Progress in palliative care for cancer in Turkey: a review of the literature

Tezer Kutluk¹, Fahad Ahmed¹, Mustafa Cemaloğlu¹, Burça Aydın¹, Meltem Şengelen², Meral Kirazli¹, Sema Yurduşen¹, Richard Sullivan³ and Richard Harding⁴

¹Department of Pediatric Oncology, Hacettepe University Faculty of Medicine and Cancer Institute, 06100 Ankara, Turkey

²Department of Public Health, Hacettepe University Faculty of Medicine, 06100 Ankara, Turkey

³King’s College London, Institute of Cancer Policy, Conflict & Health Research Group, London, UK

⁴Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, Cicely Saunders Institute, King’s College London, London, UK

Abstract

Background: The demographic transition in Turkey is shifting the burden of diseases towards non-communicable diseases including cancer. Palliative care (PC) as a component of Universal Health Coverage assures patient and family-centred care provision throughout the spectrum of cancer.

Objectives: This study aimed to make a detailed evaluation of the progress achieved since the mid-90s and the current situation of cancer PC in Turkey.

Methods: A literature review was conducted in PubMed, Scopus, Embase, ScienceDirect, Web of Science, Google Scholar, The Turkish Academic Network and Information Centre databases, Ministry of Health documents, Council of Higher Education’s thesis 01/1995 to 07/2020. The information was categorised into the six domains: history of the cancer PC; law and regulations; education and research; opioid use; patient care and palliative centres; public awareness, psychosocial support and end of life ethics.

Results: Of 27,489 studies, 331 met the inclusion criteria. The majority were published in the Turkish language and were journal articles. The findings showed that the development of PC in Turkey can be divided into three stages: early initiatives before 2000, the dissemination stage, 2000–2010 and the advanced stage after 2010. There is evidence of progress in terms of legal regulations, opioid use and number of PC services and research output. However, there is still a need for improvement in professional education, public awareness and end of life care.

Conclusion: There is evidence of progress, barriers and opportunities. However, bringing research into practice is needed for scale-up and integration of PC in cancer care in Turkey.

Keywords: palliative care, cancer, capacity building, systematic review, Turkey

Correspondence to: Tezer Kutluk
Email: tezerkutluk@gmail.com

Published: 25/11/2021
Received: 09/10/2021

Copyright: © the authors; licensee ecancermedicalscience. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Background

Demographic and disease transition has amplified the challenges for cancer care globally [1–3]. Palliative care (PC) aims to relieve the suffering of patients facing life-limiting conditions. Although PC is a newer component in the modern healthcare system, it is increasingly recognised as an essential part of it. The PC resolution adopted at the World Health Assembly in May 2014, urged governments to ‘integrate palliative care services in the continuum of care, across all levels, with emphasis on primary care, community and home-base care, and universal health coverage (UHC) schemes’ [4]. Moreover, the recommendations of the Worldwide Palliative Care Alliance stress that all governments must integrate PC along with preventive and curative health care into their national health system [5].

It is estimated that more than 56.8 million people need end of life PC every year globally [5]. If it is considered that for every terminally ill patient requiring PC, there are at least one or two caregivers involved, the total need of PC will be twice or thrice than the above estimates. Owing to physical symptoms, psycho-social and treatment effects, cancer patients are in greater need of PC and it is estimated that cancer patients only require more than one-quarter of global PC need [5].

Considering the need of PC, it is also worth noting that only a few countries have comprehensive PC programmes through a public health approach [6]. According to the most recent global survey conducted among 194 countries, funding for PC was available in 68% of countries and only 40% of countries reported that the PC services reached at least half of the patients in need [7].

Turkey is home to about 83.6 million people [8] and additionally hosts about 3.6 million refugees [9]. Based on the Global Cancer Observatory (GLOBOCAN) 2020 data, the estimated number of annual cancer cases in Turkey is 233,834 and 126,335 people die due to cancer [10]. Considering the burden of cancer and other non-communicable diseases (NCDs) along with an increase in life expectancy at birth [11], the real need for PC will be much greater in the near future. The concept of PC was developed in Turkey along with the cancer control programme. The Turkish Ministry of Health (MoH) had brought together all stakeholders under the umbrella of a National Cancer Advisory Board and ignited the Palliaturk project which became a turning point to create a national policy for PC [12]. Despite the decade long effort for establishment of the national PC programme and the progress which has been made, it is widely acknowledged that there is still a need for improvement for further dissemination and to take PC to a higher level in Turkey [13]. The aim of this review is to make a detailed evaluation of the progress achieved since the mid-90s and the current situation of cancer PC in Turkey.

Method

Search strategy

The methods for this review were based on Arksey and O’Malley’s scoping review methodology [14]. The databases were retrieved through a search of MEDLINE, Scopus, Embase, ScienceDirect and Web of Science, Google Scholar, ULAKBIM (The Turkish Academic Network and Information Centre), Turkish MoH documents, The Thesis Database of the Turkish Council of Higher Education and renowned national and international PC as well as cancer conferences. Articles were explored for PC for cancer patients in Turkey. The search was made by using three Medical Subject Headings (MeSH) categories – palliative care (palliative care, palliative therapy, end of life care, terminal care, supportive care, palliative medicine), cancer (cancer, oncology, malignancy, neoplasm, tumours, neoplasia) and Turkey (Turkey, Turkish) – combined using ‘and’ statements. The local database was also searched using the translation of the above term in Turkish. The search was limited to literature published between the year 01/1995 and 07/2020. Searches were performed on article titles, abstracts and full text. Additional studies were identified through the references of relevant studies.

Data selection procedure

Articles/studies were included in the review if they were in either the English or Turkish language and focused on PC in cancer. Articles which did not focus on Turkey, or were focused on surgical or radiological interventions for palliation of symptoms were excluded. Following the database search, duplicates were removed. Titles and abstracts were inspected jointly by all authors for inclusion in the review. Irrelevant studies were removed and the full text was examined if necessary. A Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram was used to provide information regarding the selection of the articles in this review.

Data extraction and analysis

The following information was extracted from articles: author names, the institution of affiliation of the first and corresponding author, title, name of the journal/conference/publisher, year of publication, type of publication, language of the article, study design and setting, national or international collaboration, aim/objective of the study, aspect of PC being studied and the main findings.

The main text of all articles included in this review was read by authors independently, the key findings were extracted and assigned into categories. Later these categories were examined and conceptualised in the research team meetings and were condensed into major themes; history of PC in Turkey, law and regulations, education & training, research trend, pain management, patient care and psychosocial support. The summary findings are presented in the results section.

Results

Search results

A total of 27,489 papers (7,989 research papers, 19,388 abstracts of conference presentation/poster, 101 postgraduate theses and 11 governmental documents) were identified. After removing duplicates, 24,788 papers met the condition for full-text screening. In all, 24,374 pieces of literature (the large majority of conference abstracts) were excluded based on the title or abstract. The remaining 414 were retrieved and screened in detail. Out of these, 83 were removed (there was insufficient information regarding PC for cancer in the full text of 67 literatures, five studies were specific to ethical considerations at the end of life, four were about the specific surgical procedures to palliate the obstructive symptoms due to cancer, other four were regarding PC needs of neonates with congenital malformation/birth defects, two studies were regarding geriatric health without cancer, one was about burnout of healthcare workers at oncology services). Figure 1 describes the PRISMA flowchart of the literature reviewed in this study and the details of the included 331 articles are shown in Supplementary Table 1.

Figure 1. PRISMA flowchart.

Characteristics of included studies

Of these 331 articles included in this review, the majority 161 (48.6%) are journal articles, 96 (29.0%) conference abstracts, 56 (16.9%) post-grad theses, 13 (3.9%) gray literature (mostly from the Turkish Ministry of Health), 3 (0.9%) book chapters and 2 (0.6%) are letter to a journal editor. Regarding journal articles – more than half, 98, articles were published in international journals, whereas 63 were published in Turkish/national journals.

About 193 (58.3%) literatures were published in the Turkish language, whereas 138 (41.7%) were in English. Among all the literature included in this review, 194 (58.6%) used cross-sectional surveys or retrospective analysis of datasets, 59 (17.8%) were review articles, letter to the editors, book chapters, 19 (5.7%) employed either interventional design or randomised control trials or quasi-experimental design, 14 (4.2%) studies evaluated validity and reliability of specific questionnaires among Turkish PC cancer patients, 13 (3.9%) were gray literature, 12 (3.6%) used qualitative research methods, 5 (1.5%) were case studies or case series evaluating a specific dimension of PC for cancer patients, 4 (1.2%) employed methodological design, 3 (0.9%) mixed methods research design, 3 (0.9%) articles used either prospective or cohort design and other 3 (0.9%) were cost analysis studies. Only 2 (0.6%) used a case–control design. Furthermore, 11 articles were published in collaboration with the Middle East Cancer Consortium (MECC). As shown in Figure 2, only two articles included in this review were published before the year 2000. Most of the articles were published between the year 2018 and 2019. The major themes were presented below.

History of cancer PC in Turkey

The history of PC in cancer is evaluated in three stages as summarised below and also shown in a timeline (Figure 3).

The first stage: Early initiatives (Before 2000): The earliest available information regarding PC is the establishment of the first outpatient pain unit in Istanbul University in 1986, and the establishment of the Turkish Society of Algology and the launch of the Turkish Journal of Pain in 1987. Soon after, in 1990, an inpatient pain department was established in Istanbul University and in the same year, algology was accepted as a speciality by Higher Education Council [15].

By the end of the 90s, there were no modern PC services. A lack of trained health care professionals, low public/professional awareness, limited access to opioids and opiophobia were the major barriers [16, 17]. In 2000, 13.1% of all deaths in Turkey were due to cancer and future projections showed that it would continue to rise [18]. Generally, PC was not a priority. By 2005, there were only seven supportive care units for pain and symptom management. Opioid consumption was relatively low and physicians as well as pharmacists faced legislative and practical obstacles in prescribing and dispensing opioid analgesics [19].

Figure 2. The evolution of the number of articles regarding PC for cancer in Turkey published per year, 1996–2020.

Figure 3. The evolution of the PC in Turkey from the mid-1980s to 2020. PC, Palliative care; MECC, Middle East Cancer Consortium; MASCC, Multinational Association of Supportive Care in Cancer; MoH, Ministry of Health; TOG, Turkish Oncology Group; TSMO, Turkish Society of Medical Oncology; ESMO, European Society of Medical Oncology.

The second stage: Dissemination of PC concept and awareness among the medical and scientific community (2000–2010): The new millennium witnessed interest from governmental and non-governmental stakeholders. The Turkish Oncology Group (TOG) established a supportive care working group in 1999 [16]. The National Cancer Advisory Board of MoH sets a psychosocial sub-committee in 2003. The Turkish Society of Medical Oncology started training courses [16, 20], organised a joint meeting with the Multinational Association of Supportive Care in Cancer (MASCC) in 2004 [20] and the European Society for Medical Oncology (ESMO) in 2006 [21]. The MECC, founded in 1996 in collaboration with MoH from member countries, became a platform bringing together clinical professionals and researchers [22]. As soon as Turkey became a member of MECC in 2004 [21], MECC & MoH collaboration started to organise meetings in cancer control including PC courses and workshops. PC awareness and engagement of different stakeholders were raised in the mid-2000s; The establishments of Hope Lodge by Hacettepe University Oncology Institute Foundation in 2006 [23, 24], the Palliative Care Association (PCA) in 2005 [23, 25], PC units in Ege University and Anadolu Hospital in 2006 [20] and a PC unit at MoH Oncology Hospital in 2007 [26] are examples of progress in this period. Based on a survey by MoH in 2009, there were only 10 PC units and 72 pain units in the country. Morphine use was less than in the USA and many Middle Eastern countries. Legal restrictions and lack of trained PC staff were the major barriers [12, 27, 28].

The third stage: Advancement with government and societal engagement (After 2010): MoH brought the first Cancer Control Programme in 2008 [29]. Soon after, MoH Cancer Control Department started the Palliaturk project in 2010, which was implemented in 2011 [12]. The Palliaturk project had two main objectives – namely targeting the availability of opioids and implementation of a community based PC model [12, 28]. The model included primary, secondary and tertiary level PC centres. MoH also started collaborations with international and national stakeholders (World Health Organization (WHO), Union for International Cancer Control (UICC), national non-governmental organisations (NGOs) and professional organisations, etc.) [12, 28]. Since the 2010s, new regulations and rules were set by the government; stakeholder involvement and awareness of the medical community as well as the public had increased. New PC centres were opened around the country. In 2015, the ‘Palliative Care Nursing Certificate Program’ was started by the MoH [30]. In 2017, The Home and Palliative Care section was established under MoH Public Health Directorate [31, 32]. According to the international PC scale ranking, Turkey was in group 2 (capacity-building PC activity) in 2006, and moved up to group 3b (generalised PC provision) in 2011, then in group 3a (isolated PC provision) in 2017. There were no countries except Israel in group 4 from the Middle Eastern Countries [6, 33–35].

Law and regulations

The major PC regulations and laws were released after 1998. The first regulations relating to patient’s rights were released in 1998 [36]. The first home care regulation was released in 2005 [37]. PC services were mentioned in the 2010 update of the home care directive [20, 24, 38]. The first National Cancer Control Programme was released in 2008 [29] and became a turning point – the MoH Cancer Control Department started to work on PC Projects. With the aim of PC provisions, MoH established the PC Directive in 2014 and implemented it in 2015. It became a strong legal support to the establishment of PC centres to provide and promote PC in Turkey [39]. The PC directive described inpatient PC centres within the established hospitals. The involvement of family physicians and home care services in the outpatient setting were also included. The PC coverage includes examination, evaluation, care, rehabilitation, psychosocial support, nutritional support, pain management, legal support for the patients & relatives. Social Security Administration accepted the reimbursement of the inpatient PC costs in 2014 [20, 40]. An update of the home care regulation was released in 2015 [41]. In parallel to this legal progress, the first morphine sulphate tablet was officially produced by a Turkish pharmaceutical company in 2014 [42].

Professional education, training and research

The first PC fellow of Turkey was a medical oncologist trained in the USA in 1997–1998. Between 2001 and 2010, the Supportive Care in Cancer Committee of the TOG organised 18 national/international training meetings. This committee also contributed to the development of PC within the National Cancer Control Programme after 2008 [16]. Turkish Medical Oncology Society organised the first postgraduate education on PC in 2003, joint meeting with MASCC in 2004, PC course with ESMO in 2006 [20]. More PC courses and meetings have been organised after 2013 by different stakeholders [20]. A nursing academic was trained in the USA for PC in 2006 [20]. MECC & MoH collaborations became a driving force for PC education in Turkey and regional countries. They jointly organised meetings and workshops between 2004 and 2014, training 434 health care professionals [20–22, 43, 44].

The interest in PC research and education from Medical & Nursing Schools appeared after 2010. PC lectures were included in Nursing schools under the postgraduate curriculum [20]. PC centres were established in Ege and Dokuz Eylul Universities in 2011 and 2012, respectively. The centre in Dokuz Eylul University was approved by the Higher Education Council [24, 45, 46].

Stakeholders including the Turkish Medical Oncology Society, the anaesthesiology/algology, nursing community and PCA made a significant contribution. The inclusion of a Psychosocial Committee within the National Cancer Advisory Board in 2003 also helped to increase stakeholders’ engagement [47]. In 2019, the Palliative Care Nursing Association was established [48]. The increasing number of reports from various stakeholders including medical specialities [49–51] nurses [20, 52–57], physiotherapists [58–62], social workers [47, 63], hospital managers [64], nursing students [65–68] shows the progress in the PC field in Turkey. However, there were an insufficient number of PC healthcare workers. The lack of PC training among medical, nursing, midwifery, students, physicians and nurses, healthcare staff, emergency care staff was within the range of 50%–80% [69–83].

The number of research outputs on PC increased after 2015. The different areas of PC were investigated. The need assessment and adaptation of the ENABLE (Educate, Nurture, Advise, Before Life Ends) evidence-based early PC model were also investigated for Turkish family caregivers of older persons with cancer [84]. Ulus State Hospital, MoH first comprehensive PC centre, reported that 38.4% PC patients had a cancer diagnosis [85]. A previous study found that pain was the most common symptom (27.1%) among hospitalized patients [86]. Along with an increase in PC services, burnout was also found to be a significant problem among healthcare workers working in PC units [87]. Complementary and alternative medicine (CAM) use is also a common practice in Turkey. CAM use was found to be 57% among cancer patients [88]. In another study, at least one CAM method was used by 62% [89]. Irmak et al [90] found that 46.4% of cancer patients were CAM users, however no significant difference was found with respect to quality-of-life (QoL) score among CAM users and non-users. A randomised trial found that listening to music was effective in controlling pain and anxiety among cancer patients [91]. Several studies focused on the validity, reliability and adaptation of various scales among PC and cancer patients [92–119] (See Supplementary Table 2).

Opioid use and pain management

Opioid consumption at the global level started to increase in the mid-90s. A survey on the availability and accessibility of opioids among Middle East countries showed that opioid availability was low throughout most of the Middle East countries except Israel. In 2011, Turkey was in the 10th rank as regards morphine consumption mg per capita [120]. For many years, opioids are available but the process for prescribing was complicated with a colour-coded system; red prescription for strong opioids, green for sedatives and weak opioids and white for all non-restricted prescription [16].

Opioid consumption in total morphine equivalence, milligrams per capita, in Turkey in 1980 was 0.0937 and it increased to 12.2204 in 2011. Although there was a significant increase by the time, 2011 Eastern Mediterranean Regional Office (EMRO) average was 10.56, global average was 61.66 [34, 43]. A study published in 2010 showed that the consumption of morphine has been fluctuating at doses around 0.1 mg/capita in Turkey for the period of 2004–2007. This was higher than Saudi Arabia and Egypt but lower than Israel, Cyprus, Jordan and Lebanon. Morphine consumption in Turkey was 447 times less than the USA in 2007. In the USA, the consumption was 76 mg/capita in the year 2007. The global mean was 5.57 mg/capita [121]. There was a big disparity among the Middle East countries including Turkey in terms of opioid use compared with western World and the USA. Turkey was at number 50th in the world for consumption of opioids analgesics during 2007–2009 [22]. Access to Opioid Medicine in a European Project (ATOME) in 2016 reported that Turkey had more than 40 potential barriers in different categories [122].

A number of studies have been published with a focus on pain management in cancer patients [123–132]. A study among 52 metastatic cancer patients found that the use of morphine was 5.7%; codeine 3.8% and tramadol 75% [130]. In another study, interventional procedure was used to control pain in 11% of cancer patients [131]. It was also reported that 82% of hospitalised cancer patients for PC were given different analgesic treatment of whom 50% received third step pain medicines [124]. A study among 1,467 cancer patients utilising analgesic step ladder approach showed the use of nonopioid+/−weak opioid+strong opioid in 31.5% and interventional procedures in 14.5% of patients [125].

Patient care and PC centres

PC activity was very limited in Turkey before 2010 [21]. The European Association for Palliative Care (EAPC) survey in 2007 showed that PC services are provided in ten centres with a total of 241 beds, and there was only one hospice centre in Turkey. Most of the PC centres were within oncology clinics with a major focus on pain control [133]. The earliest PC units were established in 2006 at Anadolu and Ege University Hospitals [20]. MoH Abdurrahman Yurtaslan Hospital established the comprehensive PC services in 2007 with 18 inpatient beds [26]. New PC centres in MoH Hospitals were established following 2010 [20]. A multidisciplinary PC team in 2010 and first PC unit for children in 2011 were established in Dokuz Eylul University [134, 135]. The first ‘Comprehensive PC Center’ in the Turkish MoH, Ulus State Hospital was opened in December 2012. One third of patients treated in this centre within a year had a cancer diagnosis [23].

PC services were included in home care services in 2010 [20, 38]. By the year 2014, there were a total of 834 home care teams providing services to 416,175 patients. In 2013, there were 18 PC centres in the Turkey [43]. By 2017, the number of PC services increased to 227 PC Units, 947 home care teams and trained 21,696 family physicians within the MoH organisation [44]. A study in 2018, presented that there were four paediatric PC hospital services in Turkey [136]. As of February 2020, there were 415 PC centres, with 5,577 bed capacity and 6,011 PC workers in 81 Provinces. Among these, there were 10 paediatric PC services with 119 bed capacity. More than 290,000 patients got support from these services [137] (Figure 4).

Figure 4. Number of PC beds in Turkey, 2012–2021.

The increase in PC centres also resulted in an increased number of research outputs. A study showed that 9% of 214 patients receiving home care health services in Kirikkale city had a diagnosis of cancer [138]. A study reported 45,838 out of 409,337 patients with respiratory problems benefitting from home care services had a diagnosis of lung cancer during 2011–2017 and the number of lung cancer patients increased from 1,346 in 2011 to 9,206 in 2017 [139]. Another study showed that cancer was the fourth most common diagnosis among patients receiving home care services. During the period of 2011 and 2017, total number of home care visits increased from 3,440,144 to 10,917,965; the number of home care teams increased from 593 to 662. Among home care visits, number of cancer patients increased from 7,278 to 74,261 [140].

With the increase in the number of services, PC units around the country started to report their experiences [141–145]. Most of the studies focused on symptom management [146–171]. Different aspects of supportive care were investigated in many studies including quality of life [172–181], care dependency [182], nutritional aspects [160, 183, 184]; complementary approaches like acupress [185], reflexology [186], lymphedema management [187], bio-resonance [188] and music therapy [189]. A study from a PC centre showed 87.8% of 327 patients had cancer during 2015 and 2017. The most common reason for hospitalisation was oral intake impairment in 34.6%, pain control in 25.5% and both in 16.2% [190]. Ozcelik et al [191] prepared a PC guideline in 2014. Erkal et al [192] discussed the cost, management, satisfaction and other issues in PC services.

A few studies investigating emergency department admissions showed that 20%–60% of patients had a diagnosis of cancer [193–195]. A mortality analysis of 373 stage 4 cancer cases showed that 23.9% were given chemotherapy during a month before their death [196]. A study investigated the last 2 weeks of 422 terminal cancer patients in hospital; the invasive pain management was used in 25%, terminal sedation in 12%, chemotherapy in 9%, central catheters in 38%, transfusion in 43% and MR imaging in 13% [197]. Another study in cancer patients showed that 42% of patients were given palliative chemotherapy in the last 3 months of life [198]. There are similar studies that focused on the interventions and investigations during the last weeks of life [199–201]. These studies highlight unnecessary procedures at the terminal stage and emphasise the need for PC among cancer patients.

Symptom control was not at the optimal level. A multicentre study in 1,245 lung cancer patients found that pain was controlled in only 21.7% cases, while dyspnoea in only 12.4% of cases [202].

Poor symptom control also affects home based care. A study among caregivers of terminal cancer care presented that most participants expressed that they would like to look after their patients at home, however they preferred hospital care at the end [203]. A study shows that the health literacy level of care givers has a significant effect on bedsore occurrence and survival [204]. A positive correlation between ‘the time from diagnosis to palliative care application’ and the quality of life was found in a cohort study [205].

An analysis on the nosocomial infections in PC unit showed that the average cost of antibiotics was 1,252.79 ± 1,616.50 Turkish Lira (TRY) [206]. A cost comparison was made among cancer patients treated at comprehensive PC; hospital in-patient PC and home health care services, and it was found that the mean total indirect costs were $164.10, $778.43, $344.62, respectively. The mean total direct costs were $2,384.57 and $4,775.68 in comprehensive palliative care services (CPCC) and hospital inpatient palliative care services (HIS), respectively [207]. A cost analysis in a medical intensive care unit where 77% of the patients had terminal cancer found that the median cost was 2,841 TRY, and the total cost was 581,353.2 TRY [208]. A cost analysis in Denizli State Hospital PC Centre revealed that total cost of the PC centre was 1.034.235,26 TRY [209]. In another study, the direct cost per patient per day in a PC centre was found as 391 TRY [210].

A survey showed that the patient satisfaction was higher in oncology centres having PC units [211]. A study showed that PC centre was less effective in reducing symptom levels in cancer patients compared with patients in general care at the public hospital, but provided greater patient satisfaction [212].

Public awareness, psychosocial support and end of life ethics

A low level of public awareness was identified in many studies. It was found that 60%–87% of cancer patients and their caregivers had no prior knowledge about PC [203, 210, 213, 214]. Home care awareness was found as 57% [119]. Another study presented that patient preference for home care increased from 12% at admission to 47% at discharge [215]. Quality of life for care givers was also investigated in a study, and it was found that 53% of the study subjects did not meet routine responsibilities [216].

Do not resuscitate (DNR) is an important element of PC and end of life. However, there is no DNR Law in Turkey. Many researchers stressed the need for legal arrangements for end of life care and DNR policies [20, 217–220].

Along with progress on PC at national level, many studies were conducted on the subjects of psychosocial issues [221–234], patient and professional satisfaction [235–237], burden of the caregivers [238–247] and end of life [248–251]. A survey among doctors and nurses in Middle Eastern Countries including Turkey showed that 44% of participants provided spiritual care less often than they think they should [252]. A study among PC nurses found that they perceive death as a natural and inevitable process and as their experience increases, they become desensitised [253]. A study showed that 55.7% of 70 nursing students had never heard of spiritual care [254]. Another study investigating the cultural mourning ritual, the ‘First Feast’, found this tradi tion helped to ease the grief response of relatives and might be a useful auxiliary method for PC teams to help grieving families [255]. There are other studies that focus on the psychosocial and spiritual issues on caregivers [256–258].

A study also found that 80% of the caregivers had inadequate health literacy regarding general health [259]. Barriers for PC development were discussed in some studies [20, 24, 34]. The major barriers reported by Turkish MoH, 2nd Turkish Medical General Assembly Clinical Oncology Study Group were lack of public and professional awareness, failure of PC planning and disconnection from anticancer treatment, hurdles in the accessibility of opioid analgesics, financial issues and the lack of trained PC providers [260].

Discussion

The population is ageing in Turkey, the proportion of people over 65 years of age comprised 9.5% of the population in 2020 [8]. The need for PC in Turkey has increased in parallel to the burden of NCDs and cancer. The estimated annual deaths due to NCDs in Turkey was 407,300, it makes 89% of total deaths in 2016 [261]. Cancer is listed as the second most common cause of mortality which accounts for 18.4% of all deaths in Turkey during 2019 [262]. There were very limited services mainly provided during the routine care in tertiary care hospitals before 2000. Indeed, the situation was not much different at a global level – it was reported that globally over 56.8 million people are in need of PC each year. Most of them are living in developing countries [5]. The EAPC published that the number of PC beds per million inhabitants was 45–75 in advanced European countries, the rest had few beds [133]. Both professionals (mainly oncologists and anaesthesiologists) and government have contributed on the progress of PC after 2010 significantly in Turkey. The partnership between oncology societies and cancer control department at MoH became a successful model for the planning and implementation of PC services in Turkey. MoH actions in PC boosted the involvement of other stakeholders, regional/international organisation. The PC activity was scaled up to group 3b in 2011. After the implementation of Palliaturk project in 2011, various PC related legal regulations were enacted [6, 12, 33–35]. During the same period, the demand for PC due to changing demographic patterns (ageing, decrease in household size) and burden of cancer/NCDs was also increasing.

Many studies showed that awareness and knowledge about PC among medical professionals was very limited. PC is still not a recognised speciality in Turkey. Only a few universities include PC education in the under and postgraduate curriculum. National and international meetings were the main source of PC training. There is still a large variation in palliative medicine (PM); education even in Europe. In the WHO Europe region, PM courses were included in all medical schools of 13 out of 43 countries, PM was not taught within medical curricula in 14 countries [263]. Major oncology associations like the American Society of Clinical Oncology (ASCO) & ESMO are also investing in the integration of PC services in oncology [264]. During the last 10 years, PC medicine is gaining more investment from all stakeholders. Sedhom et al [265] commented that PC is still not integrated into cancer care with such a priority focus of oncology training on treatment and research. There is still a strong need for an advanced education and structured human resource policies. An early literature review in Turkey showed the limited PC publications before 2005 [266]. The number of scientific publications and presentations started to increase after 2015; however, most of the studies were either surveys or descriptive studies. More focus on evidence-based research in PC is still needed. A bibliometric analysis on PC during 2000–2016 showed that the publications increased after 2006, the USA and UK were pioneering the scientific work [267].

The use of opioids is being recommended for the control of the pain and improving quality of life [5, 229], and it is used as an indicator for the PC service availability [268]. There were strong critics to Turkey for underuse of opioids for pain management, although Turkey was one of the leading opioid producing countries [34, 43, 121]. The situation improved after the investments on PC starting from 2010, however, it is still much lower than the global average [34, 43]. Consumption in defined daily doses for statistical purposes (S-DDD) per million inhabitants per day is within the scale of 201–1,000 during 2014–16 which was less than North America and Europe but higher than most Asian and African countries [269]. Based on our literature review, we can classify the barriers to opioid use into three groups: first is the lack of awareness and opiophobia among the health care professionals and public; second the complexity in prescription of the opioids due to legal procedures and thirdly the lack of organised PC structure until 2010. There is still a need for investments in the infrastructure, training and human resource management on PC under the concept of ‘health system strengthening’.

Before the implementation of the Palliaturk project, few hospitals and universities started to invest on PC services, there were no specialised PC centres in those years [20, 21, 23, 26, 43, 133]. The government Palliaturk project, the PC Directive and the Home Care Regulations contributed to the progress made during recent years [12, 20, 39, 41]. Currently, there is a PC section within MoH at top management level and MoH was able to invest in the dissemination of PC capacity in Turkey [137]. Our findings show that integration for PC services with oncology services is an area for further research and investment. There are a number of cultural barriers and opportunities for the utilisation of PC centres in Turkey. Talking about death is a cultural taboo. Doctors, patients and care givers are reluctant to talk about end of life care. This results in delayed referral to PC centres by professionals. Moreover, the concept of PC centres is not clear in the minds of the public. Therefore, referral to PC centres was sometimes perceived as an abandonment of oncological care. Due to this, patients and caregivers want to be under the care of the primary oncology team instead of PC centres. The integration of PC care into oncology practice will help to overcome these cultural barriers. Traditionally, terminally ill patients were cared for in their homes by family members. However, with social and economic changes, care givers now more commonly prefer their patients to be cared for in the hospital. This could be an opportunity for the utilisation of PC centres more widely. ASCO as a leading professional cancer organisation also strongly advocates the integration of PC into oncology practice to disseminate and implement it more effectively [270].

Currently, there is no DNR Law in Turkey [20, 217]. Moreover, the Turkish society is not ready to implement DNR policies due to several reasons such as health literacy, taboo of discussing death and lack of legal framework. Therefore, DNR is not a priority issue either for the public or government. End of life care and DNR policies must be brought in to the discussion at the public, professional and government level. It is also a time for Turkey to invest in hospice care. The Turkish Society of Internal Medicine also declared that they support Choosing Wisely®, a health initiative campaign with recommendations to advance a national dialogue on avoiding unnecessary medical tests, treatments and procedures and ‘Do not delay the palliative care’ is among the recommendations by this campaign [271]. A recent article by Currow et al [272] discusses the need for transition of hospice care and integration of cancer services with hospices care. It seems the hospice concept will be evolved through the changes in the cancer care in future years.

Now, monitoring the global situation of PC is highly essential. The burden of chronic diseases was in the agenda of UN General Assembly in 2011 and the international organisations/NGO’s started to speak more about the need for PC. Due to the increased burden of NCDs including cancers, Turkey must scale up its PC services. One important issue is the effect of the COVID-19 pandemic on cancer care including PC [273, 274]. An NCD pandemic is a high possibility in the post-COVID-19 period and a greater need of PC is expected.

The International Association for Hospice and Palliative Care re-defined PC as ‘Palliative care is the active holistic care of individuals across all ages with serious health-related suffering due to severe illness and especially of those near the end of life. It aims to improve the quality of life of patients, their families and their caregivers’ [275].

Conclusion

In conclusion, this review presents evidence of the significant progress made in Turkey during the last 20 years but also presents the opportunities for further improvement. Bridging the gaps in human resources and training, including PC care as a priority area in the national health agenda, the commitment of all stakeholders, and investing in public and professional awareness should be the focus of the next steps and also shaping the integration of PC in cancer care in Turkey. The inequity in PC must be a priority action for decision makers not only for Turkey but also globally. The stakeholders and decision makers should not neglect the need for PC improvement under the current pressure of the COVID-19 pandemic on health and the economy at a national and global level.

Conflicts of interest

The authors declare that there are no conflicts of interest.

Authors’ contributions

TK, FA, MC and MK contributed to the (I) Conception and design, (II) Administrative support, (III) Provision of study materials, (IV) Collection and assembly of data, (V) Data analysis and interpretation, (VI) Manuscript writing: All authors and (VII) Final approval of manuscript.

BA, MŞ and SY contributed to the (I) Conception and design, (III) Provision of study materials, (IV) Collection and assembly of data, (V) Data analysis and interpretation, (VI) Manuscript writing and (VII) Final approval of manuscript.

RS and RH contributed to the (I) Conception and design, (V) Data analysis and interpretation, (VI) Manuscript writing and (VII) Final approval of manuscript.

Funding

This work was supported by The UK Research and Innovation Global Challenges Research Fund (GCRF) Research for Health in Conflict in the Middle East and North Africa (R4HC-MENA) project; developing capability, partnerships and research in the Middle East and North Africa [ES/P010962/1].

References

1. United Nations (2017) Department of economic and social affairs, population division World Population Ageing 2017 – Highlights (ST/ESA/SER.A/397) (New York: United Nations)

2. Sleeman KE, de Brito M, and Etkind S, et al (2019) The escalating global burden of serious health-related suffering: projections to 2060 by world regions, age groups, and health conditions Lancet Global Health 7(7) e883–e892 https://doi.org/10.1016/S2214-109X(19)30172-X PMID: 31129125 PMCID: 6560023

3. Sleeman KE, Gomes B, and de Brito M, et al (2021) The burden of serious health-related suffering among cancer decedents: global projections study to 2060 Palliat Med 35(1) 231–235 https://doi.org/10.1177/0269216320957561 PMCID: 7797611

4. World Health Assembly 67 (2014) Strengthening of Palliative Care as a Component of Comprehensive Care Throughout the Life Course [<a href=https://apps.who.int/iris/handle/10665/162863>https://apps.who.int/iris/handle/10665/162863</a>] Date accessed: 12/12/20

5. Connor SR (2020) Global atlas of palliative care at the end of life World Palliative Care Alliance, World Health Organization Global Atlas of Palliative Care at the End of Life (London: Worldwide Palliative Care Alliance)

6. Connor SR and Sepulveda Bermedo MC (2014) Global Atlas of Palliative Care at the End of Life (London: Worldwide Palliative Care Alliance)

7. World Health Organization (2020) Accessing National Capacity for the Prevention and Control of NCDs [https://www.who.int/ncds/surveillance/ncd-capacity/en/] Date accessed: 12/12/20

8. Turkish Statistical Institution (2020) The Results of Address Based Population Registration System and Numbered 37210 [https://data.tuik.gov.tr/Bulten/Index?p=Adrese-Dayali-Nufus-Kayit-Sistemi-Sonuclari-2020-37210] Date accessed: 4/06/21

9. Directorate General of Migration Management (2020) Temporary Protection [https://en.goc.gov.tr/temporary-protection27] Date accessed: 12/12/20

10. World Health Organization, and IARC (2020) Global Health Observatory (Turkey: Globocan) [https://gco.iarc.fr/today/data/factsheets/populations/792-turkey-fact-sheets.pdf] Date accessed: 14/12/20

11. Hacettepe University Institute of Population Studies (2019) 2018 Turkey Demographic and Health Survey (Ankara: Hacettepe University Institute of Population Studies, TR Presidency of Turkey Directorate of Strategy and Budget and TÜBİTAK) [http://www.hips.hacettepe.edu.tr/eng/tdhs2018/TDHS_2018_main_report.pdf] Date accessed: 12/12/20

12. Ozgul N, Koc O, and Gultekin M, et al (2011) Opioids for cancer pain: availability, accessibility, and regulatory barriers in Turkey and Pallia-Turk project J Pediatr Hematol Oncol 33(Suppl 1) 29–32 https://doi.org/10.1097/MPH.0b013e3182121bd9

13. Ahmed F, Kirazlı M, and Sengelen M, et al (2020) Palliative care in 2020 & beyond workshop: a platform to develop palliative care advocacy in Turkey Palliat Med 35(1) 1–243

14. Arksey H and O’Malley L (2005) Scoping studies: towards a methodological framework Int J Soc Res Methodol 8 (1) 19–32 https://doi.org/10.1080/1364557032000119616

15. Erdine S (1996) Turkey: status of cancer pain and palliative care J Pain Symptom Manage 12 139–40 https://doi.org/10.1016/0885-3924(96)00084-X PMID: 8755003

16. Komurcu S (2011) Current status of palliative care in Turkey J Pediatr Hematol Oncol 33(Suppl 1) 78–80 https://doi.org/10.1097/MPH.0b013e3182122470

17. Kömürcü S (2009) Türkiye’de Palyatif Bakım (palliative care in Turkey) Türkiye’de Kanser Kontrolü (Cancer Control in Turkey) eds M Tuncer, N Özgül, and E Olcayto et al (Ankara: TC Sağlık Bakanlığı) pp 299–304

18. Hajjar RR, Atli T, and Al-Mandhari Z, et al (2013) Prevalence of aging population in the Middle East and its implications on cancer incidence and care Ann Oncol 24(Suppl 7) vii11–24 https://doi.org/10.1093/annonc/mdt268 PMID: 24001758 PMCID: 3767158

19. Bingley A, and Clark D (2009) A comparative review of palliative care development in six countries represented by the Middle East Cancer Consortium (MECC) J Pain Symptom Manage 37(3) 287–296 https://doi.org/10.1016/j.jpainsymman.2008.02.014

20. Can G (2015) The implementation and advancement of palliative care nursing in Turkey J Palliat Care Med S5 001

21. Ozcelik H, Fadiloglu C, and Karabulut B, et al (2010) Palliative care activity in the field of oncology in Turkey J Palliat Care 26(4) 305–310 https://doi.org/10.1177/082585971002600408

22. Silbermann M, Arnaout M, and Daher M, et al (2012) Palliative cancer care in Middle Eastern countries: accomplishments and challenges Ann Oncol 23(Suppl 3) 15–28 https://doi.org/10.1093/annonc/mds084 PMID: 22628412 PMCID: 3493144

23. Kabalak AA, Kahveci K, and Gokcinar D, et al (2013) Structuring of palliative care in Ankara Ulus State Hospital, Turkey;2012-2013 J Palliat Care Med 3

24. Gurhan N (2016) Palliative care: its importance and the practice in Turkey Austin Palliat Care 1(1) 1003

25. Palliative Care Association History [http://www.palyatifbakim.org.tr/tarihce.html] Date accessed: 15/01/21

26. Oğuz GT, Şenel GÖ, and Silbermann M (2016) Palliative care unit in an oncology hospital in Turkey Clin Oncol 1 1157

27. Gültekin M, Özgül N, and Olcayto E, et al (2010) Türki̇ye’de palyatif bakım hizmetlerinin mevcut durumu Turk J Gynecol Oncol 13(1) 1–6

28. Ozgul N, Gultekin M, and Koc O, et al (2012) Turkish community-based palliative care model: a unique design Ann Oncol 23(Suppl 3) 76–78 https://doi.org/10.1093/annonc/mds093 PMID: 22628421

29. Keskinkılıc B, Gultekin M, and Akarca AS, et al (2016) Turkey Cancer Control Programme (Ankara: Republic of Turkey Ministry of Health Cancer Control Department) [https://www.iccp-portal.org/system/files/plans/Turkiye_Kanser_Kontrol_Program_English.pdf] Date accessed: 4/06/21

30. Sağlık Bakanlığı Sağlık Hizmetleri Genel Müdürlüğü (2015) Sağlık Alanı Sertifikalı Eğitim Standartları: Palyatif Bakım Hemşireliği (Ankara: Turkish Ministry of Health)

31. The Official Gazette (2017) The presidency of the republic of Turkey Olağanüstü hal Kapsamında Bazı Düzenlemeler Yapılması Hakkında Kanun Hükmünde Kararname [https://www.resmigazete.gov.tr/eskiler/2017/08/20170825-13.pdf] Date accessed: 18/12/20

32. Kamu Hastaneleri Genel Müdürlüğü, and Sağlık Hizmetleri Daire Başkanlığı Evde Sağlık ve Palyatif Bakım Birimi [https://khgmsaglikhizmetleridb.saglik.gov.tr/TR,42977/evde-saglik-ve-palyatif-bakim-birimi.html] Date accessed: 18/12/20

33. Lynch T, Connor S, and Clark D (2013) Mapping levels of palliative care development: a global update J Pain Symptom Manage 45(6):1094–1106 https://doi.org/10.1016/j.jpainsymman.2012.05.011

34. Silbermann M, Fink RM, and Min SJ, et al (2015) Evaluating palliative care needs in Middle Eastern countries J Palliat Med 18(1) 18–25 https://doi.org/10.1089/jpm.2014.0194

35. Clark D, Baur N, and Clelland D, et al (2020) Mapping levels of palliative care development in 198 countries: the situation in 2017 J Pain Symptom Manage 59(4) 794–807 https://doi.org/10.1016/j.jpainsymman.2019.11.009 PMCID: 7105817

36. The Official Gazette (1998) The Prime Minister’s Office of the Republic of Turkey Patient Rights Regulation pp 67 [https://www.resmigazete.gov.tr/arsiv/23420.pdf] Date accessed: 18/12/20

37. The Official Gazette (2005) The Presidency of the Republic of Turkey Regulation on Home Care Services Provision [https://www.resmigazete.gov.tr/eskiler/2005/03/20050310-5.htm] Date accessed: 18/12/20

38. Ministry of Health Directive (2010) The Directive on Application of Procedures and Principles of Home Health Services Provided by The Ministry of Health (Ministry of Health Directive) [https://www.memurlar.net/haber/159492/saglik-bakanliginca-sunulan-evde-saglik-hizmetlerinin-uygulama-usul-ve-esaslari-hakkinda-yonerge.html] Date accessed: 18/12/20

39. Ministry of Health Directive (2015) The Directive on The Application Procedures and Principles of Palliative Care Services (Ministry of Health Directive) [https://khgmsaglikhizmetleridb.saglik.gov.tr/Eklenti/2817/0/palyatif-bakim-hizmetleri-yonergesipdf.pdf] Date accessed: 18/12/20

40. The Official Gazette (2014) The Presidency of the Republic of Turkey. The notification for amending the Social Security Institution Healthcare Implementation [https://resmigazete.gov.tr/fihrist?tarih=2014-12-24] Date accessed: 18/12/20

41. The Official Gazette (2015) The presidency of the republic of Turkey Regulation on Home Care Services Provision by the Ministry of Health and its Affiliates [https://www.resmigazete.gov.tr/eskiler/2015/02/20150227-14.htm] Date accessed: 18/12/20

42. Anatolian Agency (2014) The Morphine Tablet of Turkey was Licensed [https://www.aa.com.tr/tr/saglik/ilk-yerli-morfin-tablet-ruhsat-aldi/92033] Date accessed: 18/12/20

43. Hacikamiloglu E, Utku ES, and Cukurova Z, et al (2016) Community palliative care in Turkey: a collaborative promoter to a new concept in the Middle East J Public Health Manag Pract 22(1) 81–8 https://doi.org/10.1097/PHH.0000000000000252

44. Utku ES, Hacikamiloglu E, and Gultekin M, et al (2017) Chapter 19: Experience associated with the developing nationwide palliative care services in the community: what can one learn from it for the future? Palliative Care: Perspectives, Practices and Impact on Quality of Life. A Global View ed M Silbermann vol. 1 pp 287–294 (New York: Nova Science Pub Inc)

45. The Official Gazette (2011) The presidency of the republic of Turke Regulatıon on Ege University Palliative Care Research and Application Center [https://www.resmigazete.gov.tr/eskiler/2011/04/20110414-22.htm] Date accessed: 18/12/20

46. Kinay M (2011) Capacity building on new palliative care services J Pediatr Hematol Oncol 33 https://doi.org/10.1097/MPH.0b013e31821283e0 PMID: 21448045

47. Isıkhan V (2017) The place and future of social work in palliative care services in Turkey: state of the art Soc Work Public Health 32(3) 192–201 https://doi.org/10.1080/19371918.2016.1230080

48. Palliative Care Nurses Association [https://www.palhemder.org/hakkimizda] Date accessed: 15/01/21

49. Benli AR and Erbesler ZA (2016) Differences on comprehension and practice in palliative care in Turkey Turk J Fam Pract 20(1) 5–6 https://doi.org/10.15511/tahd.15.21605

50. Alkan A, Özgül S, and Mızrak D, et al (2015) Kanser hastasında ağrı yönetimi. 21st National Cancer Congress (Antalya, 22–26 April 2015)

51. Mutafoğlu K, Çetinayak O, and Güzelöz Çapar Z, et al (2011) Onkoloji doktorları kanserde palyatif bakım koşulları hakkında ne düşünüyorlar? 19th National Cancer Congress (Antalya, 20–24 April 2011)

52. Elcigil A (2011) The current status of palliative care in Turkey: a nurse’s perspective J Pediatr Hematol Oncol 33(Suppl. 1) S70–S72 https://doi.org/10.1097/MPH.0b013e318212244a PMID: 21448043

53. Terzioğlu F, Uslu Şahan F, and Boztepe H (2015) Palliative care to the cancer patient: Turkish nurses’ perspectives J Palliat Care Med S5 004 https://doi.org/10.4172/2165-7386.1000S5004

54. Akgün Kostak M, and Akan M (2011) Palliative care for children in terminal period Turk J Oncol 26(4) 182–192 https://doi.org/10.5505/tjoncol.2011.439

55. Elcigil A (2012) Palyatif bakım hemşireliği Gulhane Med J 54 329–334 https://doi.org/10.5455/gulhane.30582

56. Okçin F (2019) Onkoloji palyatif bakım hemşirelerinin mesleki yaşam deneyimlerinin incelenmesi Manisa Celal Bayar Univ J Inst Health Sci 6(4) 234–246

57. Uğur Ö, Mert H, and Bektaş M, et al (2015) Bı̇r ünı̇versı̇te hastanesı̇nde çalışan hemşı̇relerı̇n palyatı̇f bakım ve uygulama engellerı̇ne yönelı̇k algılarının ı̇ncelenmesi 21st National Cancer Congress (Antalya, 22–26 April 2015)

58. Emuk Y, and Naz I (2017) The current situation of palliative care in Turkey J Cancer Policy 13 33–337 https://doi.org/10.1016/j.jcpo.2017.07.001

59. Eyigor S, and Akdeniz S (2014) Is exercise ignored in palliative cancer patients? World J Clin Oncol 5(3) 554–559 https://doi.org/10.5306/wjco.v5.i3.554 PMID: 25114869 PMCID: 4127625

60. Eyigor S (2010) Physical activity and rehabilitation programs should be recommended on palliative care for patients with cancer J Palliat Med 13(10) 1183–1184 https://doi.org/10.1089/jpm.2010.0064 PMID: 20942758

61. Keser I, Özdemir K, and Ertürk B, et al (2017) Kanser hastalarına yönelik onkolojik fizyoterapi ve rehabilitasyon ünitesinde sunulan hizmetlerin analizi J Gazi Univ Health Sci Inst 2(1) 18–27

62. Vardar Yağlı N, Şener G, and Arıkan H, et al (2015) Do yoga and aerobic exercise training have impact on functional capacity, fatigue, peripheral muscle strength and quality of life in breast cancer survivors? Integr Cancer Ther 14(2) 125–132 https://doi.org/10.1177/1534735414565699

63. Saruç S (2013) The role of the social worker and social work standards in palliative and end of life care J Soc Soc Work 24(2) 193–207

64. Kafadar D, Ince N, and Akcakaya A, et al (2015) Evaluation of managerial needs for palliative care centers: perspectives of medical directors Asian Pac J Cancer Prev 16(11) 4653–4658 https://doi.org/10.7314/APJCP.2015.16.11.4653 PMID: 26107219

65. Güngör Tavşanlı N, Çeçen D, and Tayhan E, et al (2016) Kanser hastalarına bakım verenlerin hastalara karşı duygu ve tutumları Manisa Celal Bayar Univ J Inst Health Sci 3(4) 470–475

66. Yılmaz F, and Atay S (2014) Clinical pain management of nursing students J Hacettepe Univ Fac Nurs 1(2) 32–41

67. Sahin E, Guvenc G, and Bagcivan G, et al (2017) What are Turkish nursing students thoughts about palliative care? Support Care Cancer 21–266

68. Cetintas I, Akgun Kostak M, and Semerci R, et al (2018) Death anxiety and attitudes toward the principles of dying with dignity of nursing students who practicing in pediatric oncology clinic Support Care Cancer 26(Suppl 2) 39–364

69. Ay F, and Gençtürk N (2013) Midwifery student’s opinions related to death, terminal period and palliative care: focus group Florence Nightingale Hemşirelik Derg 21(3) 164–171

70. Yildirim YK, Cicek F, and Uyar M (2008) Knowledge and attitudes of Turkish oncology nurses about cancer pain management Pain Manag Nurs 9(1) 17–25 https://doi.org/10.1016/j.pmn.2007.09.002 PMID: 18313586

71. Akelma H, and Platin B (2018) Sağlık bı̇lı̇mlerı̇ gazı̇ yaşargı̇l eğı̇tı̇m araştırma hastanesı̇ sağlık personelinin palyatı̇f bakıma ı̇lı̇şkı̇n görüşleri Palliative Care and Hospice Congress (İstanbul, 9–11 March 2018)

72. Dokuyucu A, Ekinci O, and Yılmaz Akyüz E, et al (2018) Hastanemı̇z sağlık çalışanlarının palyatı̇f bakım bı̇lgı̇ düzeylerı̇nı̇n ölçülmesi Palliative Care and Hospice Congress (İstanbul, 9–11 March 2018)

73. Eyigor S (2013) Fifth-year medical students’ knowledge of palliative care and their views on the subject J Palliat Med 16(8) 941–946 https://doi.org/10.1089/jpm.2012.0627 PMID: 23786426

74. Oktay E, Levent M, and Gelincik H, et al (2020) Perspective of Turkish medicine students on cancer, cancer treatments, palliative care, and oncologists (ARES Study): a study of the palliative care working committee of the Turkish Oncology Group (TOG) J Cancer Educ 35(1) 69–75 https://doi.org/10.1007/s13187-018-1441-6

75. Akdeniz Kudubes A, and Bektas M (2020) The effect of web-based pediatric palliative care education on the palliative care knowledge level and practices of nursing students Perspect Psychiatr Care 56(3) 533–540

76. Turgay G, and Kav S (2012) Turkish healthcare professionals’ views on palliative care J Palliat Care 28(4) 267–273 https://doi.org/10.1177/082585971202800405

77. Peker L, Celebi N, and Canbay Ö, et al (2008) Doctors’ opinions, knowledge and attitudes towards cancer pain management in a university hospital Agri 20(2) 20–30 PMID: 19021007

78. Bağtatlı Aydın H, and Eşer I (2010) Comparison of the pain assessment of the nurses and cancer patients J Ege Univ Nurs Fac 26(1) 11–23

79. Uslu-Sahan F, and Terzioglu F (2017) Nurses’ knowledge and practice toward gynecologic oncology palliative care J Palliat Care Med 7(4) 1–6 https://doi.org/10.4172/2165-7386.1000315

80. Polat U, and Karatas T (2018) Nursing students’ knowledge of palliative care at a university in Turkey Res Theory Nurs Pract 32(3) 276–295 https://doi.org/10.1891/1541-6577.32.3.276 PMID: 30567839

81. Tanriverdi O, Yavuzsen T, and Akman T, et al (2015) The Perspective of non-oncologist physicians on patients with metastatic cancer and palliative care (ALONE Study): a study of the palliative care working cmmittee of the Turkish oncology group (TOG) J Cancer Educ 30(2) 253–259 https://doi.org/10.1007/s13187-015-0794-3 PMID: 25631655

82. Demirgil M (2019) Ethical Sensitivity of Emergency Service Employees and Their Thoughts About and Knowledge Levels Concerning Palliative Care [Dissertation] (Tokat:Gaziosmanpaşa University)

83. Çakıcı NI (2010) Palliative Care Practice of Physicians and Nurses for the Children with Cancer [Dissertation] (Istanbul: Marmara University)

84. Akyar I, Dionne-Odom JN, and Ozcan M, et al (2019) Needs assessment for Turkish family caregivers of older persons with cancer: first-phase results of adapting an early palliative care model J Palliat Med 22(9) 1065–1074 https://doi.org/10.1089/jpm.2018.0643 PMID: 30969144 PMCID: 7364320

85. Dincer M, Kahveci K, and Doger C (2018) An examination of factors affecting the length of stay in a palliative care center J Palliat Med 21(1) 11–15 https://doi.org/10.1089/jpm.2017.0147

86. Sarıcam G, Kahvecı K, and Akdogan D (2019) Prevalence of neurological symptoms in palliative care cancer patients: a retrospective study Neurol Asia 24(4) 333–341

87. Tertemiz OF, and Tuyluoglu E (2020) Are signs of burnout and stress in palliative care workers different from other clinic workers? Agri 32(2) 79–84 PMID: 32297959

88. Ben-Arye E, Schiff E, and Mutafoglu K, et al (2015) Integration of complementary medicine in supportive cancer care: survey of health-care providers’ perspectives from 16 countries in the Middle East Support Care Cancer 23(9) 2605–2612 https://doi.org/10.1007/s00520-015-2619-7 PMID: 25617072

89. Kucukoner M, Bilge Z, and Isikdogan A, et al (2012) Complementary and alternative medicine usage in cancer patients in southeast of Turkey Afr J Tradit Complement Altern Med 10(1) 21–25 https://doi.org/10.4314/ajtcam.v10i1.4 PMID: 24082321 PMCID: 3746353

90. Irmak Z, Tanriverdi O, and Odemis H, et al (2019) Use of complementary and alternative medicine and quality of life of cancer patients who received chemotherapy in Turkey Complement Ther Med 44 143–150 https://doi.org/10.1016/j.ctim.2019.04.008 PMID: 31126547

91. Düzgün G (2020) Effect of Music on Patients with Pain in Palliative Care Service: A Randomized Controlled Study [Dissertation] (Izmir: Ege University)

92. Guzelant A, Goksel T, and Ozkok S, et al (2004) The European Organization for research and treatment of cancer QLQ-C30: an examination into the cultural validity and reliability of the Turkish version of the EORTC QLQ-C30 Eur J Cancer Care 13(2) 135–144 https://doi.org/10.1111/j.1365-2354.2003.00435.x

93. Soylu C, Babacan T, and Sever AR, et al (2016) Patients’ understanding of treatment goals and disease course and their relationship with optimism, hope, and quality of life: a preliminary study among advanced breast cancer outpatients before receiving palliative treatment Support Care Cancer 24(8) 3481–3488 https://doi.org/10.1007/s00520-016-3182-6 PMID: 27003902

94. Usta Yeşilbakan Ö, Özkütük N, and Karadakovan A, et al (2008) Validity and reliability of the edmonton symptom assessment scale in Turkish cancer patients Turk J Cancer 38(2)

95. Süren M Oİ, Kaya Z, and Karaman S, et al (2016) Initial experience with delivery of palliative care to terminal cancer patients Turk J Med Sci 46 388–392 https://doi.org/10.3906/sag-1411-38

96. Bülbül Y ÖT, Arınç S, and Özyürek BA, et al (2018) Sleep disturbances in patients with lung cancer in Turkey Tuber Thorax 66 297–303 https://doi.org/10.5578/tt.67689

97. Topkaya O (2019) Palliative care requirements of cancer patients and investigation of knowledge and expectations related to palliative care of the patients and their families Ann Oncol 30(Suppl 5) 822–823 https://doi.org/10.1093/annonc/mdz273.003

98. Bagcivan G, Tosun N, and Komurcu S, et al (2009) Analysis of patient-related barriers in cancer pain management in Turkish patients J Pain Symptom Manage 38(5) 727–737 https://doi.org/10.1016/j.jpainsymman.2009.03.004 PMID: 19692202

99. Yildirim Y, Tokem Y, and Bozkurt N, et al (2011) Reliability and validity of the Turkish version of the memorial symptom assessment scale in cancer patients Asian Pac J Cancer Prev 12(12) 3389–3396 PMID: 22471486

100. Ozalp GS, Uysal N, and Oguz G, et al (2017) Identification of symptom clusters in cancer patients at palliative care clinic Asia Pac J Oncol Nurs 4(3) 259–264 https://doi.org/10.4103/apjon.apjon_17_17 PMID: 28695173 PMCID: 5473098

101. Sahin ZA, Tan M, and Polat H (2013) Hopelessness, depression and social support with end of life Turkish cancer patients Asian Pac J Cancer Prev 14(5) 2823–2828 https://doi.org/10.7314/APJCP.2013.14.5.2823 PMID: 23803038

102. Tanriverdi O, Yavuzsen T, and Turhal S, et al (2016) Depression and socio-economical burden are more common in primary caregivers of patients who are not aware of their cancer: TURQUOISE study by the palliative care working committee of the Turkish oncology group (TOG) Eur J Cancer Care (Engl) 25(3) 502–515 https://doi.org/10.1111/ecc.12315

103. Sahin ZA, and Tan M (2012) Loneliness, depression, and social support of patients with cancer and their caregivers Clin J Oncol Nurs 16(2) 145–149 https://doi.org/10.1188/12.CJON.145-149 PMID: 22459523

104. Ciraci Y, Nural N, and Salturk Z (2016) Loneliness of oncology patients at the end of life Support Care Cancer 24(8) 3525–3531 https://doi.org/10.1007/s00520-016-3159-5 PMID: 27007284

105. Yuceege M, Sanisoglu B, and Firat H, et al (2015) The clinical utility of memorial symptom assessment-short form and condensed memorial symptom assessment scale in Turkish lung cancer patients Clin Respir J 9(2) 221–227 https://doi.org/10.1111/crj.12127 PMID: 25849299

106. Ozcelik H, Cakmak DE, and Fadiloglu C, et al (2015) Determining the satisfaction levels of the family members of patients with advanced-stage cancer Palliat Support Care 13(3) 741–747 https://doi.org/10.1017/S1478951514000534

107. Ozcelik H, Guzel Y, and Sonmez E, et al (2016) Reliability and validity of the Turkish version of the EORTC QLQ-C15-PAL for patients with advanced cancer Palliat Support Care 14(6) 628–634 https://doi.org/10.1017/S1478951516000195 PMID: 27068607

108. Seven M, Sahin E, and Yilmaz S, et al (2016) Palliative care needs of patients with gynecologic cancer J Clin Nurs 25 https://doi.org/10.1111/jocn.13280

109. Alkan A, Guc ZG, and Senler FC, et al (2016) Breast cancer survivors suffer from persistent postmastectomy pain syndrome and posttraumatic stress disorder (ORTHUS study): a study of the palliative care working committee of the Turkish oncology group (TOG) Support Care Cancer 24(9) 3747–3755 https://doi.org/10.1007/s00520-016-3202-6 PMID: 27039206

110. Iyigun E, Tastan S, and Gezginci E, et al (2017) Cross-cultural adaptation and psychometric evaluation of the Turkish version of the cancer behavior inventory-brief version J Pain Symptom Manage 54(6) 929–935 https://doi.org/10.1016/j.jpainsymman.2017.08.006 PMID: 28807698

111. Senel G, Uysal N, and Oguz G, et al (2017) Delirium frequency and risk factors among patients with cancer in palliative care unit Am J Hosp Palliat Care 34(3) 282–286 https://doi.org/10.1177/1049909115624703

112. Bagcivan G, Bredle J, and Bakitas M, et al (2019) Reliability and validity of the Turkish version of the FACIT-PAL quality of life instrument J Pain Symptom Manage 58(2) 297–305 https://doi.org/10.1016/j.jpainsymman.2019.04.020 PMID: 31096004

113. Yildiz Celtek N, Suren M, and Demir O, et al (2019) Karnofsky performance scale validity and reliability of Turkish palliative cancer patients Turk J Med Sci 49(3) 894–898 https://doi.org/10.3906/sag-1810-44 PMID: 31192546 PMCID: 7018389

114. Kocatepe V, Kayikci EE, and Saygili U, et al (2020) The palliative care outcome scale: Turkish validity and reliability study Asia Pac J Oncol Nurs 7(2) 196–202 https://doi.org/10.4103/apjon.apjon_51_19 PMID: 32478138 PMCID: 7233559

115. Dincer M, Torun N, and Aksakal H (2018) Determining nurses’ perceptions of patient safety culture in palliative care centres Contemp Nurse 54(3) 246–257 https://doi.org/10.1080/10376178.2018.1492350 PMID: 29966495

116. Ozcelik H, Fadiloglu C, and Karabulut B, et al (2014) Examining the effect of the case management model on patient results in the palliative care of patients with cancer Am J Hosp Palliat Care 31(6) 655–664 https://doi.org/10.1177/1049909113506980

117. Uysal N, Senel G, and Karaca S, et al (2015) Symptoms seen in inpatient palliative care and impact of palliative care unit on symptom control Agri 27(2) 104–110 PMID: 25944137

118. Eskigulek Y, and Kav S (2019) Opinions of palliative care patients and nurses regarding dignified care Ann Oncol 30(Suppl 5) 822–824 https://doi.org/10.1093/annonc/mdz273

119. Gültaş C, and Yılmaz M (2017) Challenges experienced by and quality of life of relatives of cancer patients requiring palliative care at home Turk J Oncol 32(2) 55–62

120. Cleary J, Silbermann M, and Scholten W, et al (2013) Formulary availability and regulatory barriers to accessibility of opioids for cancer pain in the Middle East: a report from the global opioid policy initiative (GOPI) Ann Oncol 24(Suppl 11) 51–59 https://doi.org/10.1093/annonc/mdt503

121. Silbermann M (2010) Opioids in middle eastern populations Asian Pac J Cancer Prev 11 1–6 PMID: 20590340

122. Vranken MJ, Lisman JA, and Mantel-Teeuwisse AK, et al (2016) Barriers to access to opioid medicines: a review of national legislation and regulations of 11 central and eastern European countries Lancet Oncol 17(1) e13–e22 https://doi.org/10.1016/S1470-2045(15)00365-4 PMID: 26758755

123. Senel G, Oguz G, and Kocak N, et al (2016) Opioid use and the management of cancer patient pain in palliative care clinic Agri 28(4) 171–176

124. Can H, Pamuk G, and Bilyay Hİ, et al (2017) Narcotic analgesic use of hospitalized patients with lung cancer in palliative care service Fam Pract Palliat Care 1(3) 61–64

125. Kurşun YZ, Yıldız F, and Kaymaz Ö, et al (2015) Analgesic step ladder treatment in cancer patients with pain Agri 27(1) 26–34 https://doi.org/10.5505/agri.2015.08216

126. Orhan ME, Bilgin F, and Ergin A, et al (2008) Pain treatment practice according to the WHO analgesic ladder in cancer patients: eight years experience of a single center Agri 20(4) 38–44

127. Bilen A, Ali A, and Baturay F, et al (2010) Breakthrough pain frequency in cancer patients and the efficiency of oral transmucosal fentanyl citrate Agri 22(3) 103–108 PMID: 20865581

128. Taçyıldız N, Ünal E, and Dinçaslan H, et al (2018) Ankara Üniversitesi Tıp Fakültesi çocuk onkoloji bölümünde 2016–2018 yıllarında izlenen son dönem kanser hastalarında ağrı yönetimi TPOG National Childhood Cancer Congress (Antalya, 2–6 May 2018)

129. Çolak D, Oguz A, and Yazilitas D, et al (2013) The attitudes of cancer patients about morphine usage for pain management Support Care Cancer 21(Suppl 1) S2-301

130. Görgün G, Aslan F, and Ünal Z, et al (2009) Metastatik kanserli hastalarda ağrı değerlendirmesi ve palyasyonu 18th National Cancer Congress (Antalya, 21–26 April 2009)

131. Urlu S, Yücel A, and Yanar A, et al (2009) Onkoloji hastalarında girişimsel ağrı tedavisi 18th National Cancer Congress (Antalya, 21–26 April 2009)

132. Koyuncu İ, and Aksu M (2009) Terminal dönemdeki ağrılı kanser hastalarına uygulanan morfin sülfat infüzyonunun ağrı düzeyine etkisi 18th National Cancer Congress (Antalya, 21–26 April 2009)

133. Centeno C, Clark D, and Lynch T, et al (2007) Facts and indicators on palliative care development in 52 countries of the WHO European region: results of an EAPC Task Force Palliat Med 21(6) 463–471 https://doi.org/10.1177/0269216307081942 PMID: 17846085

134. Mutafoglu K, and Group DEUPCS (2011) A palliative care initiative in Dokuz Eylul University Hospital J Pediatr Hematol Oncol 33(Suppl 1) S73–S76 https://doi.org/10.1097/MPH.0b013e318212245d PMID: 21448044

135. Mojen LK, Rassouli M, and Eshghi P, et al (2017) Palliative care for children with cancer in the Middle East: a comparative study Indian J Palliat Care 23(4) 379–386 https://doi.org/10.4103/IJPC.IJPC_69_17 PMID: 29123342 PMCID: 5661338

136. Arias-Casais N, Garralda E, and Pons JJ, et al (2020) Mapping pediatric palliative care development in the WHO-European region: children living in low-to-middle-income countries are less likely to access it J Pain Symptom Manage 60(4) 746–753 https://doi.org/10.1016/j.jpainsymman.2020.04.028 PMID: 32437945

137. Koçatakan P (2020) Current status of the palliative care in Turkey R4HC Workshop on Palliative Care in 2020 & Beyond (Ankara, 27–28 February 2020)

138. Işık O, Kandemir A, and Erişen MA, et al (2016) Evde sağlık hizmeti alan hastaların profili ve sunulan hizmetin değerlendirilmesi Hacettepe Sağlık İdaresi Derg 19(2) 171–186

139. Ozdemir T, Ozdilekcan C, and Goksel F (2019) The contribution of hospital-based home health services in pulmonary diseases: current practice in Turkey Medicine (Baltimore) 98(48) e18032 https://doi.org/10.1097/MD.0000000000018032

140. Göksel F, and Doğan L (2019) Türkiyede gastrointestinal sistem kanseri olan hastalarda evde sağlık hizmetlerinin gelişimi 23rd National Cancer Congress (Antalya, 17–21 April 2019)

141. Benli AR, and Sunay D (2017) A model of collaboration between palliative care unit and home health care services: Karabük Ankara Med J 17(3) 153–150 https://doi.org/10.17098/amj.277493

142. Pilatin B, and Araç E (2018) Diyarbakır ili palyatif bakım biriminde yatan hastaların retrospektif analizi Palliative Care and Hospice Congress (İstanbul, 9–11 March 2018)

143. Toprak SF, and Pilatin B (2018) Sağlık bilimlerı̇ unıversitesı̇ Gazı̇ Yaşargil eğitim ve araştırma hastanesı̇ palyatif bakım biriminde yatan hastaların retrospektif analizi Palliative Care and Hospice Congress (İstanbul, 9–11 March 2018)

144. Ekinci O, Keleş Z, and Düzgün Keskin M, et al (2018) Palyatı̇f bakım merkezimizin hasta profili Palliative Care and Hospice Congress (İstanbul, 9–11 March 2018)

145. Sezer M, Üskent N, and Onat H (2010) 2008-2009 yıllarında merkezimizde yatarak tedavı̇ gören hastaların özellikleri TTOK: 3rd Turkish Society of Medical Oncology Congress (Antalya, 24–28 March 2010)

146. Balyılmaz H, Karayağız Muslu G, and et al (2009) Parental views regarding symptoms in children with cancer and recognition of cancer-related fatigue Turk J Oncol 24(3) 122–127

147. Dayanç I, Çakır B, and Moral A, et al (2015) Kemoterapi sonrasında taburcu edilen telefon ile danışmanlık hizmeti almak için arayan hastaların bildirdikleri semptomların ve sorunların analizi 21st National Cancer Congress (Antalya, 22–26 April 2015)

148. Yavuzşen T, Arslan D, and Çehreli R, et al (2011) Ayaktan kemoterapi alan hastalarda semptom sıklığı 19th National Cancer Congress (Antalya, 20–24 April 2011)

149. Topaloğlu N, Çelik Onur S, and Doğan S, et al (2011) Kanser ağrısına sahip hastalarda ağrı kontrolünü etkileyen faktörler 19th National Cancer Congress (Antalya, 20–24 April 2011)

150. Tapar H, Yıldız Çeltek N, and Süren M (2018) Kolon kanserlı̇ hastalarda nöropatı̇k ağrı sıklığı Palliative Care and Hospice Congress (İstanbul, 9–11 March 2018)

151. Özsoy Z, Okan İ, and Daldal E, et al (2018) Palyatif cerrahi uygulamalarımız: 75 hastanın değerlendirilmesi Palliative Care and Hospice Congress (İstanbul, 9–11 March 2018)

152. Kuşçu A, Topkaya Ö, and Yanar A, et al (2014) Asit palyasyonu uygulanan onkolojı̇ hastalarında tedavı̇ ve hemşirelik bakımı TTOK: 5th Turkish Society of Medical Oncology Congress (Antalya, 19–23 March 2014)

153. Bagcivan G, Bakitas M, and Palmore J, et al (2017) Symptom experience of patients with cancer presenting to an academic outpatient palliative / supportive care clinic Support Care Cancer 21–266

154. Yıldız Savran F, and Semerci R, et al (2017) Kanser tanısı ile izlenen çocuklarda semptom kümelemesi 22nd National Cancer Congress (Antalya, 19–23 April 2017)

155. Sögütlü Çetin M, and Kuran Akburak İ (2017) İstanbul Üniversitesi Onkoloji Enstitüsü’nde kemoterapi alan hastaların semptomlarının değerlendirilmesi 22nd National Cancer Congress (Antalya, 19–23 April 2017)

156. Kuşçu A, Topkaya Ö, and Erbay Ç (2015) Malignite tanısı alıp küratif tedavı̇ planı olan hastaların yatış endikasyonları ve hemşirelik bakımı 21st National Cancer Congress (Antalya, 22–26 April 2015)

157. Özçelik H, Güzel Y, and Fadıloğlu Ç, et al (2013) İlerı̇ evre kanser hastalarının semptom dağılımları ve etkı̇leyen faktörlerin belirlenmesi 20th National Cancer Congress (Antalya, 19–23 April 2013)

158. Özçelik H, Çakmak DE, and Fadıloğlu Ç, et al (2013) İleri evre kanser hastasinin aile memnuniyet düzeylerinin belirlenmesi 20th National Cancer Congress (Antalya, 19–23 April 2013)

159. Demirkaya M, Özdemir R, and Güler S, et al (2013) Pediatrik onkolojı̇ hastalarının ağrı deneyimlerinin değerlendirilmesi 20th National Cancer Congress (Antalya, 19–23 April 2013)

160. Çakır FB, and Uzuner S (2017) Kanserli çocuk hastalarda bir palyatif bakım olarak nazogastrik tüple beslenme 22nd National Cancer Congress (Antalya, 19–23 April 2017y)

161. Topkaya Ö, Kuşçu A, and Sezer M, et al (2016) Malignite tanısı ıie exitus olan hastaların semptom değerlendirmesı TTOK: 6th Turkish Society of Medical Oncology Congress (Antalya, 23–27 March 2016)

162. Kılıçkap S, Hayran M, and Erman M, et al (2010) Kanser hastalarında yaşam kalitesı̇ ı̇le hastalığın klinikopatolojı̇k özelliklerı̇ arasındakı̇ ilı̇şkinin değerlendirilmesi TTOK: 3rd Turkish Society of Medical Oncology Congress (Antalya, 24–28 March 2010)

163. Kılıçkap S, Hayran M, and Yüce D, et al (2012) Kanser hastalarında tanı anındakı̇ yaşam kalitesı̇ genel sağkalımı etkiliyor mu? TTOK: 4th Turkish Society of Medical Oncology Congress (Antalya, 21–25 May 2012)

164. Bagcivan G, Akbayrak N, and Cinar FI, et al (2011) Evaluation of the relationship between level of nursing care satisfaction and symptom experience due to chemotherapy in cancer patients Support Care Cancer 19(Suppl 2) S67–S370

165. Erol O, Unsar S, and Yacan L, et al (2015) Pain experiences of patients with cancer: a phenomenological study Support Care Cancer 23(Suppl 1) 1–388

166. Koç Z, Kiymaz D, and Saglam Z (2015) Determining the fatigue level and the affecting factors in oncologic patients Support Care Cancer 23(Suppl 1) 1–388

167. Seven M, Akyüz A, and Sever N, et al (2012) Palliative care needs of patients with cancer Support Care Cancer 20(Suppl 1) 1–283

168. Gok Metin Z, Izgu N, and Karadas C, et al (2019) Mindfulness meditation and progressive muscle relaxation for breast cancer patients receiving adjuvant Paclitaxel regimen: a randomized controlled trial Support Care Cancer 1–302

169. Genç F, Köçkar Ç, and Mutlu F, et al (2018) Non-pharmacological methods for the pain management of cancer patients J Educ Res Nurs 15(2) 88

170. Arslan M, Albaş S, and Küçükerdem HS, et al (2016) The evaluation of the effectiveness of palliative pain management in cancer patients with visual analogue scale Fam Pract Palliat Care 1(1) 5–8

171. Avcı D, and Çetinkaya A (2019) The impact of nutritional status on the outcomes of cancer patients such as mortality, survey and length of hospitalization in palliative care Eur Res J 5(2) 375–381

172. Gelin D, and Ulus B (2015) The life quality of the patients receiving chemotherapy in the hospital and the influencing factors ACU Sağlık Bil Derg 6(1) 31–35

173. Usta Yeşilbakan Ö, Durmaz Akyol A, and Çetinkaya Y, et al (2005) Studying the symptoms that are beıng experienced due to treatment by the patients who receive chemotheraphy and their effects on the quality of life J Ege Univ Nurs Fac 21(1) 13–31

174. Çivi S, Kutlu R, and Çelik HH (2011) Depression status and the factors affecting the quality of life in the relatives of the patients with cancer Gulhane Med J 53(4) 248–253

175. Palalı F, Karaman N, and Şahin S, et al (2018) Çocuk hematoloji-onkoloji klinı̇ğinde yatarak tedavı̇ gören hastalarda ağrının değerlendirilmesı̇ ve yaşam kalitesı̇ne etkisı̇ TPOG National Childhood Cancer Congress (Antalya, 2–6 May 2018)

176. Savran F, Semerci R, and Akgün Kostak M, et al (2018) Kanserlı̇ çocukların yaşam kalitelerı̇ ile annelerin sağlık bakım memnuniyetlerı̇ arasındakı̇ ilı̇şki TPOG National Childhood Cancer Congress (Antalya, 2–6 May 2018)

177. Kutlutürkan S, Sözeri E, and Bay F (2013) Kanser hastalarının kemoterapı̇ye bağlı gelı̇şen sorunlara ilişkin yaptıkları uygulamalar ve yaşam kalitesı̇ne etkisi 20th National Cancer Congress (Antalya, 19–23 April 2013)

178. Karciga F, and Oflaz F (2018) Metastatik kanserlı̇ çocukların anne ve babalarının çocuklarının yaşam kalitesı̇ algılarının ve anksiyete düzeylerinin incelenmesi Palliative Care and Hospice Congress (İstanbul, 9–11 March 2018)

179. Eren MF, Börklü Doğan Ö and Şimşek E, et al (2016) Palyatif destek gerektiren kanser hastalarında evde bakım ve değerlendirmenin yatış sıklığı ve bakım kalitesı̇ne etkisi TTOK: 6th Turkish Society of Medical Oncology Congress (Antalya, 23–27 March 2016)

180. Yavas C, Zorlu F and Ozyigit G, et al (2011) Quality of life in patients with malignant glioma: a prospective study in Turkish population Support Care Cancer 19(Suppl 2) S67–S370

181. Koç Z, Kiymaz D and Saglam Z (2013) The determination of life quality and satisfaction and pain perception in cancer patients Support Care Cancer 21(Suppl 1) S2–S301

182. Bİlgin Ö, Özdemir D and Saçkan F, et al (2020) Evaluation of care dependence levels of inpatients in nephrology and oncology J Gen Health Sci 2(1) 14–23

183. Tosun B, Aslan Ö and Yaranoğlu C et al (2017) Palyatif bakım alan akciğer kanserli hastalarının beslenme deneyimleri ve bakım vericilerinin yaşadıkları güçlükler 22nd National Cancer Congress (Antalya, 19–23 April 2017)

184. Almaca B, Gökçen S and Kılınç M, et al (2019) Palyatif destek amacıyla onkoloji servisine yatırılan kanser hastalarında enteral ve parenteral beslenmenin klinik sonuçlara etkisi 23rd National Cancer Congress (Antalya, 17–21 April 2019)

185. Özdemir Ü and Taşçı S (2017) Kanserli yaşlı bireylerde akupresin kanserle ilişkili yorgunluğa etkisi 22nd National Cancer Congress (Antalya, 19–23 April 2017)

186. Şen D, Yüntem A and Akbal E, et al (2017) Refleksoloji uygulamasının ağrı, anksiyete ve bulantı üzerine etkisi 22nd National Cancer Congress (Antalya, 19–23 April 2017)

187. Yildiz A, Ozdemir O and Atik A, et al (2015) The effect of individual physiotherapy and rehabilitation training program on lymphedema in patients with mastectomy Support Care Cancer23(Suppl 1) 1–388

188. Kırsever E, Kızıltan HŞ and Yilmaz R, et al (2018) Metastatı̇k kanser hastalarında palyatı̇f bı̇yorezonans tedavı̇si Palliative Care and Hospice Congress (Istanbul, 9–11 March 2018)

189. Yıldırım S and Gürkan A (2007) The influence of music on anxiety and the side effects of chemotherapy Anatolian J Psychiatry 8 37–35

190. Çınkır HY and Kahraman A (2017) Retrospective analysis of patients followed at Van Training and Research Hospital palliative care unit Eastern J Med 22 172–175 https://doi.org/10.5505/ejm.2017.92005

191. Ozcelik H, Fadiloglu C and Karabulut B, et al (2014) Case management based multidisciplinary care protocol in the palliative care of cancer patients Agri 26(2) 47–56 https://doi.org/10.5505/agri.2014.93585

192. Erkal KH, Yüce Y and Geyik FD, et al (2018) Üçüncü basamak yoğun bakım ünitesinde tedavı̇ edilen palyatif bakım hastalarının değerlendirilmesı̇ Palliative Care and Hospice Congress (Istanbul, 9–11 March 2018)

193. Karaoren G, Akbas S and Ocak Serin S, et al (2016) Hospice units as a requirement for terminal stage patients in need of intensive care in Turkey Int J Clin Exp Med 9 14907–14912

194. Tanriverdi O, Beydilli H and Yildirim B, et al (2014) Single center experience on causes of cancer patients visiting the emergency department in southwest Turkey Asian Pac J Cancer Prev 15(2) 687–690 https://doi.org/10.7314/APJCP.2014.15.2.687 PMID: 24568479

195. Yildirim B and Tanriverdi O (2014) Evaluation of cancer patients admitted to the emergency department within one month before death in Turkey: what are the problems needing attention? Asian Pac J Cancer Prev 15(1) 349–353 https://doi.org/10.7314/APJCP.2014.15.1.349 PMID: 24528055

196. Sezgin Goksu S, Gunduz S and Unal D, et al (2014) Use of chemotherapy at the end of life in Turkey BMC Palliat Care 13(1) 51 https://doi.org/10.1186/1472-684X-13-51 PMID: 25435808 PMCID: 4247666

197. Kömürcü Ş, Çay Şenler F and Özyılkan Ö, et al (2012) Klinikte ölen terminal dönem kanserlı̇ hastalarda son ikı̇ hafta ı̇çinde yapılan tetkik ve tedaviler TTOK:4th Turkish Society of Medical Oncology Congress (Antalya, 21–25 March 2012)

198. Kütük B, Topkaya Ö and Virdil B, et al (2012) Son dönem hastalarda palyatif kemoterapi TTOK: 4th Turkish Society of Medical Oncology Congress (Antalya, 21–25 March 2012)

199. Kart L, Akkoyunlu ME and Akkoyunlu Y, et al (2011) Evaluation of end stage patient in intensive care unit Selcuk Med J 27(3) 146–148

200. Üçgül Çavuşoğlu E, Akkurt M and Kömürcü Ş, et al (2007) Klinikte Ölen Terminal Dönem Kanserli Hastalarda Son İki Hafta İçinde Yapılan Tetkik ve Tedavilerin Retrospektif Analizi 17th National Cancer Congress (Antalya, 19–23 April 2007)

201. Doruk H, Çay Şenler F and Akbulut H, et al (2007) Hastanede Yatan Terminal Dönemdeki Kanser Hastalarına Uygulanan Tıbbi Yaklaşımlar ve Destek Tedavilerinin Değerlendirilmesi 17th National Cancer Congress (Antalya, 19–23 April 2007)

202. Bulbul Y, Ozlu T and Arinc S, et al (2017) Assessment of palliative care in lung cancer in Turkey Med Princ Pract 26(1) 50–56 https://doi.org/10.1159/000452801 PMCID: 5588338

203. Kara T (2017) Opinions of Relatives of Patients with Terminal Cancer About Palliative Care [Dissertation] (Istanbul: Marmara University)

204. Metin S (2018) Relationship Between the Health Literacy Level of Palliative Care Service Patient Companions and Patient Care Results and Survival Status of the Patients [Dissertation] (Bursa: Bursa Yüksek İhtisas Education and Research Hospital)

205. Erdem E (2020) The Effects of Early Palliative Care on Quality of Life [Dissertation] (İzmir: Tepecik Education and Research Hospital)

206. Dagli O, Tasdemir E and Ulutasdemir N (2020) Palliative care infections and antibiotic cost: a vicious circle Aging Male 23(2) 98–105 https://doi.org/10.1080/13685538.2019.1575353

207. Saygılı M and Çelk Y (2019) An evaluation of the cost‐effectiveness of the different palliative care models available to cancer patients in Turkey Eur J Cancer Care 28 https://doi.org/10.1111/ecc.13110

208. Aygencel G and Türkoğlu M (2014) General characteristics and costs of terminal-stage patients in a medical intensive care unit J Turk Soc Intens Care 5 1–4

209. Çalışkan AN (2019) Cost Analysis of Palliative Care Centers: a Case of Public Hospital [Dissertation] (Muğla: Sıtkı Koçman University)

210. Gürel Yavuzdemir H (2019) Evaluation of a Palliative Care Center Sample with Inpatient Features, User Satisfaction, Quality of Care Service and Cost Aspects [Dissertation] (Zonguldak: Bülent Ecevit University)

211. Akyüz S (2015) Kanser hastalarına uygulanacak palyatı̇f bakım uygulamalarına ı̇lı̇şkı̇n bı̇r araştırma 21st National Cancer Congress (Antalya, 22–26 April 2015)

212. Saygili M and Celik Y (2020) An evaluation of palliative care service effect in patients with cancer diagnosis: comparison in terms of the symptom level and care satisfaction Agri 32(2) 61–71 PMID: 32297968

213. Kahveci K and Gokcinar D (2014) Knowledge about palliative care in the families of patients Acta Medica Mediterr 30 1369–1373

214. Topkaya Ö and Yürügen B (2019) Kanser hastalarının palyati̇f bakım gereksinimleri̇ ile hasta ve ai̇leleri̇ni̇n palyati̇f bakıma ili̇şki̇n bi̇lgi̇ ve beklenti̇leri̇ni̇n Iincelenmesi 23rd National Cancer Congress (Antalya, 17–21 April 2019)

215. Doruk H, Çay Şenler F and İçli F (2007) Terminal dönemdeki kanser hastaları ve yakınlarının hastanede uygulanan tıbbi yaklaşımlar ve tedavilerle ilgili görüşleri 17th National Cancer Congress (Antalya, 19–23 April 2007)

216. Karabuğa Yakar H and Pınar R (2013) Evaluation of quality of life among family caregivers of patients with cancer Hemşirelikte Araştırma Geliştirme Derg 15(2) 1–16

217. Oğuz N, Miles S and Büken N, et al (2003) End-of-life care in Turkey Camb Q Healthc Ethics 12 279–284 https://doi.org/10.1017/S0963180103123109

218. Zeybek Ünsal Ç and Büken N (2017) Comparison of palliative care in Turkey and Europe from ethical and legal perspective with country examples JARSS Anestezi Derg 25 44–51

219. Sert G and Guven T (2013) Examining the ethico-legal aspects of the right to refuse treatment in Turkey J Med Ethics 39(10) 632–635 https://doi.org/10.1136/medethics-2011-100408 PMID: 23596316

220. Baykara N, Utku T and Alparslan V, et al (2020) Factors affecting the attitudes and opinions of ICU physicians regarding end-of-life decisions for their patients and themselves: a survey study from Turkey PLoS One 15(5) e0232743 https://doi.org/10.1371/journal.pone.0232743 PMID: 32433670 PMCID: 7239490

221. Guclu YA, Can H and Atsiz Sezik H et al (2018) Assessment of the signs of anxiety and depression in relatives giving care to cancer patients hospitalized in the palliative care service Fam Pract Palliat Care 3(2) 98–101

222. Avcı D (2018) Are the nutritional Nrs-2002 scores of cancer patients at the palliative care center related to inflammation? Bozok Med J 8(3) 71–75

223. Babaoğlu E and Öz F (2003) The relationship between psychological and social problems of the spouses who cared for the terminal cancer patients Hemşirelikte Araştırma Geliştirme Derg 2 24–33

224. Çulha Ateşçi F, Kalkan Oğuzhanoğlu N and Baltalarlı B, et al (2003) Psychiatric disorders in cancer patients and associated factors Turk J Psychiatry 14(2) 145–152

225. Düzgün G, Uzun M and Topaloğlu Ö, et al (2016) Comparison of the mourning process of relatives of patients who received internal medicine intensive care and palliative care FNG Demiroğlu Bilim Tıp Derg 2(4) 250–255 https://doi.org/10.5606/fng.btd.2016.045

226. Çırpan Kantarcıoğlu A, Sevinir B and Demirkaya M, et al (2018) Kanser tanısı alan ergenlerı̇n hastalık algılarının değerlendı̇rı̇lmesi TPOG National Childhood Cancer Congress (Antalya, 2–6, May 2018)

227. Abca Yılmazer M and Okyayüz Ü (2013) Palyatı̇f radyoterapı̇ alan kemı̇k metastazlı hastalarda bı̇lgı̇lendı̇rme odaklı ağrı ve depresyon değerlendı̇rmesı̇ 20th National Cancer Congress (Antalya, 19–23 April 2013)

228. Aslan Ö and Akyol M (2010) Hope among family caregivers of cancer patients Support Care Cancer 18(Suppl 3) 77–220

229. Yetisen AY, Arslan D and Yavuzsen T, et al (2011) Scoring anxiety, depression and quality of life in colorectal cancer patients and the effect of patient education on these parameters Support Care Cancer 19(Suppl 2) S67–S370

230. Çıracı Y and Nural N (2015) Loneliness of cancer patients at end of life Support Care Cancer 23(Suppl 1) 1–388

231. Çıracı Y and Nural N (2015) A study of emotional status of cancer patients at end of life Support Care Cancer 23(Suppl 1) 1–388

232. Koç Z, Kiymaz D and Saglam Z (2015) Determining the loneliness and perceived social support levels in oncologic patients Support Care Cancer 23(Suppl 1)

233. Altınışık M, Kocabıyık B and Arıkan F, et al (2019) Kanser hastalarına bakım verenlerı̇n destekleyı̇cı̇ bakım gereksı̇nı̇mlerı̇ ve umut düzeyleri 23rd National Cancer Congress (Antalya, 17–21 April 2019)

234. Eskigülek Y and Kav S (2019) Opinions of palliatıve care patients and nurses regarding dignified care Support Care Cancer 1–302

235. Zengin L and Büyükbayram Z (2019) Determining satisfaction levels of cancer patients who receive treatment in the palliative care J Tradit Complem Med 2(1) 17–24 https://doi.org/10.5336/jtracom.2018-63748

236. Dokuyucu A, Ekinci O and Yılmaz Akyüz E, et al (2018) Palyatı̇f bakım merkezı̇mı̇zde hemşı̇relı̇k hı̇zmetlerı̇ memnunı̇yetı̇nı̇n değerlendı̇rı̇lmesi Palliative Care and Hospice Congress (İstanbul, 9–11 March 2018)

237. Okcin F, Ogce F and Zengin Y, et al (2011) Study of nursıng care satisfaction of patients receiving chemotherapy Support Care Cancer 19(Suppl 2) S67–S370

238. Turkoglu N and Kilic D (2012) Effects of care burdens of caregivers of cancer patients on their quality of life Asian Pac J Cancer Prev 13(8) 4141–4145 https://doi.org/10.7314/APJCP.2012.13.8.4141 PMID: 23098532

239. Koç Z, Sağlam Z and Çınarlı T (2016) Determination of factors affecting the care taking load of care takers for Individuals diagnosed with cancer J Samsun Health Sci 1(1) 99–116

240. Tunçel Yİ, Kaya M and Kuru RN, et al (2014) Nurses’ burnout in oncology hospital critical care unit J Turk Soc Intens Care 12 57–62

241. Uzelli Yılmaz D, Akın Korhan E and Khorshid L (2017) Evulation of nursing care quality in a palliative care clinic Int J Clin Exp Med 14(3) 2968–2980

242. Kurt S, Ünsar S and Erol Ö (2020) Evaluation of quality of life of caregivers for patients with cancer Süleyman Demirel Univers J Health Sci 11(1) 43–48

243. Akyar I, Korkmaz F and Atakul E (2017) Caregiver outcomes of geriatric oncology patients Mersin Univers J Health Sci 10(3) 158–167

244. Kardaş Özdemir F, Akgün Şahin F and Küçük D (2009) Determination of burden cares for mothers having children with cancer N J Med 26 153–158

245. Yılmaz Karabulutlu E, Akyıl R and Karaman S, et al (2013) Investigation of sleep quality and psychological problems in cancer caregivers Turk J Oncol 28(1) 1–9 https://doi.org/10.5505/tjoncol.2013.807

246. Şener A, Aydoğan A and Koç Z (2018) Palyatı̇f bakım ünı̇tesı̇nde yatan hastaların bakımından sorumlu hasta yakınlarının bakım yüklerı̇ ile yaşam doyumlarının belı̇rlenmesi Palliative Care and Hospice Congress (İstanbul, 9–11 March 2018)

247. Ozcelik H, Usta Yesilbalkan O and Fadiloglu C, et al (2011) The relationshıp between caregiving burden and social support in caregivers of patient with cancer Support Care Cancer 19(Suppl 2) S67–S370

248. Koku F (2015) Termı̇nal dönemde hasta bakımına yönelı̇k hemşı̇relı̇k tutumları 21st National Cancer Congress (Antalya, 22–26 April 2015)

249. Kuşçu A, Topkaya Ö and Yanar A, et al (2015) Yaşam sonu bakımda değerlendirme 21st National Cancer Congress (Antalya, 22–26 April 2015)

250. Özyalçın D and Çevik B (2019) Kanser Hastaları, Yakınları ve Hemşı̇relerı̇n Ölüme İlı̇şkı̇n Tutumu ve İyı̇ Ölüme İlı̇şkı̇n Görüşlerı̇ 23rd National Cancer Congress (Antalya, 17–21 April 2019)

251. Köse F (2019) Palliative sedation in terminal term cancer patients 23rd National Cancer Congress (Antalya, 17–21 April 2019)

252. Bar-Sela G, Schultz MJ and Elshamy K, et al (2019) Training for awareness of one’s own spirituality: a key factor in overcoming barriers to the provision of spiritual care to advanced cancer patients by doctors and nurses Palliat Support Care 17(3) 345–352 https://doi.org/10.1017/S147895151800055X

253. Temelli G and Cerit B (2019) Perceptions of palliative care nurses related to death and palliative care practices Omega (Westport) 30222819890457 https://doi.org/10.1177/0030222819890457

254. Ozveren H and Kirca K (2019) Influence of palliative care training on last-year nursing department students’ perception on regarding spirituality and spiritual care: a single-group pretest-posttest intervention study J Relig Health 58(3) 860–869 https://doi.org/10.1007/s10943-018-0701-4

255. Okan I, Suren M and Onder Y, et al (2019) An evaluation of the mourning tradition, the ‘First Feast’, in the context of palliative care: the possibility of incorporating cultural rituals into palliative care Palliat Support Care 17(4) 453–458 https://doi.org/10.1017/S1478951518000767 PMID: 30628562

256. Akbulut Şahin E (2019) Hasta yakını olmanın getirdiği güçlükler ve dini başa çıkma (Palyatif bakım servisi onkoloji hasta yakınları) [Dissertation] (Izmir: İzmir Katip Çelebi University)

257. Gemalmaz A and Avşar G (2015) Cancer diagnosis and after experiences: a qualitative study J Educ Res Nurs 12(2) 93–98

258. Ozdemir F, Dogan S and Timucin Atayoglu A (2020) Psychosocial problems of family caregivers of palliative care patients and their spiritual coping styles Perspect Psychiatr Care 56(3) 636–641 PMID: 32017126

259. Demirci H and Metin T (2019) Effect of health literacy of caregivers on survival rates of patients under palliative care Scand J Caring

260. Ozmen V, Dagoglu N and Dede I, et al (2016) Turkish Ministry of Health, 2(nd) Turkish Medical General Assembly Clinical Oncology Study Group report J Breast Health 12(1) 9–17 https://doi.org/10.5152/tjbh.2015.2869 PMID: 28331725 PMCID: 5351437

261. World Health Organization (2020) Non-communicable diseases progress monitor 2020 [https://www.who.int/publications/i/item/ncd-progress-monitor-2020] Date accessed: 18/12/20

262. Turkish Statistical Association (2019) Mortality and cause specific mortality statistics [https://data.tuik.gov.tr/Bulten/Index?p=Olum-ve-Olum-Nedeni-Istatistikleri-2019-33710] Date accessed: 18/11/20

263. Carrasco JM, Lynch TJ and Garralda E, et al (2015) Palliative care medical education in European universities: a descriptive study and numerical scoring system proposal for assessing educational development Pain Symptom Manage 50(4) 516–523 10.1016/j.jpainsymman.2015.04.019>https://doi.org/10.1016/j.jpainsymman.2015.04.019

264. Kamal AH, Bausewein C and Casarett DJ, et al (2020) Standards, guidelines, and quality measures for successful specialty palliative care integration into oncology: current approaches and future directions J Clin Oncol 38(9) 987–994 https://doi.org/10.1200/JCO.18.02440 PMID: 32023165 PMCID: 7082154

265. Sedhom R, Gupta A and Von Roenn J, et al (2020) The case for focused palliative care education in oncology training J Clin Oncol 38(21) 2366–2368 https://doi.org/10.1200/JCO.20.00236 PMID: 32271674 PMCID: 8205264

266. Akyar İ (2016) Palliative and Supportive care in Turkey: literature review and current status of research 27th Sigma International Nursing Research Congress (Cape Town, 13 July 2016)

267. Özsoy Z (2018) 2000 – 2016 Sürecı̇ndekı̇ palyatı̇f bakım yayınlarının bı̇blı̇yometrı̇k analı̇zı̇ Palliative Care and Hospice Congress (İstanbul, 9–11 March 2018)

268. Cleary J, Radbruch L and Torode J, et al (2013) Next steps in access and availability of opioids for the treatment of cancer pain: reaching the tipping point? Ann Oncol 24(Suppl 11) 60–64 https://doi.org/10.1093/annonc/mdt504

269. International Narcotics Control Board Availability of narcotic drugs for medical use [https://www.incb.org/incb/en/narcotic-drugs/Availability/availability.html] Date accessed: 18/12/20

270. Ferrell BR, Chung V and Koczywas M, et al (2020) Dissemination and implementation of palliative care in oncology J Clin Oncol 38(9) 995–1001 https://doi.org/10.1200/JCO.18.01766 PMID: 32023151 PMCID: 7082157

271. Yildiz P, Tanriover MD and Unal S (2020) Turkish Society of Internal Medicine choosing wisely project Eur J Intern Med 76 125–126 https://doi.org/10.1016/j.ejim.2020.03.001 PMID: 32156494

272. Currow DC, Agar MR and Phillips JL (2020) Role of hospice care at the end of life for people with cancer J Clin Oncol 38(9) 937–943 https://doi.org/10.1200/JCO.18.02235 PMID: 32023154

273. Boufkhed S, Harding R and Kutluk T, et al (2020) What is the preparedness and capacity of palliative care services in Middle-Eastern and North African countries to respond to COVID-19? A rapid survey J Pain Symptom Manage e13–e50 PMID: 33227380 PMCID: 7679234

274. Kutluk MT, Ahmed F and Kirazlı M, et al (2021) The effect of the COVID-19 pandemic on paediatric cancer care: lessons learnt from a major paediatric oncology department in Turkey Ecancermedicalscience 15 1172 https://doi.org/10.3332/ecancer.2021.1172 PMID: 33680086 PMCID: 7929778

275. Radbruch L, De Lima L and Knaul F, et al (2020) Redefining palliative care-a new consensus-based definition J Pain Symptom Manage 60(4) 754–764 https://doi.org/10.1016/j.jpainsymman.2020.04.027 PMID: 32387576 PMCID: 8096724

276. Al-Shahri M (2002) The future of palliative care in the Islamic world West J Med 176(1) 60–61 https://doi.org/10.1136/ewjm.176.1.60 PMID: 11788543 PMCID: 1071657

277. Ertaş IE, Sehirali S and Ozsezgin Ocek S, et al (2014) The effectiveness of subcutaneously implanted epidural ports for relief of severe pain in patients with advanced-stage gynecological cancer: a prospective study Agri 26(1) 8–14 https://doi.org/10.5505/agri.2014.14227

278. Büken N (2017) Physician-patient communication during the clinical ethical decision-making process in palliative care in Turkey Anestezi Derg 25 3–14

279. Walker DK, Edwards RL and Bagcivan G, et al (2017) Cancer and palliative care in the United States, Turkey, and Malawi: developing global collaborations Asia Pac J Oncol Nurs 4(3) 209–219 https://doi.org/10.4103/apjon.apjon_31_17 PMID: 28695167 PMCID: 5473092

280. Müller-Schwefe GH, Wimmer AM and Dejonckheere J, et al (2014) Patients’ and physicians’ perspectives on opioid therapy for chronic cancer and musculoskeletal pain in Germany, Italy, and Turkey: PAin RESearch (PARES) survey Curr Med Res Opin 30(3) 339–347 https://doi.org/10.1185/03007995.2013.861349

281. Akyar I, Dionne-Odom JN and Yang GM, et al (2018) Translating a US early palliative care model for Turkey and Singapore Asia Pac J Oncol Nurs 5(1) 33–39 PMID: 29379831 PMCID: 5763436

282. Isikhan V (2010) Coping with stress in patients with advanced cancer Asian Pac J Cancer Prev 11(Suppl 1) 81–92 PMID: 20590356

283. Bar-Sela G, Schultz MJ and Elshamy K, et al (2019) Human development index and its association with staff spiritual care provision: a Middle Eastern oncology study Support Care Cancer 27(9) 3601–3610 https://doi.org/10.1007/s00520-019-04733-0 PMID: 30895381

284. Yalcin S, Gumus M and Oksuzoglu B, et al (2019) Nutritional aspect of cancer care in medical oncology patients Clin Ther 41(11) 2382–2396 https://doi.org/10.1016/j.clinthera.2019.09.006 PMID: 31699437

285. Tekin N (2011) An example of support program to elderly patients and elderly relatives during the terminal period in a developed model of residential home and geriatric care center Turk J Geriatri 14(3) 273–275

286. Yildirim YK, Fadiloğlu C and Uyar M (2006) Palyatif kanser bakımında tamamlayıcı tedaviler [Complementary therapies in palliative cancer care] Agri 18(1) 26–32 PMID: 16783665

287. Çavdar I (2011) Care of the cancer patient in the terminal period Türk Onkol Derg 26(3) 142–147

288. Kabalak AA (2014) Palliative care in Turkey; 2014, current developments, requirements Anestezi Derg 22(3) 121–123

289. Demir M (2016) Palliative care ethics Yoğun Bakım Derg 7 62–66 https://doi.org/10.5152/dcbybd.2016.1202

290. Isikhan V (2008) Choices of death place in terminal stage cancer patients Türk Onkol Derg 23(1) 34–44

291. Aydoğan F and Uygun K (2011) Kanser hastalarında palyatif tedaviler Klinik Gelişim Derg 4–9

292. Sarıhan E, Kadıoğlu E and Artıran İğde F (2012) Kanser ağrısı, tedavi prensipleri ve Dünya Sağlık Örgütü ağrı basamak tedavisi Nobel Med 8(1) 5–15

293. İnci F and Öz F (2012) Palliative care and death anxiety Currr Approaches Psychiatry 4(2) 178–197

294. Uslu Şahan F and Terzioğlu F (2015) Palliative care education and organization in the world and Turkey Cumhuriyet Nurs J 4(2) 81–90

295. Madenoğlu Kıvanç M (2017) Palliative care services in Turkey J Health Pro 4(2) 132–135

296. Guven DC, Aktepe OH and Berk Z, et al (2019) Embedded outpatient palliative care service within the oncology clinic: preliminary experience in Hacettepe Oncology Hospital Ann Oncol 30(5) V666 https://doi.org/10.1093/annonc/mdz261.017

297. Alkan A, Yaşar A and Güç ZG, et al (2019) Worse patient-physician relationship is associated with more fear of cancer recurrence (Deimos Study): a study of the Palliative Care Working Committee of the Turkish Oncology Group (TOG) Ann Oncol 30(Suppl 5) 667–670 https://doi.org/10.1093/annonc/mdz262.001

298. Gültaş C and Yılmaz M (2015) Palyatı̇f bakım gereksı̇nı̇mı̇ olan kanserlı̇ hasta yakınlarının evde bakımda yaşadığı güçlükler ve yaşam kalı̇tesı̇nı̇n belı̇rlenmesı̇ 21st National Cancer Congress (Antalya, 22–26 April 2015)

299. Bozkurt M (2018) Destek tedavı̇ ve hospı̇se yönlendı̇rı̇len ı̇lerı̇ evre mı̇de adenokanserı̇ hastalarının genel sağkalımı Palliative Care and Hospice Congress (İstanbul, 9–11 March 2018)

300. Çakır FB, Uzuner S and Daşkaya H, et al (2018) Kanserli çocuklarda serviste invasiv işlemler için uygulanan derin sedasyonun hastalar ve ebeveynler için oluşturduğu rahatlık Palliative Care and Hospice Congress (İstanbul, 9–11 March 2018)

301. Yavas C, Zorlu F and Ozyigit G, et al (2011) Prospective asessment of quality of life in adult patients treated for low grade glioma Support Care Cancer 19(Suppl 2) S67–S370

302. Tanriverdi O, Yavuzsen T and Akman T, et al (2015) The perspective of non-oncologist physicians on patients with metastatic cancer and palliative care (ALONE Study): a study of the palliative care working committee of the Turkish Oncology Group (TOG) Support Care Cancer 23(Suppl 1) 1–388

303. Özkan S (2012) Self-care and end-of-life care in cancer patients and carers Support Care Cancer 20(Suppl 1) 1–283

304. Cakir FB and Kaygusuz SB (2016) Nasogastric tube feeding in children with cancer as a part of palliative care Pediatr Blood Cancer 63(Suppl 3) S5–S321

305. Bagcivan G, Tosun N and Kömürcü S, et al (2009) Analysis of the patient-related barriers in cancer pain management in Turkish patients Support Care Cancer 17 857–1039

306. Tanrıverdi Ö and Yıldırım B (2014) Ölümlerı̇nden bı̇r ay önce acı̇l servı̇se başvuran ve acı̇l servı̇se başvurmayan son dönem kanser hastalarının ı̇rdelenmesı̇ TTOK: 5th Turkish Society of Medical Oncology Congress (Antalya, 19–23 March 2014)

307. Demir F and Yılmaz M (2015) Onkolojı̇ hasta ve hasta yakınlarının evde bakım hı̇zmetlerı̇nden beklentı̇lerı̇ 21st National Cancer Congress (Antalya, 22–26 April 2015)

308. Aktaş S, Kuşçu A and İnce A (2009) Kolanjiosarkom’lu bir olguda palyatif bakım uygulamaları 18th National Cancer Congress (Antalya, 21–26 April 2009)

309. Tiryaki N, Sarıtaş B and Yüntem A, et al (2009) Akciğer kanserli bir olguda, palyatif bakımda hemşirenin rolü 18th National Cancer Congress (Antalya, 21–26 April 2009)

310. Demiral A (2009) Desmoplastik round cell tümörlü bir olguda palyatif bakım uygulamaları ve hemşirelik bakımı 18th National Cancer Congress (Antalya, 21–26 April 2009)

311. Arias-Casais N, Garralda E and Rhee JY, et al (2019) EAPC Atlas of Palliative Care in Europe 2019 (Vilvoorde: EAPC Press)

312. Temelli G (2018) Perceptions of Palliative Care Nurses Related to Death and Palliative Care Practices [Dissertation] (Bolu: İzzet Baysal University)

313. Topkaya Ö (2018) Palliative Care Requirements of Cancer Patients and Investigation of Knowledge and Expectations Related to Palliative Care of the Patients and Their Families [Dissertation] (Istanbul: İstanbul Okan University)

314. Yılmaz A (2015) Frequency of Symptomatic Manifestations in Cancer Patients in Palliative Care Unit and the Place of Palliative Symptom Treatment in Symptom Management [Dissertation] (Izmir: İzmir Katip Çelebi University, İzmir Atatürk Training and Research Hospital)

315. Arkın S (2017) Investigation of Anxiety Depression and Social Support Levels in Caregivers of Palliative Patients [Dissertation] (Izmir: İzmir Tepecik Training and Research Hospital)

316. Sağlam Z (2020) Needs of Family Members Caring for Palliative Patients in the Care and Treatment Processes [Dissertation] (Samsun: Ondokuz Mayıs University)

317. Taş M (2020) Evaluation of Nutritional Treatment Approach Results in Palliative Care Patients with Malnutrition [Dissertation] (Kırıkkale: Kırıkkale University)

318. Tanıl E (2020) The Perceptions and Expectations of Pallative Period Oncology Patients About Bad News and Their Attitudes to Death [Dissertation] (Istanbul: Istanbul University)

319. Ardıç S (2020) An Investigation of Self-Compassion Levels of the Relatives of Palliative Stage Oncology Patients in Terms of Psychological Resilience and Quality of Life [Dissertation] (Istanbul: Istanbul University)

320. Duman Ö (2020) The Effect of Care Transmitter Load of Patient Relationships’ Views on Paliative Care [Dissertation] (Samsun: Ondokuz Mayıs University)

321. Damak N (2020) Nurses’ Perceptions Of Good Death and Levels of Knowledge About Palliative Care [Dissertation] (Istanbul: Biruni University)

322. Karakaya C (2020) Evaluation of Quality of Life Among Caregivers of Palliative Care Patients: Karabük Case [Dissertation] (Ankara: Hacettepe University)

323. Kurtgöz A (2019) Effects of Nursing Care on the Spiritual Well-Being and Hopefulness in Relatives of Palliative Care Patients [Dissertation] (Samsun: Ondokuz Mayıs University)

324. Tarakçı F (2019) Retrospective Evaluation of Term of Hospitalization and Di̇scharge Status of Patients in the Palliative Care Service of a Third Step Hospital [Dissertation] (Izmir: İzmir Tepecik Training and Research Hospital)

325. Çelik A (2019) The Effect of Bright White Light Application on Fatigue Levels and Sleep Quality in Cancer Patients Receiving Palliative Care [Dissertation] (İzmir: Ege University)

326. Özhan E (2019) Evaluation of Psycho-Social Situations of Relatives of Cancer Patients: a Case of Palliative Care Center of Eyüpsultan State Hospital [Dissertation] (Sakarya: Sakarya University)

327. Adanır A (2019) Determination of Compassion Fatigue and Coping Styles with Stress of Nurses Working at Oncology and Palliative Care Units [Dissertation] (İzmir: Dokuz Eylül University)

328. Balcıoğlu İ (2019) Investigation of the Relationship Between Nutrition, Infection, and Hospitalisation Time During Palliative Care [Dissertation] (Kütahya: Kütahya Health Sciences University)

329. Altay M (2019) The Effect of Palliative Care Education on Nurses’ Knowledge Levels for Nurses Caring for Oncology Patients [Dissertation] (Istanbul: Koç University)

330. Uslu Şahan F (2018) Effect of Interprofessional Simulation Training on Bringing Palliative Care Competencies to Gynecologic Oncology [Dissertation] (Ankara: Hacettepe University)

331. Kaya H (2018) Consultation of Patients in Palliative Care Service for 1 Year [Dissertation] (Adıyaman: Adıyaman University)

332. Eskigülek Y (2018) Opinions of Palliative Care Patients and Nurses Regarding Dignified Care [Dissertation] (Ankara: Başkent University)

333. Güçlü Y (2018) The Effect of Nutritional Status and Muscle Strength on Survival of the Patients Treated in Palliative Care Units [Dissertation] (Bursa: Bursa Yüksek İhtisas Eğitim ve Araştırma Hastanesi)

334. Bağçivan G (2018) The Study of Turkish Reliability and Validity of Functional Assessment of Chronic Illness Therapy-Palliative Care (facit-pal) Scale [Dissertation] (Ankara: Hacettepe University)

335. İlhan H (2018) Effects on the Soci̇al Li̇fe of Balanced Levels i̇n Care of Palliative Care Patients [Dissertation] (Tokat: Tokat Gaziosmanpaşa University)

336. Öksüzoğlu S (2018) The Relationship Between the Depression and Burnout in Maintenance of Palliative Care Diseases [Dissertation] (Izmir: İzmir Bozyaka Training and Research Hospital)

337. Karadeniz N (2018) Evaluation of Symptom Control in Patients Monitored in the Palliative Care Unit [Dissertation] (Izmir: İzmir Tepecik Training and Research Hospital)

338. Kahraman Ö (2017) Perception of Social Support in Palliative Care: the Case of Ankara [Dissertation] (Konya: Selçuk University)

339. Kado A (2017) Palliative Care Needs Cancer Patients and their Proximity Questions and Solution Suggestions [Dissertation] (Istanbul: Yeni Yüzyıl University)

340. Güney H (2017) Determination of Patients with Applied Emergency Service and Palliative Care with a New Screening Method, Investigation of Needs and Symptoms by Speed, Edmonton and Karnofsky Scales [Dissertation] (Tokat: Tokat Gaziosmanpaşa University)

341. Filiz S (2017) Determination of Nursing Care Satisfaction Levels and Effective Factors in Patients with Patient Care [Dissertation] (Istanbul: Üsküdar University)

342. Saygılı M (2016) An Evaluation of Three Different Palliative Care Service Models in Terms of Patients with Cancer Diagnosis-their Family Caregivers and Cost-Effectiveness Analysis [Dissertation] (Ankara: Hacettepe University)

343. Gürakan G (2016) Effect of Aromatherapy Massage on Pain and Plasma Beta-Endorphine Levels in Palliative Cancer Patients [Dissertation] (İzmir: Ege University)

344. Akyüz S (2014) Examination of Palliative Care Offered to Cancer Patients [Dissertation] (Ankara: Gazi University)

345. Uslu F (2013) Determination of the Palliative Care Practices of the Midwives and Nurses in the Gynecological Oncology Units in the Centrum of Ankara [Dissertation] (Ankara: Hacettepe University)

346. Özçelik H (2011) Examining the Effect of Case Management Model on Patient Results in Palliative Care of Cancer Patients [Dissertation] (İzmir: Ege University)

347. Turgay G (2010) Healthcare Professionals’ Views on Palliative Care [Dissertation] (Ankara: Başkent University)

348. Ekici Kocakafa G (2019) Determination of the Caregiving Burden of Family Members Caring for the Inpatients in Palliative Care Unit [Dissertation] (Istanbul: Marmara University)

349. Karabuğa H (2009) Evaluation of Quality of Life Among Caregivers of Patients with Cancer [Dissertation] (Istanbul: Marmara University)

350. Çalışkan T (2012) Inadequacy and Differences about the Attitudes in Pain Control of Cancer Patients: Assessment of Algology Department [Dissertation] (Ankara: Hacettepe University)

351. Elevli E (2012) Home Care Services in an Investigation that Determined You Need [Dissertation] (Istanbul: Beykent University)

352. Kılınç G (2015) Evaluation of the Prognosis of Cancer Patients Treated in Intensive Care Units [Dissertation] (Denizli: Pamukkale University)

353. Uzunkaya P (2016) Determining Attitudes of Nurses Working in Oncology Clinics Towards Care of Dying Patients and Principles about Death with Dignity and their Opinions Regarding Good Death [Dissertation] (Ankara: Hacettepe University)

354. Terzi K (2018) End of Life Care from the Perspectives of Patients with Cancer and Nurses [Dissertation] (Ankara: Hacettepe University)

355. Yalçın S (2018) Process Evaluati̇on of End Stage İntensi̇ve Care Pati̇ents [Dissertation] (Denizli: Pamukkale University)

356. Özyalçın D (2019) Opinions of Cancer Patients, Nears and Nurses Related to Death and Good Death [Dissertation] (Ankara: Başkent University)

357. Şipal G (2019) Supportive Care Needs and the Disease Acceptance Level of Hematological Cancer Patients [Dissertation] (Konya: Selçuk University)

Supplementary appendix

The supplementary tables are also available online at https://doi.org/10.6084/m9.figshare.17057009.v1.

Supplementary Table 1. Details of the included studies.

Supplementary Table 2. Scales used as assessment tool in PC for cancer research in Turkey.

ecancermedicalscience

Progress in palliative care for cancer in Turkey: a review of the literature

Abstract

Background

Method

Search strategy

Data selection procedure

Data extraction and analysis

Results

Search results

Characteristics of included studies

History of cancer PC in Turkey

Law and regulations

Professional education, training and research

Opioid use and pain management

Patient care and PC centres

Public awareness, psychosocial support and end of life ethics

Discussion

Conclusion

Conflicts of interest

Authors’ contributions

Funding

References

Supplementary appendix

Table of Contents

More from ecancer

ecancermedicalscience

Progress in palliative care for cancer in Turkey: a review of the literature

Abstract

Background

Method

Search strategy

Data selection procedure

Data extraction and analysis

Results

Search results

Characteristics of included studies

History of cancer PC in Turkey

Law and regulations

Professional education, training and research

Opioid use and pain management

Patient care and PC centres

Public awareness, psychosocial support and end of life ethics

Discussion

Conclusion

Conflicts of interest

Authors’ contributions

Funding

References

Supplementary appendix

Related Articles

Table of Contents

More from ecancer