Turkey is an area where supportive care with hospice/ palliative care is linked to the development of other services, particularly within hospital based oncology units. We have taken the view that where a service is in the process of development from (largely) physical care to a broader form of holistic care it should be included in the review.

There are no specialist palliative care services in Turkey. Medical oncology units and departments of algology (pain) at major hospitals in the country provide pain control and symptom relief.² Oncologists and pain specialists in 7 hospitals report actively working to establish the concepts of palliative care (Table 1).

Table 1 Palliation in Turkey 2005 (hospitals with some active development of palliative care concepts)

Development of palliative care tends to be focused around cancer patients in oncology units and ‘algology’ (pain) departments and centres. The majority of cancer patients are treated in university hospitals that support units with pain specialists and medical oncologists.³ Pain centres and departments also offer palliation for patients at the end of life with other illnesses. Some specialist cancer state hospitals such as the Dr Ahmet Andicen Oncology Hospital and Demetevler Oncology Hospital will provide pain relief and symptom management. No information, however, is currently available about the development of palliative care services in the state hospital system or the development of training in the 57 medical schools around the country.⁴ There are around 30 specialist ‘pain centres’ and 20 medical faculties with departments of algology in Turkey.⁵ There are no reported activities for paediatric palliative care.

Individual physicians (and their colleagues) have reported active involvement in developing the concepts of palliative care within departments and units in three main areas of the country; in Ankara, a pain specialist at Hacettepe University Hospital, three oncologists, one at Başkent University Hospital, one in the Gulhane Military Academy,(GATA) and one at Gazi University Hospital ; in Istanbul, a pain specialist at the Istanbul University Medical Faculty and two oncologists at the Marmara University Medical Faculty ; there is one pulmonary specialist developing concepts of palliative care at the Pamukkale University Medical School, Denizli. Medical and nursing professionals have also expressed interest in palliative care at Ankara University Faculty of Medicine.

Başkent University Hospital Faculty of Medicine

Başkent University, founded in 1993 through the cooperation of the Turkish Organ Transplant and Burns Treatment Foundation, (established in 1980), and the Hasberal Education Foundation, runs a large university hospital in Ankara with several other sites around the country. A broad spectrum of up-to-date diagnosis and treatment in all fields of medicine is provided including oncology and algology. Medical Oncologist, Professor Özgür Özyilkan, chair of the Medical Oncology Department is encouraging palliative care approaches in his unit.⁶ Professor Özyilkan is also a founder member of the Turkish Oncology Group.⁷

Gulhane Military Academy (GATA)

Medical Oncologist, Dr Seref Komurçu is providing palliation in the 33 bed oncology unit at GATA, a large (1500 bed) military hospital in Ankara. The oncology unit has a staff of 7 physicians and 18 nurses. They treat around 1200 patients annually with around 100 inpatients every year requiring palliation at the end of life. Dr Komurçu explains that at GATA:

‘We don’t have a separate unit for palliative care, but we need it. I’m mostly involved in palliative care, and I’m preparing some project to set up a separate unit, but it’s not easy. We need a separate floor and some other personnel, so I think it will take some time, a couple of years maybe.I do palliative care in that department and we follow the terminal patient also in the department. End of life care is done in the inpatient situation and most of the patients stay at home at their end of life period, and some patients prefer to stay at hospital in their terminal phase, and we apply terminal sedation sometimes. We don’t have a home care program: our insurance on each level doesn’t cover the home care program. But some new regulations are being [developed] and maybe after this year the general insurances will cover home care treatment.’⁸

Hacettepe University School of Medicine, Ankara

Pain specialist and surgeon Dr Osman Abbasoglu, is involved in encouraging a palliative care approach in the Department of Anaesthesiology. The department offers a ‘pain relief service with one assistant professor in charge.’ Dr Abbasoglu explains that he works with adults, seeing around 400 patients each year, ‘ about 80 % are inpatients, 15 % day care, 5 -10 % home-based.’ Patients are referred to the department for palliative pain relief by other physicians, ‘more than half have cancer, about 25 % chronic diseases like COPD.’ ^9,10 The physicians can call on a social worker to support a patient if they perceive a need. There are plans to build an inpatient hospice unit at the Hacettepe.

Gazi University Hospital, Ankara

Medical oncologist Dr Deniz Yamac, based at the 20 bed oncology unit specialises in head, neck and breast cancer. Whilst she offers pain relief and symptom control, she is also actively developing palliative care training for doctors, nurses and students, but says that at this time there are no funds to develop the service in the way she hopes, for example, by employing a psychologist or setting up home care support. Working as part of a 6 doctor team, Dr Yamac sees up to 100 patients a week, around 10 of whom need end of life palliative care.

Marmara University Medical School Hospital, Istanbul

With 350 beds, Marmara Hospital’s services include a 14 bed oncology out patient unit,¹¹ where medical oncologists Dr Perran Fulden Yumuk and Dr Nazim Turdal are actively developing the principles of palliative care. They are part of a team including 3 medical oncologists, 2 medical fellows, 7 nurses, a psychologist, a pharmacist, a data manager and 2 secretaries. They see around 1000 new cancer patients a year. They write: ‘We are also following our patients who need palliative care and try to give them support for their pain management, nutritional status, etc. We try to be with our patients and relatives from the beginning of their disease till the end with all our team.’¹²

Istanbul University Faculty of Medicine

Pain specialist and Chairman of the Department of Algology, Professor Serdar Erdine has developed pain relief, known in Turkey as ‘algology’ as a specialty.^13,14 In his 14 bed unit they see around 3000 patients each year referred from other departments for pain relief. Around 1000 are cancer patients, most at the end of life. The remainder are patients with chronic pain from other illnesses. He follows the WHO ‘analgesic ladder’ when prescribing.¹⁵ His aim is to support patients to have sufficient pain relief at the end of life so they can be cared for at home.¹⁶

Pamukkale University Hospital Medical School,Denizli

Pulmonary specialist Dr Sevin Baser is keen to develop training for department staff, medical and nursing students in the concepts of palliative care. His enthusiasm follows his own specialist palliative care training in the US. The hospital sees a high number of patients with late stage lung cancer who need palliation. There is no medical oncologist and as yet, no dedicated palliative care.¹⁷