of ‘teuk’ and ‘boon’; of the benefits of following Buddha’s ‘middle way’ through life; of keeping cancer located in the physical (as opposed to the spiritual) self; and of learning to be kind to the cancer that is part of one’s body: all factors that Earmporn considers relevant to end of life care in Thailand.

Assoc Prof Gavivann Veerakul – head, Division of Haematology/ Oncology, Thai Paediatric Oncology Group; and chairperson, Palliative Care Committee, Siriraj Hospital, Mahidol University, Bangkok:
interviewed by Michael Wright, 10 March 2007. Length of interview (with Pongaparadee Chaudakshetrin): 24 minutes.

Gavivann Veerakul speaks of her training as a paediatric oncologist in Denver, Colorado (US), and of the twenty years she has worked at Siriraj Hospital. She recalls how, as a young oncologist, she and her colleagues made strenuous efforts to cure every patient but gradually realised that more should be done for those who could not be cured. With her interest in palliative care increased, she was seconded to her current post as chairperson of the hospital’s palliative care committee, and charged with the responsibility of developing the hospital’s palliative care structure, policy and implementation. A current priority is to change the attitudes of doctors so that the absence of a cure is not viewed as a medical and professional failure. Gavivann points out that sooner or later, both doctor and patient have to accept the Buddhist truth that ageing and dying are part of the natural way of life.

Janravee Laurujisawat – pain clinic nurse, Siriraj Hospital Mahidol University, Bangkok:
interviewed by Michael Wright, 10 March 2007. Length of interview (with Puchong Laurujisuwat): 22 minutes.

After Janravee completed her training as a nurse at Mahidol University, Bangkok, she was appointed to a post in the on-call clinic of Siriraj Hospital’s out-patients’ department. With a list of over 3000 cancer patients, she saw up to 200 people a day at the clinic, and wished to do more for those she saw each day. Motivated by her mother’s experience of breast cancer, Janravee was drawn to the work of the hospital’s pain clinic and the palliative approach to care. Having undertaken some local training, she now wishes to move on from her self-perceived role as ‘professional friend’ and take a palliative nursing course in the UK. Influenced by the Buddhist approach to death, she seeks to blend the inspiration she has received from the monks with the academic knowledge of the professional nurse.

Nantaka Kungstan – researcher, infectious diseases; and member of the Palliative Care Committee, Siriraj Hospital, Mahidol University, Bangkok:
interviewed by Michael Wright, 7 March 2007. Length of interview: 7 minutes.

Nantaka Kungstan has worked as a researcher in the paediatric infectious diseases section of Siriraj Hospital for about four years. She says she was drawn to research because she has a personal mission to find new information which will assist people who are ill. As a member of Siriraj Hospital’s palliative care committee, she brings to the forum her experience of working with HIV positive children, and tells how parents also need support to deal with the illness of their children. She considers Siriraj Hospital to be one of the first institutions to adopt the palliative care approach and sees it as a ‘vision from the heart’.

Kasinee Phetsri – head nurse, neurosurgery ward Songklanagarind Hospital, Prince of Songkla University, Hat Yai:
interviewed by Michael Wright, 8 March 2007. Length of interview: 36 minutes.

Kasinee Phetsri explains how the hospital’s palliative care guidelines have been implemented in Songklanagarind Hospital’s neurosurgery ward. She considers that the palliative approach has been welcomed by staff; many have experienced the death of a family member and the enhanced care brings a sense of personal and professional fulfilment. Better communication has meant that patients and their families make informed choices about where they wish to die – at home or in hospital – and the kind of support that is required. Those who stay in hospital have their pain carefully monitored and controlled. Spiritual care is provided by leaders of the local faith communities, mostly Buddhist or Muslim, and spiritual texts, objects and music are readily available. Turning to patients who decide to go home, Kasinee speaks of the ward’s ‘second home’ facility. Here, family members receive up to five days training and supervised caregiving to prepare them for the patient’s discharge. Links are established with the patient’s local hospital and, wherever possible, continuing support is provided by home visits.

Kesanee Boonyawatanamgkoolk – clinical nurse specialist (paediatric cancer) and nurse coordinator - paediatric palliative care, Srinagarind Hospital, Khon Kaen University, Khon Kaen:
interviewed by Michael Wright, 6 March 2007. Length of interview: 58 minutes.

Kesanee took her first and Master’s degrees in nursing in Bangkok and thereafter moved to Srinagarind Hospital, Khon Kaen, where she has worked ever since. She speaks of the challenges and rewards of caring for children who have cancer and of the integrated approach to care that has been developed to meet their needs. This includes a comprehensive ‘Child Life’ programme which incorporates psychosocial and spiritual support, non-pharmacological interventions that include hypnotherapy and, since 2005, a palliative care component to complement curative treatment from the time of diagnosis. She outlines details of the hospital’s paediatric service provision: team work, the assessment and management of pain, preparing children for chemotherapy and other interventions, family support, breaking bad news, memory preservation and bereavement care. Kesanee recalls the importance of her four-month visit to Minneapolis-St Paul (US) and the experience she gained there in both clinical and university settings. As the importance of palliative care becomes recognised, she looks forward to a larger group of practitioners country-wide and increased support from national government.

Assist Prof Kittikorn Nilmanat – Faculty of Nursing, Songklanagarind Hospital, Prince of Songkla University, Hat Yai:
interviewed by Michael Wright, 8 March 2007. Length of interview: 30 minutes.

Kittikorn Nilmanat studied nursing in Bangkok before undertaking a PhD that focused on the care of people with AIDS. She explains how her research led to an interest in end of life care, which was raised further when she attended a conference in Bangkok. She speaks of the circumstances surrounding those living with HIV and AIDS in Thailand. Although the government is trying to increase access to ART, she considers that up to thirty per cent of those in need do not receive treatment. Fear of stigmatisation suggests an under-estimation of those infected, and concern is growing about the number of orphans being cared for by grandparents. She is aware that palliative care education is being conducted in some Thai nursing schools, but information is lacking due to poor publicity and the lack of systematic record-keeping. Her nursing faculty offers a palliative care course for Master’s Students but there is little enthusiasm for it among the student body. Yet care for the dying patient, including the concept of palliative care and its associated ethical issues are included in the general nursing course. Each nurse on the Bachelor course is required to care for a dying patient. Kittikorn then speaks of the ethical issues surrounding the care of the dying and of her hopes for the development of palliative care as a multidisciplinary approach in the future.

Dr Krishna Suvaranbhumi – lecturer, family medicine, Songklanagarind Hospital, Prince of Songkla University, Hat Yai:
interviewed by Michael Wright, 8 March 2007. Length of interview (with Sakon Singha): 1 hour 27 minutes.

Krishna tells how he became interested in family medicine when he worked in the community after graduating from medical school. During that time, he realised the importance of primary care and the need to strengthen provision at the grass roots level. He speaks of Thailand’s health care structure and how, at the local level, the health centre caters for the surrounding community. While Krishna acknowledges the innovations in university hospitals, his vision is to raise palliative care awareness and skills among local health care providers who will meet patients and families in their own home. To this end, he speaks of the integration of palliative care into the family medicine curriculum, and of a newly established network of doctors and local health care providers designed to promote ‘inter-professional education’ among doctors, nurses and social workers in the community.

Assoc Prof Pongparadee Chaudakshetrin – director, Pain Clinic, Siriraj Hospital, Mahidol University, Bangkok:
interviewed by Michael Wright, 7, 10 March 2007. Length of interviews (interview 2 with Gavivann Veerakul): 50 minutes.

Pongparadee is an anaesthesiologist with a broad interest in pain relief that was further extended during her attachment to Guy’s Hospital, London, during 1985. On her return to Thailand, she advocated for the availability of morphine which became available at Siriraj from the late 1980s. Pongparadee tells of the resistance to morphine that was prevalent at the time but how, over the years, MST and morphine syrup have become available, an education programme is in operation, and one-year fellowships are offered in pain management. After attending a palliative care course in the UK and visiting hospice facilities there, Pongparadee accepted the role of chairperson of the Siriraj Hospital’s Palliative Care Committee, a body that was charged with an exploration of the issues and construction of a policy. Although the implementation stalled, Pongparadee speaks warmly of the reconstituted committee and the progress currently being made. Turning to palliative care services, Pongparadee explains the headway being made by university hospitals and the grass-roots care being provided by temples that are rooted in their communities, such as Wat Phrabat Nampu.

Pornpen Kiatkamchorn – paediatric nurse, Siriraj Hospital, Mahidol University, Bangkok:
interviewed by Michael Wright, 7 March 2007. Length of interview: 13 minutes.

Pornpen tells of the holistic approach to care which is designed to support children and their families at Siriraj Hospital. Siriraj receives children from the length and breadth of Thailand and some of them stay as hospital inpatients for up to a year, which at times places a strain on families that live some distance from Bangkok. Pornpen explains how the Power of Mind programme incorporates elements of counselling and play, underpinned by the Buddhist approach to life. The programme features music therapy, storytelling, a parents’ support group, spiritual guidance from Buddhist monks, exercises in relaxation and meditation and visits to the temple. Pongpern tells how such activities help children to cope with their illness and become distracted from their pain and treatment.

Dr Puchong Laurujisawat – psychiatrist, King Chulalongkorn Memorial (University) Hospital, Bangkok:
interviewed by Michael Wright, 10 March 2007. Length of interview (with Janravee Laurujisawat): 22 minutes.

Puchong has developed an interest in palliative care through his work with patients who are referred to him supposedly suffering from ‘depression’ as they approach the end of life. Yet Puchong considers that for many of these patients, their ‘depression’ is not a disorder but the natural consequence of confronting the truth that ‘everything is not OK in my life’. He is a member of the hospital’s innovative palliative care committee and teaches medical students how to communicate with dying patients. He speaks about the practice of psychiatry in a Buddhist context and explains his approach to existential and spiritual issues. Puchong has attended the pain management course at Siriraj Hospital and is now looking towards taking a Master’s degree in palliative care in the United Kingdom.

Assoc Prof Pulsuk Siripul – director, Master of Nursing Science International Programme, Faculty of Nursing, Khon Kaen University, Khon Kaen:
interviewed by Michael Wright, 6 March 2007. Length of two interviews (interview 2 with Earmporn Thongkrajai): 33 minutes.

Pulsuk Siripul has a background in nurse education and became interested in end of life care when she undertook doctoral studies in paediatric nursing at Case Western Reserve University in Cleveland, Ohio (US). While studying at the university she worked with the paediatrician Karen Olness and became interested in her non-pharmacological approaches to pain and stress in children. On her return to Thailand, Pulsuk made contact with Rosalie Shaw which led to a visit to Singapore and experience of the palliative care services there. Pulsuk tells of her collaboration with the Khon Kaen paediatrician, Srivieng Pairokul and how, in 2003, palliative care was incorporated into the Master’s level paediatric nursing course as an elective element with three credits attached to it. She speaks of the nature of the course and of the cultural issues surrounding children’s palliative care in Thailand.

Dr Sakon Singha – chairperson, Hospice Foundation of Thailand; and also of Songklanagarind Hospital Palliative Care Development Committee, Prince of Songkla University, Hat Yai:
interviewed by Michael Wright, 8 March 2007. Length of interview (with Krishna Suvaranbhumi): 1 hr 27 minutes.

Sakon Singha speaks of his background as a surgeon with an interest in stem cell research and how, after his doctoral studies in England, he became drawn to palliative care on his return to Thailand. He puts this down to his desire to bridge the gap between medical science and human experience and incorporate into the education of future doctors a saying he remembers from a leading Thai physician, ‘I not only want you to be a doctor, I want you be a human being.’ Sakon outlines the challenges facing palliative care in Thailand: the lack of awareness among medical practitioners, the difficulty of collecting data from interested parties and practitioners within Thailand, the fragmentation between health care disciplines and the lack of penetration into home care. Yet the successes are encouraging. The universities are setting a much needed lead, interest is growing and palliative care elements are being introduced into medical and nursing curricula. The national association has lead to a greater dialogue between professionals and government and discussions have begun with the ministry of health to see whether home care services can be brought funded through the national health care system, known as the 30 baht scheme.

Assoc Prof Srivieng Pairokul – Assistant Dean (Medical Education), Faculty of Medicine, Khon Kaen University, Khon Kaen:
interviewed by Michael Wright, 6 March 2007. Length of interview: 58 minutes.

Srivieng Pairokul graduated from Siriraj Medical School (Bangkok) and undertook further training in paediatrics in Edinburgh (Scotland) and Melbourne (Australia). She tells how her interest in children arose during her childhood at a Catholic school in Bangkok, which arranged weekend visits to local children’s hospitals and orphanages. Srivieng speaks of her work with children in distress, her international interests and her links with the US-based paediatrician Dr Karen Olness. Already working in pain management, Srivieng became increasingly interested in palliative care after the death of a close friend, after which she attended a palliative care workshop in Hat Yai. As she became committed to the palliative care approach, she speaks of her visit to Rosalie Shaw in Singapore along with Pulsuk Siripul and two paediatric nurses. She then explains how a palliative care team was formed in Khon Kaen’s Srinagarind Hospital, how funds were sourced, education undertaken and palliative care became viewed as an integral part of patient’s programme from the time of diagnosis. Srivieng speaks of the logistical problems of caring for children living up to 300 kilometres from the hospital, often in poor conditions. Yet by implementing a range of measures that include home visits for children nearby, community support for those further a-field, and the possibility of dispatching morphine from the hospital pharmacy, progress is being made.

Prof Sumalee Nimmannit – Chair of Medicine (retired); and Chair of the Ethical Committee on Human Research, member of the Palliative Care Committee, Siriraj Hospital, Mahidol University, Bangkok:
interviewed by Michael Wright, 9 March 2007. Length of interview: 44 minutes.

Sumalee Nimmannit speaks of her interest in palliative care: as a physician with a long-standing involvement in medical education; as a patient living with cancer; and as a Buddhist seeking a peaceful death through the practice of ‘mindfulness’. As a physician, she acknowledges that medicine has a special place in palliative care and understands the complexity of the ethical issues that confront doctors engaged in end of life care. As a teacher, she is keen to integrate the physical with the spiritual aspects of care and avoid any unnecessary fragmentation. Consequently, Sumalee recommends that all doctors are trained in the principles of palliative care and that such care is delivered on each of the hospital’s wards rather than in a separate unit. As a patient, she recounts her first-hand experience of how cancer has impacted her life and speaks tellingly of a near-death experience. In her professional life, she had seen the value of ‘mindfulness’ and the peace such activity had given to patients in potentially stressful situations. She concludes that the palliative care ideal resonates with Thai perceptions of life and death so long as it is unencumbered with inappropriate assumptions from the West. Sumalee died in September 2007.

Supasinee Kungwarinouvarat – paediatric social worker, King Chulalongkorn Memorial (University) Hospital, Bangkok:
interviewed by Michael Wright, 9 March 2007. Length of interview (with Supranee Niruthisard and Veeramonl Chantaradee): 1 hour 28 minutes.

Supasinee highlights some of the challenges which accompany the care of children at Chulalongkorn Hospital including the long stays, dislocation from home and family, pressures on adult relationships and extended treatments. She explains the significance of the ‘psychosocial ward round’ designed to avoid fragmentation and bring together, at the same time and place, the wide-ranging group of health professionals involved in the care of a child. She goes on to speak about the children’s activities and therapies, the role of the hospital teachers, and the importance of the nearby shelter which accommodates relatives who have accompanied their children from the length and breadth of Thailand. For those children who especially need their parent’s care, their mothers are allowed to live on the ward and sleep in their child’s bed. Volunteers have a special role to play, especially in the Wishing Well programme, where they work hard to fulfil a child’s wish - to have a visit from a well-known celebrity, for example, or visit a zoo. Turning to bereavement care, Supasinee says that support is available for a family as long as is necessary – a year and beyond – and there is no restriction about the number of contacts with any particular family.

Assoc Prof Supranee Niruthisard – anaesthesiologist and chairperson of the Committee for the Development of End of Life Care, King Chulalongkorn Memorial (University) Hospital, Bangkok:
interviewed by Michael Wright, 9 March 2007. Length of interview (with Veeramonl Chantaradee and Supasinee Kungwarinouvarat): 1 hour 28 minutes.

Supranee tells how her growing awareness of palliative care increased when she visited Joseph Weld Hospice in Dorset (UK) during 2003. That same year, a multidisciplinary group of health professionals began activities that influenced the formation of the Chulalongkorn Committee for the Development of End of Life Care, acknowledged by the hospital administrator in 2005. Supranee explains how the profile of end of life care was raised throughout the hospital by its inclusion as a panel discussion at the hospital’s annual meeting and by incorporating the topic into a newly-designed curriculum for medical students. The ‘Critical, Chronic and Terminal Care’ module runs in year five but elements of end of life care are included in other years under the headings of ‘Doctor and Society’ and the ‘Cycle of Life’. Alongside this increasing focus on what Supranee calls the ‘human’ side of medicine has been the introduction of a ‘Breaking Bad News’ course which she regards as an important step forward. As greater emphasis is placed on the care of the dying, she hopes to see a corresponding commitment to support health professionals’ care for themselves and each other.

Dr Tanadej Sinthusake – director, Mahavajiralongkorn Cancer Centre, Phatum Thani; and council member, Asia Pacific Hospice Network:
interviewed by Michael Wright, 10 March 2007. Length of interview: 53 minutes.

Tanadej Sinthusake speaks of his role as director of the regional cancer centre in Thanyaburi, Phatum Thani: a Ministry of Public Health facility with 100 beds that serves five surrounding provinces. He explains that as his interest in end of life care grew, he visited San Diego Hospice (California) and Hernando Pasco Hospice (Florida) and thereafter established a hospice facility at Mahavajiralongkorn. He tells how, at present, this is the only palliative care service in Thailand that routinely provides inpatient and home care services delivered by a team comprised of a doctor, nurses, social worker and volunteers. Housed in a separate unit, the hospice accommodates both patients and family members for up to 15 days to ensure that, on the patient’s return home, family caregivers are trained to undertake routine tasks with ongoing nursing support. Tanadej’s vision is for hospice care to become established in each of Thailand’s 76 provinces. As the first president of the Thai Hospice Palliative Care Club, he initiated discussions within the Ministry of Public Health concerning funding for home care by extending the 30 baht scheme, and speaks of the need for a pilot project and more research. He considers that the Hospice Club has provided a much-needed forum for the discussion of end of life care in Thailand and in the future, foresees the Club becoming a foundation with fund-raising potential.

Assoc Prof Temsak Phungrassami – Radiotherapy Division, Department of Radiology, Songklanagarind Hospital, Prince of Songkla University, Hat Yai; and council member, Asia Pacific Hospice Network:
interviewed by Michael Wright, 8 March 2007. Total length of three interviews: 2 hours 13 minutes.

Temsak reflects on the development of palliative care in Thailand and suggests that, in view of the Thai approach to life and death, it is difficult to point to a definitive time when the movement began. In his own hospital of Songklanagarind, he points to the visit of Ian Maddocks in 1997, but mentions also the 1992 hospice initiative at the temple of Wat Phrabat Nampu in the central province of Lop Buri. He is clear, however, about what he perceives to be a growing interest on the part of government and health professionals to take better care of people at the end of life. This is shown by the government’s support for palliative care in the hospital context, the willingness to consider bringing home care within the national health reimbursement system, and the 2007 legislation governing a person’s right to die without unwanted resuscitation or ventilation. Among health professionals, attendance at training courses continues to rise and the inclusion of palliative care in medical and nursing curricula signals hope for future change. Yet if palliative care is going to become generally accessible to the Thai population, Temsak thinks that the issue of domiciliary care must be seriously addressed. More should be done to acknowledge and utilise the palliative care skills of nurses, whose education at both under- and postgraduate levels is ahead of their medical colleagues. Yet Temsak is optimistic about the future. Given a higher profile, national co-ordination, a better means of gathering and disseminating information and the development of community initiatives, he is confident that the palliative approach can incorporate the lessons from the West into the wisdom of the East and provide better care for Thai people at the end of life.

Veeramonl Chantaradee – paediatric social worker, King Chulalongkorn Memorial (University) Hospital, Bangkok:
interviewed by Michael Wright, 9 March 2007. Length of interview (with Supranee Niruthisard and Supasinee Kungwarinouvarat): 1 hour 28 minutes.

Veeramonl outlines her work as a paediatric social worker and of the great interest in end of life care among the hospital’s paediatric staff. Aware of the deep-seated oriental attitudes towards delivering and receiving bad news, she conducted a three-group survey of medical/ nursing staff, patients and relatives in 2003. She speaks of her findings: that patients want to know their diagnosis; relatives want to know, but think it should be kept from the patient; and health care personnel wish to disclose the diagnosis but need training to do it. It was these results which led to the ‘Breaking Bad News’ workshops that added impetus to the founding of the hospital’s end of life care committee. Veeramonl then speaks of a new project designed to bring medical students alongside patients as supportive volunteers during years two and three of their training. Forty students were involved in 2006 and she explains how befriending patients through conversation, writing letters for them and reading to them, lifts the patients’ spirits and helps students understand the personal impact of the patients’ condition.

Vilaiwan Khantiwong – head nurse, Aids Hospice, Wat Phrabat Nampu, Lob Puri:
interviewed by Michael Wright (translated by Gavivann Veerakul), 10 March 2007. Length of interview: 9 minutes.

Vilaiwan Khantiwong became aware of the care provided by the monks at Wat Phrabat Nampu Aids Hospice during her training as a nurse aid in the north east of Thailand, her home region. She first visited the temple during her student days and thereafter wished to return when her training was completed. After qualifying, she subsequently took a two-month course in end of life care at Khon Kaen, with funding provided by the temple’s founder. Valaiwan says that she is motivated to care for the patients at Wat Phrabat Nampu because they have mostly been abandoned by their families and friends and have no-one else to turn to and nowhere else to go.

‘Yae’ Sunee Niyondaela – palliative care officer, Songklanagarind Hospital, Prince of Songkla University, Hat Yai:
interviewed by Michael Wright, 8 March2007. Length of interview: 13 minutes.

Yae tells how she trained as a nurse at Bhurapha University in the Thailand’s central province of Chonburi, about 100km from Bangkok. When her training was completed, Yae took up a post in the Burns Unit at Songklanagarind Hospital where she stayed for five years. From the Burns Unit she moved to a trauma ward where she developed an interest in palliative care and, in her spare time, began working as a palliative care volunteer. Her current role as palliative care officer involves the co-ordination of meetings, organization of training courses and the production of materials. As a Muslim in a predominantly Buddhist country, Yae also offers support to patients who subscribe to Islam. She speaks of the Muslim view of death and of the pleasure in ‘preparing to go to God’ as life draws to its close. She expresses a profound commitment to palliative care and looks forward to a time when services are more generally available in Thailand.