Mitigating Total Suffering in Critical Illness: The Imperative of Integrating Palliative Care Medicine into Resource-Constrained Intensive Care Units in Nigeria
Author: Eranga Isaac Omo-Ehiabhi
Professional Affiliation: Hospice and Palliative Care Association of Nigeria
1. Introduction and Background
In critical care settings, clinicians often focus heavily on organ replacement, invasive monitoring, and hemodynamic stabilization. While these interventions save lives, the intensive care unit (ICU) environment can inadvertently cause severe physical, psychological, and existential distress for patients and families.
Palliative Care Medicine (PCM) addresses these challenges not as an alternative to curative or life-sustaining treatment, but as an added layer of support. The World Health Organization defines palliative care as an approach that improves the quality of life of patients and families facing life-threatening illness through the prevention and relief of suffering via early identification, assessment, and treatment of pain and other physical, psychosocial, and spiritual issues (WHO, 2020).
In low- and middle-income countries (LMICs) like Nigeria, integrating PCM into critical care faces unique structural challenges:
- Late clinical presentation of advanced disease (e.g., late-stage malignancies, end-stage organ failures, severe stroke).
- High out-of-pocket healthcare spending without universal coverage.
- Regulatory and educational barriers to essential analgesics like oral morphine.
- Deeply rooted socio-cultural and spiritual beliefs surrounding death and dying.
Relieving suffering in critically ill patients requires expanding PCM from a late-stage service to an active, co-managed discipline alongside critical care medicine.
2. Historical Evolution of Palliative Care in Nigeria
Understanding the current landscape of palliative care in Nigeria requires examining its historical development over the past three decades (Soyannwo, 2012):
- The Early Pioneers (1990s): Palliative care in Nigeria emerged through grassroots initiatives led by pain clinicians, oncologists, and healthcare advocates. A seminal milestone occurred in 1993 with the founding of the Society for the Study of Pain, Nigeria (SSPN), which spearheaded early advocacy for systematic pain relief and hospice principles (Soyannwo, 2012).
- Establishment of Institutional Services (1996–2007): The first formal palliative care service in Nigeria was established at the University College Hospital (UCH), Ibadan, in 1996, led by Professor Olaitan Soyannwo and her team (Onyeka, 2011). This was followed by the formation of the Centre for Palliative Care, Nigeria (CPCN) in 2005, which served as a national advocacy and training hub (Soyannwo, 2012).
- Expansion across Tertiary Centers: Over the following decade, dedicated palliative care units and multidisciplinary teams were instituted across other major federal tertiary centers, including the Lagos University Teaching Hospital (LUTH), University of Nigeria Teaching Hospital (UNTH), Enugu, and the Ahmadu Bello University Teaching Hospital (ABUTH), Zaria (Desalu et al., 2013).
- Policy and Professional Recognition (2000s–Present): The establishment of the Hospice and Palliative Care Association of Nigeria (HPCAN) unified practitioners nationwide. Furthermore, advocacy efforts led to the inclusion of liquid oral morphine production initiatives in select teaching hospitals and the partial integration of palliative care guidelines into national cancer control strategies (Onyeka, 2011; Soyannwo, 2012).
Despite these historical milestones, the historical growth of PCM in Nigeria has largely remained confined to oncology and tertiary hospice initiatives, with minimal integration into high-intensity environments like emergency departments and ICUs.
3. Conceptual Framework: The Domain of “Total Suffering”
Dame Cicely Saunders introduced the concept of “Total Suffering”, establishing that distress at the end of life or during critical illness is rarely purely physical (Clark, 2018). In an ICU setting, integrated palliative care addresses total suffering across four interconnected domains:
- Physical Suffering: Severe pain, dyspnea, nausea, fatigue, air hunger, and procedural discomfort.
- Psychological Suffering: ICU-acquired delirium, anxiety, acute stress, loss of autonomy, and fear of death.
- Social and Economic Suffering: Financial catastrophe from prolonged ICU stays, family caregiver burden, out-of-pocket expenses, and disruption of household livelihoods.
- Spiritual and Existential Suffering: Loss of meaning, spiritual guilt, feeling abandoned by God, or unresolved community conflicts.
When integrated early into the ICU, palliative care addresses these domains through early symptom control, structured communication regarding goals of care, financial navigational support, and culturally competent spiritual counseling.
4. Clinical Interventions: How PCM Ameliorates Suffering
Palliative care clinicians use specific strategies to address distress alongside primary ICU teams:
Symptom Control & Multimodal Analgesia
Managing physical symptoms in critical care requires a balanced pharmacological approach:
- Pain Management: Using multimodal regimens (opioids, non-opioids, and neuropathic agents like gabapentin or pregabalin) while monitoring for organ failure.
- Dyspnea: Low-dose opioids (e.g., intravenous or oral morphine) remain the gold standard for reducing the perception of respiratory drive and air hunger without causing respiratory arrest when titrated carefully (Mularski et al., 2016).
- ICU Delirium and Restlessness: Non-pharmacological protocols combined with judicious targeted therapy (e.g., dexmedetomidine, atypical antipsychotics) to limit distressing hallucinations and agitation.
Goals-of-Care (GOC) Conferences
Misalignment between medical prognosis and family expectations can lead to non-beneficial, prolonged invasive interventions (Aslakson et al., 2014). Structured PCM communication frameworks help align treatment plans with the patient’s underlying values. A comparison between traditional ICU communication and a palliative integrated approach shows key differences across major domains:
- Primary Focus:
- Traditional ICU Approach: Focuses on organ restoration and lab values.
- Palliative Integrated Approach: Focuses on patient values, comfort, and total quality of life.
- Family Role:
- Traditional ICU Approach: Treats family members as passive recipients of medical updates.
- Palliative Integrated Approach: Engages family members as active partners in shared decision-making.
- Prognostic Delivery:
- Traditional ICU Approach: Relies on fragmented, purely statistical updates.
- Palliative Integrated Approach: Employs empathic, realistic framing (such as the VALUE framework).
- Conflict Resolution:
- Traditional ICU Approach: Tends toward a defensive medical posture.
- Palliative Integrated Approach: Focuses on exploring values, underlying fears, and religious beliefs.
5. Palliative Care in the Nigerian Context: Realities and Challenges
While high-income countries often utilize dedicated palliative consultation teams or hospice beds, the Nigerian healthcare landscape presents distinct challenges categorised into three main dimensions:
- Systemic and Policy Barriers:
- Prevalence of a “pay-for-service” healthcare model where critical illness frequently causes family bankruptcy due to high out-of-pocket costs (Onyeka, 2011; Soyannwo, 2012).
- Lack of comprehensive national insurance coverage, leaving families vulnerable to severe financial distress during prolonged ICU stays.
- Scarcity of specialized facilities and trained manpower, with services concentrated mostly in a few tertiary centers (e.g., University College Hospital, Ibadan; Lagos University Teaching Hospital), leaving peri-urban and rural populations under-served (Desalu et al., 2013).
- Clinical and Medical Obstacles:
- Widespread “opioid phobia” and strict, restrictive narcotic regulations that limit access to essential oral morphine powder and parenteral opioids (Onyeka, 2011; Soyannwo, 2012).
- Shortages of specialized palliative medicine personnel leading to unmanaged severe acute and chronic pain.
- Socio-Cultural and Spiritual Factors:
- High prevalence of late clinical presentations for advanced illnesses.
- Cultural taboos surrounding death and end-of-life planning, where discussing non-beneficial treatment is viewed as “giving up hope” or inviting bad luck (Onyeka, 2011).
- ”Miracle expectations” driven by strong religious beliefs, causing families to insist on prolonged mechanical ventilation or invasive support long after physiological brain death or irreversible multi-organ failure (Desalu et al., 2013).
6. Strategic Recommendations for Implementation in Nigeria
To reduce suffering among critically ill patients in Nigeria, structural and policy changes building on historical developments are needed:
- Policy Integration into Universal Health Coverage: Palliative care services, essential analgesics (oral morphine), and end-of-life consultations should be covered under the National Health Insurance Authority (NHIA) framework.
- De-centralization and Primary Health Integration: Train Community Health Extension Workers (CHEWs) and primary care nurses in basic pain management and home-based palliative care to reduce unnecessary tertiary ICU visits (Desalu et al., 2013).
- Mandatory Undergraduate and Residency Curriculum Integration: Incorporate structured palliative care and pain management modules into medical, nursing, and pharmacy curricula across Nigeria to eliminate “opiophobia” (Soyannwo, 2012).
- Culturally Sensitive Family Meetings: Engage hospital chaplains, Islamic scholars, and traditional family leaders early in Goals-of-Care conferences to bridge the gap between religious faith and clinical reality.
7. Conclusion
Palliative Care Medicine is not a substitute for intensive care, but a vital component of compassionate, high-quality critical care. Building upon decades of historical advocacy in Nigeria, transitioning PCM from tertiary oncology clinics into acute intensive care settings is the logical next step. By actively addressing physical pain, psychological distress, spiritual angst, and financial risk, palliative care ensures that even when a cure is unattainable, comfort and human dignity remain paramount. In resource-constrained settings like Nigeria, expanding palliative care into emergency rooms and ICUs is both a medical necessity and a moral imperative.
References
- Aslakson, R. A., Curtis, J. R., & Nelson, J. E. (2014). The initiative to improve palliative care in the ICU: Transforming critical care practice for patients, families, and clinicians. Critical Care Medicine, 42(5), 1263–1272. https://doi.org/10.1097/CCM.0000000000000169
- Clark, D. (2018). To illuminate the dark spaces: Cicely Saunders and the development of hospice care. Oxford University Press.
- Desalu, O. O., Onyedum, C. C., Iseh, K. R., Salawu, F. K., & Sanya, E. O. (2013). Palliative care in Nigeria: Progress, challenges, and prospects. Annals of African Medicine, 12(2), 71–78. https://doi.org/10.4103/1596-3519.112392
- Mularski, R. A., Campbell, M. L., Asch, S. M., Reeve, B. B., Ko, C. Y., Adams, J. L., & Lorenz, K. A. (2016). A review of quality indicators for pain and symptom management in ICU palliative care. Journal of Pain and Symptom Management, 51(2), 326–337. https://doi.org/10.1016/j.jpainsymman.2015.10.007
- Onyeka, T. C. (2011). Palliative care in Ibadan, Nigeria: Present status and future challenges. Journal of Palliative and Supportive Care, 9(3), 257–263. https://doi.org/10.1017/S1478951511000211
- Soyannwo, O. A. (2012). Development of palliative care in Nigeria: The journey so far. African Journal of Primary Health Care & Family Medicine, 4(1), 1–4. https://doi.org/10.4102/phcfm.v4i1.328
- World Health Organization. (2020). Integrating palliative care and symptom relief into primary health care: A WHO guide for planners, implementers and managers. World Health Organization.
