Armenians Struggle for the Right to Die without Pain

For Heghine Simonian, the memories of her 27-year-old daughter's suffering are still raw. She can hear her daughter's pleas for relief from the pain caused by terminal-stage breast cancer, yet no help was available -- for the simple reason she lacked access to painkillers.

Alleviating the suffering of the terminally ill often is difficult, if not impossible in Armenia. Although eligible patients are entitled to free, state-subsidized opioid painkillers, the process for acquiring them can prove so complicated and time-consuming that patients often die before they receive the medication.

A lack of clear, time-efficient procedures is a big part of the problem. No law on palliative care exists. Under current practices, a medical commission and, then, local police officials must approve each morphine prescription. The medical commissions themselves are a cumbersome arrangement; since they comprise the patient's attending physician, the head of the local clinic or hospital where the patient is receiving treatment, as well as two other qualified doctors, it's not always easy to convene a commission in a timely manner and then get members to agree on a course of action.

"Before a commission would come to the regional center hospital, before they would prescribe morphine, my daughter passed away in intolerable pain," said Simonian, wiping her eyes. "My heart breaks every time I recall the imploring look in her eyes. And because I felt helpless, unable to stop that pain, I felt like dying with her."

For rural Armenians like Simonian, a 64-year-old homemaker from the northern hamlet of Akhtala, the process for obtaining permission to administer painkillers to a terminally ill patient must begin with a costly and time-consuming trip to the nearest administrative center. Medical commissions tend to wait until they have received applications from a several patients before meeting to decide whether or not to authorize the use of painkillers. The delays involved in the process can be -- quite literally - agonizing for patients.

To dodge the hassle involved in convening a medical commission, many doctors try to persuade "their patients that they do not need painkillers, that they cause addiction; overlooking the fact that it's given to people in the advanced stage of their disease, on the verge of death," noted oncologist Dr. Hrant Karapetian, director of palliative-care services at Yerevan's National Oncology Center.

Lack of knowledge about palliative care can complicate matters. Armenian medical schools do not provide instruction about palliative medicine, so doctors often do not know how to evaluate a patient's level of pain, or to prescribe an appropriate dose of morphine, noted Dr. Stephen Connor, a clinical psychologist and longtime American hospice-palliative-care advocate who has worked in Armenia as a consultant for the Open Society Institute's International Palliative Care Initiative. [Editor's Note: The Open Society Foundation-Armenia, a part of the Soros Foundations network, conducts research and advocacy on palliative-care issues in Armenia. EurasiaNet.org operates under the auspices of the New York-based Open Society Foundations, a separate entity in the Soros network].

"Often that's where the problems start," Connor noted.

Uninformed doctors make decisions for uninformed families of the dying, agreed Dr. Karapetian. "Often, [family members] do not know that cancer patients do not have to suffer pain. They can get painkillers, yet every day thousands are simply suffering."

Since 2011, financial support from the Global Fund to Fight AIDS, Tuberculosis and Malaria has provided for four pilot palliative-care projects in public hospitals in Yerevan and the regional towns of Ararat and Vanadzor. But the impact of these projects appears limited. Research by the Open Society Foundations-Armenia suggests that not even 10 percent of the registered 18,000 hospital patients with terminal diagnoses get access to painkillers as part of end-of-life care.

Those families who decide to persevere with trying to get morphine for a dying loved one must go through a "big ceremony," commented Hovhannes Madoian, an HIV/AIDS-awareness activist with the non-governmental organization Real World, Real People.

"One member of the family has to dedicate two days a week to that process," he elaborated. "It is not just going and getting. It is about getting several signatures, knocking at a few doors, and if the patient lives in a region, that becomes a time-consuming and costly procedure because they have to get to the nearest town to get the drugs."

Obtaining sufficient dosages poses an additional challenge. The usual permitted prescription -- three ampoules of morphine per day - has an effect for only about 12 hours, Dr. Karapetian said.

One Yerevan resident told EurasiaNet.org that he spent two days fighting to increase the prescribed amount of painkillers for his 39-year old wife, who is dying from lung cancer. The man only gave his first name, Manvel, since his children do not yet know about their mother's diagnosis. "Her physician prescribed a higher dose [of morphine], but the chief doctor [at the hospital] would not allow it, for no reason, and only after going to lawyers for help and getting Healthcare Ministry employees involved was I able to get the painkillers," said Manvel.

Frustrated by seemingly unnecessary obstacles, some Armenians suspect medical personnel of selling what should be free morphine on the black market. One local, privately owned company, Arpharmacia, supplies the drug to the Ministry of Healthcare.

An official from the national police's anti-drug-trafficking office claims that illegal peddling of morphine is a rare occurrence. "There might be two to three cases per year, when medical morphine appears on the black market," said Lt. Col. Artur Minasian. In general, he continued, a doctor's refusal to increase a morphine dosage has more to do with trying "to avoid the headache" involved with securing official permission for the prescription.

Suren Krmoian, chief of staff at the Ministry of Healthcare, conceded that dying patients' access to painkillers is problematic, but maintained that a bill expected to be submitted by the government this year would improve the situation. Under intended changes, only a patient's doctor and another physician employed at the clinic where the patient is registered would need to authorize the use of morphine, Krmoian said.

Palliative-care advocates do not expect an imminent breakthrough, but believe that public awareness of the problem, at least, is increasing. "The progress is slow, but the will is obvious," noted Dr. Connor.