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Palliative care; Family physicians; Thailand; Healthcare system; Service provision; Competency; Medical education

Introduction

Palliative care, a multidisciplinary approach aimed at improving the quality of life for patients facing life-threatening illnesses, has been a growing global focus for the past decade. Many countries have invested in establishing high-quality palliative care programs and frameworks, emphasizing the importance of funding models, training, and education for healthcare providers. The United Kingdom, for instance, underscores the need for a sustainable funding model and robust training initiatives to ensure the delivery of high-quality palliative care [1]. In North America, Canadian palliative care associations have introduced a palliative care model to guide healthcare professionals in developing comprehensive palliative care services [2 ]. In Thailand, the landscape of palliative care is evolving, with a focus on integrating palliative medicine into family medicine residency programs and postgraduate training initiatives [3-5]. Despite the continuous growth in palliative care, Thailand's palliative care system is still in need of further development and integration. The period from 2011 to 2017 witnessed the progression of palliative care in Thailand from isolated service provision to preliminary integration into mainstream healthcare services [6]. While many hospitals provide some form of palliative care, whether through home visits or pain management, the extent of comprehensive palliative care programs varies. The heterogeneity of palliative care provision in different health jurisdictions underscores the challenges of ensuring quality and coverage. Key factors contributing to this variability include resource limitations, both in terms of human resources and funding [7 ,8].

The integral role of family physicians in palliative care cannot be overstated, given their presence alongside general practitioners and other medical specialists. Understanding this requires an appreciation of the structure of medical education in Thailand, where undergraduate medical degrees span a 6-year curriculum. Graduates receive a medical degree and independent licensure, allowing them to practice as general practitioners with diverse roles. While some general practitioners provide family medicine services, others focus on semi-urgent, acute, and chronic disease care.

Upon completing their medical degree and obtaining a general practice license, general practitioners have the opportunity to undergo further training in family medicine residency programs to become family physicians. These 3-year residency programs encompass various competencies, including palliative care. As of 2022, Thailand counted 1,341 family physicians, with a doctor-population ratio of 1:50,000. This figure includes family physicians from different training tracks, encompassing formal training, certifying, and community-based training tracks [9 ,10]. In 2017, a policy shift mandated the participation of family physicians in the Primary Care Cluster Model, aimed at providing more comprehensive care to patients in their respective catchment areas. Despite these strides, challenges such as doctor retention issues, limited resources, and training systems continue to be prevalent [11].

While significant progress has been made in Thailand's palliative care system, the nation still faces challenges relating to accessibility, a limited proportion of palliative care providers, and healthcare providers' confidence in communicating with patients and families. Drug availability remains a concern, and the role of family physicians is pivotal in ensuring access to palliative care and opioid availability across primary to tertiary care settings. As such, the adequacy and quality of family physicians in delivering palliative care have a direct impact on the country's palliative care systems as a whole. It is imperative to tailor the medical curriculum to align with the needs of healthcare systems effectively. Consequently, there is a need to solicit input for revising palliative care training and conducting need assessments. Currently, there is a lack of information regarding the specific aspects of palliative care that family practitioners provide, their confidence levels, and the proportion of family physicians offering palliative care. To address these gaps in knowledge, a survey has been initiated to determine the extent to which Thai family physicians deliver palliative care, to identify any discrepancies between the services they offer and the expected competencies, and to highlight the challenges they encounter in the process. This survey aims to provide valuable insights for enhancing palliative care training programs and conducting the necessary needs assessments. Ultimately, the findings will be instrumental in improving and expanding palliative care services in Thailand. As the healthcare landscape continues to evolve, ensuring that palliative care is comprehensive, accessible, and of high quality is crucial, and family physicians have a central role in achieving this goal [12-15]. In conclusion, the field of palliative care in Thailand is experiencing remarkable progress, with a growing number of family physicians playing a vital role in delivering palliative care services. As the nation addresses ongoing challenges, it is essential to focus on professional development, training, and the continuous improvement of palliative care provisions. With this dedicated approach, Thailand can create a more robust, integrated, and patient-centered palliative care system that caters to the unique needs of its population.

Discussion

Palliative care, a crucial element in healthcare systems worldwide, encompasses a broad spectrum of services aimed at enhancing the quality of life for patients dealing with life-threatening illnesses. Symptom management and end-of-life care, among other domains, are key components of palliative care that healthcare providers frequently offer and feel confident delivering. Conversely, grief and spiritual care are less commonly provided and evoke less confidence among respondents. To gain a deeper understanding of these findings, two distinct frameworks were employed for analysis. The first framework is the Model to Guide Hospice Palliative care by the Canadian hospice palliative care association. Rooted in the National Principles and Norms of Practice, this framework seeks to standardize palliative care and promote the establishment of hospice palliative care programs. It encompasses various aspects, including definitions, principles, significance, norms of practice, and management. Pertinently, this framework resides in the Domains of Issues Associated with Illness and Bereavement section, which presents an encompassing view of critical aspects that palliative care providers should focus on. These domains span disease management, physical symptoms, psychological care, social care, spirituality, grief, end-of-life care, and other practical concerns. Each domain is further elaborated, addressing issues such as pain management, function, nutrition, wound care, and habits within the physical symptoms domain. These domains essentially delineate scopes of practice or standardized care bundles that patients and their families should receive. Furthermore, our narrative analysis shed light on domains frequently addressed and those that warrant more attention, paralleling other well-recognized palliative care standard frameworks.

The second framework draws from family medicine residency curricula. In Thailand, formal palliative care training programs were initiated in 2018, and a substantial portion of palliative care services is rendered by family physicians. Palliative care has been integrated into numerous training programs, spanning from undergraduate medical degree curricula to various specialties and family medicine residency training. According to the Royal College of Family Physicians of Thailand’s current curriculum, palliative care competency forms a subcategory under Patient Care Competency. This competency encompasses seven domains in which learners should demonstrate proficiency upon completing the residency program: palliative care principles, communication skills, common symptom management, comprehensiveness, bereavement care, interprofessional skills, and appropriate referral. Additionally, the curriculum incorporates Palliative Care-related Entrustable Professional Activities to ensure all graduates achieve the requisite proficiency. By the third year of training, the final year, residents should possess the ability to engage in symptom management, end-of-life care, spiritual health, family meetings and counseling, and doctor-patient-family relationships with supervision available on demand. The utilization of these two frameworks serves to comprehensively assess the landscape of palliative care delivery and competency among family physicians in Thailand. The findings offer valuable insights into areas that are robust and those that require further enhancement. As palliative care gains increasing recognition as a fundamental component of healthcare, the proficiency of family physicians in providing these services is pivotal for ensuring quality care for patients with life-threatening illnesses. In summary, the analysis of palliative care delivery and competency in Thailand underscores the significant progress that has been made, particularly in family medicine residency curricula. Yet, this analysis also reveals specific areas that require more attention, providing a roadmap for further development and improvement of palliative care services. As the healthcare landscape continues to evolve, the importance of offering comprehensive and high-quality palliative care remains a top priority, with family physicians playing a central role in this endeavor.

Conclusion

This comprehensive overview of palliative care in Thailand has shed light on both the strengths and areas in need of improvement within the healthcare system. Palliative care, a vital component of patientcentered services for those confronting life-threatening illnesses, is of paramount importance. The analysis has underscored that symptom management and end-of-life care are consistently provided and evoke the most confidence among healthcare providers. However, it has also revealed the relative neglect of grief and spiritual care, both in terms of delivery and confidence levels. Two key frameworks were instrumental in our assessment. Firstly, the Model to Guide Hospice Palliative Care provided an organized structure for understanding the various domains of palliative care, highlighting critical aspects that require attention. While many areas align with established palliative care standards, the findings emphasized the importance of addressing the grief and spiritual care domains more effectively. Secondly, the family medicine residency curriculum in Thailand has played a significant role in shaping palliative care competency among family physicians. The integration of palliative care principles and competencies is a commendable step forward. The curriculum’s emphasis on seven key domains ensures that graduates are well-equipped to provide comprehensive care to patients. The analysis has underscored that as palliative care continues to gain recognition, there is a compelling need to elevate the level of competency among family physicians. Addressing the relative gaps in grief and spiritual care should be a primary focus. These aspects are integral to holistic patient-centered care and must be given due attention in training programs. In conclusion, Thailand's healthcare system has made significant strides in integrating palliative care into medical education and training. However, there is always room for improvement. Elevating palliative care competency and ensuring the delivery of comprehensive care should be central to future developments. By addressing these key areas, Thailand can ensure that palliative care remains a cornerstone of compassionate, patient centered healthcare services for those facing life-threatening illnesses. As we move forward, the journey to enhancing palliative care services is ongoing. It is a testament to the commitment of healthcare providers in Thailand to continually improve and adapt to the evolving needs of patients and their families.

Acknowledgement

Not applicable.

Conflict of Interest

Author declares no conflict of interest.

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