Palliative Care in Humanitarian Settings: An International Survey on Perceived Importance and Readiness among Health Emergency Response Unit Delegates

A 2024 survey of Red Cross and Red Crescent Health Emergency Response Unit delegates reveals that while palliative care is widely recognized as essential, its implementation in humanitarian settings is severely hindered by insufficient training, resource constraints, and policy gaps, highlighting an urgent need for standardized protocols and competency-based blended learning.

The Gist

Imagine a humanitarian crisis—like a massive earthquake or a war zone—as a chaotic, overcrowded emergency room where the lights are flickering, the phones are ringing off the hook, and the doctors are running on fumes. In this room, the primary goal is usually "save the life at all costs." It's a race against the clock to fix broken bones, stop bleeding, and fight infections.

But what happens to the people who are too sick to be saved? What about the elderly with advanced cancer, or the victims of trauma whose injuries are too severe to repair?

This paper is like a report card given to the "Red Cross and Red Crescent" medical teams (the ERU delegates) who rush into these disaster zones. The researchers asked these heroes: "Do you know how to care for the people who are dying? Do you have the tools, the training, and the permission to make their final moments peaceful?"

Here is the story of what they found, explained simply.

1. The Big Disconnect: "We Know It Matters, But We Can't Do It"

The survey found that almost everyone agrees: Palliative care is essential. Think of palliative care not as "giving up," but as switching the goal from "fixing the car" to "making the ride comfortable." It's about managing pain, easing fear, and helping families say goodbye with dignity.

• The Good News: 71% of the medical delegates said, "Yes, this is extremely important!" They understand that relieving suffering is part of being a good doctor.
• The Bad News: Only about half of them actually do it. For many, "palliative care" just means giving a painkiller and walking away. A quarter of them said, "We don't do this at all."

The Analogy: Imagine a chef who knows that a beautiful garnish makes a meal complete. They all agree the garnish is important, but when the kitchen is on fire and they are starving, they forget to add it. They focus only on the main course (saving lives) and forget the garnish (comfort care).

2. The Missing Toolbox

Why aren't they doing it? The paper reveals three main reasons, like three locked doors blocking the way:

• Door #1: The Training Gap. Most of these medical heroes have never been taught how to do this. It's like sending a pilot to fly a plane but never teaching them how to land it in a storm. 83% said they had no training in palliative care.
• Door #2: The Empty Medicine Cabinet. Even if they want to help, they often can't. Painkillers (like morphine) are often locked away due to strict laws, or the supply trucks just haven't arrived. It's like having a first-aid kit with bandages but no painkillers.
• Door #3: The "How-To" Manual is Missing. There are no simple checklists or rules for what to do when a patient is dying in a war zone. They are flying blind.

3. The Hardest Part: Breaking Bad News

One of the most emotional parts of the survey was about telling families the truth.
Imagine you have to tell a mother that her child won't survive, but you speak a different language, you are in a tent with no privacy, and you are terrified of making things worse.

• 75% of the delegates had to do this.
• Most had no training on how to say it gently.
• They felt like they were walking on eggshells, worried about cultural taboos or causing more pain.

4. What the Heroes Are Asking For

The delegates aren't complaining; they are asking for help. They want a "Humanitarian Palliative Care Starter Kit."

They specifically asked for:

• Blended Learning: A mix of online lessons (so they can study on their phones) and hands-on practice (like role-playing difficult conversations).
• Quick Guides: One-page cheat sheets that say, "If the patient has X pain, give Y medicine," or "If the family is asking this, say that."
• Better Access: A way to get pain medication through customs and borders without getting stuck in red tape.
• Support for Themselves: They admitted that watching people die without being able to help them is heartbreaking. They need psychological support so they don't burn out.

The Bottom Line

This paper is a wake-up call. It says that humanitarian medicine is currently incomplete. You can't call a medical response "complete" if you only treat the living and ignore the dying.

The authors suggest that if we add a few simple things to the training of these medical teams—like a new module in their school, a better supply chain for painkillers, and a few pages of clear instructions—we can transform these disaster zones from places of just "survival" into places where dignity and comfort are also preserved.

In short: We have the doctors, we have the will, but we are missing the tools. It's time to pack the toolbox so no one has to suffer alone.

Technical Summary

1. Problem Statement

Despite the World Health Organization's (WHO) 2021 update to the Emergency Medical Teams (EMT) Minimum Standards, which explicitly mandates palliative care as a core clinical capability, its implementation in humanitarian field operations remains inconsistent.

• The Gap: While there is a consensus on the ethical necessity of palliative care (pain relief, symptom management, psychosocial support) during crises, frontline health workers often lack the training, protocols, and resources to deliver it.
• The Consequence: Clinicians face "moral distress" when unable to alleviate suffering due to barriers such as opioid stockouts, restrictive regulations, lack of time, and insufficient communication skills.
• The Context: The study focuses on the Red Cross and Red Crescent Health Emergency Response Units (ERUs), which are standardized, rapidly deployable teams operating in austere environments (conflict zones, natural disasters, epidemics).

2. Methodology

• Study Design: A cross-sectional, web-based survey conducted between October 1 and December 31, 2024.
• Population: Health professionals with deployment experience in Red Cross/Red Crescent Health ERUs.
  • Inclusion: Direct involvement in clinical care or coordination of medical humanitarian operations within the last 15 years.
  • Exclusion: Non-health ERU deployments or no deployment history.
• Data Collection:
  • Platform: LimeSurvey (anonymous, self-administered).
  • Distribution: Closed survey via internal IFRC/ICRC mailing lists and National Society focal points (no public advertising).
  • Instrument: A 35-item questionnaire covering demographics, perceived importance, readiness, barriers, opioid access, communication skills, and training needs.
• Analysis:
  • Quantitative: Descriptive statistics (frequencies/percentages) for categorical variables.
  • Qualitative: Rapid content analysis of free-text responses by two independent reviewers.
  • Data Integrity: Only submissions with ≥50% completion were included (114 of 173 total submissions).

3. Key Contributions

This study provides the first large-scale, specific assessment of palliative care readiness within the Red Cross/Red Crescent ERU network. Its primary contributions include:

• Operationalizing the Gap: Quantifying the disparity between the high perceived importance of palliative care and the low actual provision rates in the field.
• Identifying Specific Barriers: Moving beyond general "lack of resources" to pinpoint specific systemic failures, such as the disconnect between prescriber confidence and actual opioid availability due to regulatory/stockout issues.
• Training Preferences: Defining the specific format and content preferences of humanitarian workers (e.g., a strong preference for blended learning with practical components).
• Policy Alignment: Offering evidence-based recommendations to align ERU protocols with WHO EMT standards and the Sphere Humanitarian Charter.

4. Key Results

A. Participant Profile

• Sample: 114 respondents (50.9% had >10 years of humanitarian experience).
• Demographics: Predominantly female (64.9%), with a median age of 45–54.
• Roles: Nurses (35.1%), Nurse Specialists (28.1%), General Practitioners/Senior Medical Officers (17.5%), and Pharmacists/Allied Health (18.4%).
• Context: Deployments spanned the Middle East/North Africa, Africa, and Asia Pacific, primarily in armed conflict and complex humanitarian emergencies.

B. Perceived Importance vs. Reality

• Importance: 71.1% rated palliative care as "extremely important."
• Provision: Only 49.1% reported providing palliative care (usually limited to pain relief), while 25.4% reported providing none.
• Target Population: 90.4% agreed care should extend to both patients and relatives.

C. Barriers to Implementation

The most cited barriers were:

1. Insufficient time/resources: 56.1%
2. Lack of training: 49.1%
3. Absence of policies: 48.2%
4. Cultural barriers: 47.4%
5. Limited knowledge: 36.8%
6. Restricted opioid access: 28.1%

D. Opioid Access and Management

• Availability: 64.9% had access to opioids; 28.9% had none.
• Prescriber Confidence: Among those who prescribe, 85.1% felt comfortable prescribing opioids.
• Constraints: Despite confidence, 54.2% cited stockouts and 44.9% cited strict regulations as primary constraints.

E. Communication Skills

• Experience: 75.4% had to deliver bad news during deployments.
• Training Gap: 72.1% of those who delivered bad news had no prior structured training.
• Frameworks: Only 12.8% used established frameworks like SPIKES; most relied on ad-hoc methods.
• Challenges: Language barriers (80.4%) and cultural/religious differences (75.7%) were the top hurdles.

F. Training Needs and Preferences

• Prior Training: 82.7% had received no prior training on palliative care in humanitarian settings.
• Demand: 91.4% endorsed the need for dedicated training.
• Preferred Format: 50% favored blended learning (online + practical).
• Key Topics: Pain management (77.1%), self-care/resilience for providers (78.1%), communication skills (75.2%), and cultural sensitivity (65.7%).

5. Significance and Recommendations

Significance

The study highlights a critical "implementation gap" where humanitarian teams are clinically capable of acute care but under-equipped for end-of-life care. It demonstrates that the barrier is not a lack of willingness (as 71% view it as essential) but a lack of competency, policy, and supply chain integration.

Strategic Recommendations

The authors propose a three-tiered action plan:

1. People (Competencies):
   • Embed core palliative competencies into ERU pre-deployment induction.
   • Utilize simulation for high-stress communication and symptom control.
   • Implement peer support systems to mitigate moral distress.
2. Processes (Protocols):
   • Develop concise Standard Operating Procedures (SOPs) and "quick-reference" kits (including dosing guides and communication prompts).
   • Standardize a minimal palliative kit (oral morphine, adjuvants, antiemetics) mapped to WHO EMT types.
   • Create clear triggers for "goals of care" discussions.
3. Platforms (Systems):
   • Establish emergency pathways for controlled medicines with national authorities.
   • Integrate palliative indicators into ERU readiness reviews and after-action reports.
   • Develop offline-capable digital tools for tele-consultation and decision support.

Conclusion

The paper concludes that integrating palliative care is not an admission of therapeutic failure but a fundamental requirement of quality humanitarian healthcare. By adopting competency-based training, standardized protocols, and reliable access to essential medicines, the Red Cross and Red Crescent Movement can align its operations with global standards and effectively relieve suffering in crisis zones.