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

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.


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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][142][143][144][145]. Most of the studies focused on symptom management . Different aspects of supportive care were investigated in many studies including quality of life [172][173][174][175][176][177][178][179][180][181] [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][194][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][200][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]. Along with progress on PC at national level, many studies were conducted on the subjects of psychosocial issues [221][222][223][224][225][226][227][228][229][230][231][232][233][234], patient and professional satisfaction [235][236][237], burden of the caregivers [238][239][240][241][242][243][244][245][246][247] and end of life [248][249][250][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 tradition 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][257][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.      Among 369 healthcare professionals, most of the respondents admitted lack of continuing PC education programme and more than half affirmed that they had never received education in palliative care. However, the majority of the respondent had a clear meaning of PC and make the correct option.

(Continued).
Supplementary With the population ageing, the inadequacy of end-oflife healthcare is a critical issue for Turkey. The healthcare provider must learn to communicate the risks and benefits of medical procedures and alternatives treatment with terminally ill patients as well as their relatives. Legislative procedure for DNR and public discussion about end-of-life care are needed.
Yildirim and Tanriverdi [195] English Journal paper Retrospective/ cross-sectional This retrospective study focused on how often and why patients with cancer visited the emergency department (ED) of a university hospital before death.
The medical record of 107 deceased cancer cases showed 60% of cases had at least one visit to ED within 1 month before death. Of these, 38% were discharged, 9% died in the ED while 53% were hospitalised. The most common site of the primary tumour was the lung (38%), the three most common presenting symptoms were dyspnoea/shortness of breath, pain and deterioration in general health status. The most common reason for hospitalisation was 'social support'.
Zeybek Interviews were carried out with 70 hospital managers and clinical directors in two oncology hospitals in Istanbul.
The need for establishment of PC unit in the hospital was suggested by most (87%) of participants. Participants also revealed institutional social and educational factors as potential barriers in providing PC and integrating PC into health systems. To overcome the barriers for integration of PC into health systems, providing education for health professionals and patient relatives, raising awareness in society, financial arrangements and providing infrastructure were suggested.

Supplementary Table 1. Details of the included studies.
Oktay et al [74] English Journal paper Cross-sectional The perspectives of 4,224 medical students on cancer, its treatment, PC and the role of oncologists.
The result showed that oncology education among phase III to VI students was useful for the students' understanding of cancer, cancer screening and prevention. However, oncology education to phase III to VI students failed to conceptualise the true meaning of palliative/supportive care and student thought that it was the oncologist's responsibility to treat symptoms such as pain, nutrition and shortness of breath in cancer patients. Cancer persons report using more avoidant coping strategies such as escape/avoidance denial or behavioural disengagement. The use of such strategies is associated with increased psychological distress and may be a risk factor for adverse responses to illness. PC staff who are may identify the need for support and assistance with coping strategies. English Journal paper Cross-sectional To reveal the differences in the signs of burnout and stress between PC workers and those working in neurology and internal disease clinics.
Emotional burnout and desensitisation scores were found to be elevated, and personal success scores were low in both groups. The Beck Anxiety Inventory revealed moderate anxiety in both groups, while cognitive-sensorial, physiological and pain complaints, as well as signs of stress, were more pronounced among workers in internal disease and neurology clinics. There were nine PC services across the country and seven were located in university hospitals. There were 72 pain centres of these, 35 were in located governmental hospitals and 31 were in university hospitals while 6 were in the private sector. Approximately 40% of pain centres were located in Ankara and Istanbul. It was found that morphine consumption rates per capita were relatively lower and the availability of different types of opioid analgesics was limited.
Saygili and Celik et al [212] Turkish Journal paper Case-control To evaluate the effect of PC on the symptom level assessment and satisfaction of patients diagnosed with cancer.
The PC provided to 60 cancer patients at the PC centre was less effective in reducing symptom levels (fatigue, nausea and dyspnoea) compared with the 59 cancer patients who received general care services at a public hospital. However, the mean satisfaction of the patients who received services at the PCC was significantly higher.
Ozcelik et al [191] Turkish Journal paper Review This review discussed case management-based multidiscıplinary care protocol in the PC of cancer patients.
Care coordination and case management are essential of a multidisciplinary team approach to provide effective and quality care, to patients and families. A lot of care guidelines and protocols are developed by a team of experts to contribute to the PC activities and could be used.

Şenel et al [123]
Turkish Journal paper Cross-sectional The objective of the study was to describe patterns of opioid use in the PC clinic of a training hospital.
Out of 418 cancer patients, 65% were prescribed strong opioids, 26% of patients were with weak opioids. The daily oral morphine equivalent dose per patient was 172 ± 58 mg. The indications for opioid use were pain (61%), dyspnoea (19%) and both dyspnoea and pain (20%).

Tekin [285]
Turkish Journal paper Case report This is a case report of an old lady who had given institutional care at the terminal period of her lung cancer.
In this report, the interdisciplinary geriatric teamwork including the role of the family physician was evaluated.

Supplementary Table 1. Details of the included studies.
Uysal et al [117] Turkish Journal paper Interventional To evaluate the effect of PC on patient symptoms by recording changes during the first week after hospital admission.
Among 108 patients admitted to the PC unit, 50% rated pain intensity at the level of 5 upon admission, and in follow-up, only 6.5% of patients had pain intensity at 5 on the 7th day of admission. The mean values of the symptoms of pain, insomnia, loss of appetite and status of well-being decreased significantly on the third day of admission compared to the time of admission to the hospital. However, no significant difference was found among the symptoms of nausea, anxiety, shortness of breath and constipation after 7 days of admission. The satisfaction of the patients in terms of nursing was found to be above average. It can be suggested to evaluate the patient satisfaction in with nursing care and take steps to increase satisfaction.

(Continued).
Supplementary A statistically significant positive correlation was found between sleep quality score and anxiety and depression levels. 88.7% of caregivers had poor sleep quality and the average total sleep quality was 9.87 ± 3.95. The rate of anxiety was 46% and risk of depression was 72% among caregivers.

Bağtatlı and Eşer [78]
Turkish Journal paper Cross-sectional Pain assessments of the nurses and factors affecting their pain assessments.
The nurses working in oncology clinics mostly evaluate verbal expressions of patients for assessing pain and none of them used pain scale, the level of assessed pain was lower than the self-report of cancer patients. Nurses' education level, training about pain and working duration in oncology clinic affected their pain assessment.

Yıldırım and Gürkan [189]
Turkish Journal paper Cross-sectional The influence of music on anxiety level of patients and chemotherapy side effects.
The findings indicated that, music has a meaningful relation with respect to anxiety states of the sample group (p > 0.05), and had no such a relation for the side effects of chemotherapy (p < 0.001).
Kart et al [199] Turkish Journal paper Cross-sectional Medical cost of the terminally ill cancer patients hospitalised in the medical intensive care unit (ICU) of university hospital.
Medical cost of the 15 patients died in the intensive care unit and two patients discharged with home mechanical ventilator support was 208.200,640/TL. They were hospitalised for 233 bed/days. The number of beds occupied by these terminal phase patients in this period was considered to be high. Foundation of PC units or hospice service with necessary law evaluations is very useful and important not only for optimal use of limited financial sources but also for comfort of patient and relatives.

Babaoğlu and Öz [223]
Turkish Journal paper Cross-sectional Psychological and social problems of the spouses of terminal cancer patients.
The most frequent psychological problem was depressive affect and the most frequent social problem was impaired social interactions. Physiological and social problems are related with each other. Spiritual distress and hopelessness were related with ineffective coping and ineffective role performance, and ineffective coping was related with impaired home maintenance and caregiver role strain.
The following significant relations are found for the social problems. These relations are between; impaired home maintenance, social interaction and role performance, deficient diversional activity, social isolation. At the same time it have been observed a relationship between ineffective role performance and social isolation, too.

Gemalmaz and Avşar [257]
Turkish Journal paper Qualitative Feelings of patients after the news of cancer and changes of life.
Patients easily shared their diagnosis of cancer with their friends, but it was hard with family. They were overwhelmed by intense concern of the family. The support of the family in accepting the cancer after diagnosis was positive and they also indicated they tend to feel spirituality more intensely.

Akgün and Akan [54]
Turkish Journal paper Review Paediatric PC. PC in children contains the assessment and handling of the childrens' and family's physical, psychosocial and spiritual needs and also symptom control and support to family during the illness and mourning process. Nursing students took notice of pain complaint of their patients (86) and they observed pain in the patients in postoperative period (51%). Half of the students (48%) defined pain as a discomforting condition. In the sample case given, 63.5% of the students defined the nursing interventions in order of assessing the pain with scale, using non-pharmacological methods, and giving analgesic drugs. And 36% of the students stated giving analgesics according to pain scale was routine nursing interventions. Two hundred and thirty-eight cancer patients presenting to a PC outpatient. Patients' most common symptoms were pain, fatigue, disturbed sleep and mild to severe depression.

Supplementary Table 1. Details of the included studies.
Kütük et al [198] Turkish Adolescents' negative beliefs should be determined and replaced with more positive cognitive content. It was reported that distressing symptoms such as pain required to be reduced as much as possible. Besides these, emotional states such as depression and anxiety should be treated.

Özdemir and Taşçı [185]
Turkish Oral presentation Interventional Acupressure in fatigue of elderly people with cancer.
Acupressure can be recommended to elderly people with cancer as an easily applicable and tolerable method without serious side effects in reducing cancer-related fatigue.

Şen et al [186] Turkish Oral presentation
Interventional Reflexology for pain, anxiety and Nausea.
A positive effect on pain, nausea and anxiety score after the application of reflexology was noted in approximately 100% of patients. The total symptom levels of the patients were high, they experienced of pain and fatigue more intensely. Their appetite and well-being levels were low. It was determined that patients with low performance level experienced more intense pain and lethargy symptoms. There was no difference between the mean scores of Life Satisfaction Scale and Care Burden Scale of the study and control group patients' relatives. There was no correlation between the mean scores of the Life Satisfaction Scale and the Caregiving Burden Scale (p > 0.05).
Dokuyucu et al [72] Turkish Oral presentation Cross-sectional PC knowledge of the healthcare professionals.
It was found that the PC awareness levels of healthcare staff were moderate and there were no major differences between the doctors and nurses in terms of correct answers.

(Continued).
Supplementary Invasive procedures in children with cancer can be performed safely with anaesthesiology guidance. Deep sedation in inpatient unit both prevents the pain of the patients and eliminates the concerns of the patients and parents.

Retrospective
Retrospective analysis of patients hospitalised in the PC unit in Diyarbakır.
The average age of the 203 patients was 67 (20-95) years. It was found that 54.5% of the patients were hospitalised due to malignancy and complications related to malignancy. Average hospital stay was 10.8 days. About 42% of the patients were discharged, 13% were expired and 45% were referred to another centre.

Toprak and Pilatin [143]
Turkish Oral presentation Retrospective Retrospective analysis of patients hospitalised in the PC unit.
A total of 137 hospitalisations of 98 patients were detected. The number of hospitalisations due to malignancy and malignancy-related complications was 108 (78.8%). Average hospital stay was 11.9 days. Forty (90.9%) of the patients who died were hospitalised due to malignancy.

(Continued).
Supplementary Study included 45 cancer patients who were followed up in the oncology clinic and died. Palliative Performance Scale of all were 40% and below. Seventy-six percent of patients experienced more than one symptom and 7% had pain, insomnia, respiratory distress and constipation together. Other 82% had pain, 41% had pain & insomnia, 31% had constipation, 57% had respiratory distress, 64% patients had respiratory distress, 41% of them experienced insomnia and 72% of them experienced pain. 29% patients had constipation and 92%of them had also pain. Planning the appropriate treatment and care according to the complex symptoms increases the success in symptom management and increase the quality of life in end-of-life care.

Özyalçın and Çevik [250]
Turkish Oral presentation Cross-sectional The attitudes of cancer patients, their caregivers and nurses towards death.
The mean score of the well-being scale and the attitude towards death scale (DAP-R) of the patients participating in the study was higher than the relatives and nurses, and the difference between them was found to be statistically significant. A significant relationship was found between the age, gender, marital status of the patients, and, the fear of death, death avoidance and acceptance. There was no significant difference in the sociodemographic characteristics of the patients and the unmet care needs of the patients and their caregivers. Significant differences were found in the stage of the disease, the duration of diagnosis, the treatment status in the last 2 months, the knowledge and the income level of the caregiver. The most needed healthcare service was pain control (39.3%). The average score of the hope levels of the caregivers is 35.52 ± 7.66. Regression analyses showed that the advanced stage of the disease increased the needs of the caregivers, and the treatment of the patient in the last two months decreased the health care needs.

Özsoy et al [151]
Turkish Oral presentation Cross-sectional Use of surgical procedures among PC cancer patients.
A total of 75 patients underwent palliative surgery. The most common symptoms were abdominal pain, vomiting and weakness. Indications were; oral intake disorder, bleeding, ileus, perforation, bile drainage deterioration (jaundice). Stomach, colon and rectum were the most frequently affected organs.

Kuşçu et al [152]
Turkish Oral presentation Retrospective Retrospective analysis of patients who underwent acid palliative treatment via catheter insertion.
One hundred and seventy-nine oncology patients were evaluated. Procedure reduces the number of repetitive paracentesis, provides symptomatic relief, increases the quality of life of the patient and his family. It also reduces the number of clinical visits. No infection was seen except for local infections due to catheter.

Kılıçkap et al [162]
Turkish Oral presentation Cross-sectional The relationship between quality of life and clinicopathological features in cancer patients.
In patients with anaemia (10g/dL), hypoalbuminaemia (3.2 g/dL), and leukopenia (3,000/mm 3 ), QoL was significantly lower (p ≤ 0.001). Inpatient treatment (p ≤ 0.001), comorbid disease (p ≤ 0.001), family history of cancer (p ≤ 0.001), active treatment (p ≤ 0.001), admitted within the first year after diagnosis (p ≤ 0.001) and patients who had relapse (p ≤ 0.001) had significantly lower QoL. Patients with distant metastases had lower QoL compared to patients with local metastases or non-metastases markedly (p ≤ 0.001). According to the presence of the disease and the status of receiving treatment, the general QoL of the patients was found to be significantly different (p ≤ 0.001).
Patients without active disease and who did not receive any treatment, the overall QoL was the highest, while others who had terminal disease and received active treatment had the lowest (p ≤ 0.001). No relationship was found between gender, marital status, previous cancer history and age and overall quality of life score. The total mean score of satisfaction scale was 4.37 ± 0.81 showing high patient satisfaction. It is a positive result for nursing care. There were no significant difference between patient socio-demographic variables and satisfaction mean score. The most frequent symptoms of patients were lack of appetite (n = 50, 83.3%), debility (n = 49, 81.7%) and nausea (n = 41, 68.3%). There were no relationship between patient symptom severity and satisfaction mean score (r = −0.094, p = 0.474).

Özçelik et al [247]
English Poster Cross-sectional The relationship between caregiving burden and social support in caregivers of patients with cancer.
There were no significant differences between mean caregiving burden, social support scores and some sociodemographic characteristics (marital, employ, occupational and to be primary caregiver status). The caregiving burden levels of the caregivers were lower in patients with higher educational background. There was a negative weak significant correlation between the mean caregiving burden scores and social support scores (r = −0.29, p = 0.000). The results of the study show that caregiving burden of caregivers can be reduced by increasing social support.

(Continued).
Supplementary There were many changes about parameters related to both quality of life and cognitive functions compared to baseline scores and follow-up scores. Most of them were found to be related to disease progression. We did not observe any depression and anxiety in our patients. Nursing students find their curriculum is superficial for PC and would like it to be strengthened. They suggest that this specialty content be expanded as part of a speciality degree programme.
Cetintas et al [68] English Poster Cross-sectional Death anxiety and attitudes toward the principles of dying with dignity of nursing students.
Death Anxiety Scale (DAS) and Assessment Scale of Attitudes Toward Principles About Dying with Dignity scales were used. There was a significant difference between the students who witnessed the death of a child on 'uncertainty of death' subscale mean scores of DAS (p < 0.05) and Assessment Scale of Attitudes Toward Principles About Dying with Dignity scores (p < 0.05). There was a negative correlation between the number of deaths that students witnessed and total scores of DAS (p = 0.045). The age (p = 0.010) and gender of the patient (p = 0.038) and their knowledge about morphine (p = 0.000) had a statistically significant effect on the preference of the patients. The patients who defined morphine as narcotic drug were less likely to use morphine (p = 0.015). There was no relationship between the patients' preference and the diagnosis (p = 0.247), the stage (p = 0.552), the education status (p = 0.112) and the pain. The risk of addiction to opioids remains a major obstacle preventing effective pain management.

Cakir and Kaygusuz [304]
English Poster Cross-sectional Nasogastric tube feeding in children with cancer as a part of PC.
Weight loss is an important problem in patients with cancer. Patients who lost weight should be fed by nasogastric tube (NG). Palliative enteral feeding by NG tube is safe, inexpensive, and has a low complication rate. NG feeding, rather than PEG, could be better than enteral feeding in children with cancer. Study group consisted of 107 deceased cancer patients who applied to the emergency service. In Group 1, there were 64 patients admitted to the emergency department at least once in a month before their death. Remaining 43 had never needed the emergency department within 1 month before their death (Group 2). Thirty-eight percent of patients in group 1 had lung cancer and the most common reason for presentation was dyspnoea (92%) and 26% of the patients in group 2 had colorectal cancer. In Group 1, 38% of the patients were discharged from the emergency room and 9% died in the emergency room. It was found that 10% of the patients in group 1 were hospitalised in ICU, and the rest were hospitalised in: oncology (28%), chest or infectious diseases (11%) and general surgery (4%) wards. Patients who applied to the emergency department. In the last month of their lives were positively correlated with tumour location (primary lung or lung metastasis), good performance status, presence of pleural effusion and the presence of pain.

Ekinci et al [144]
Turkish Poster Cross-sectional Characteristics of patients treated in a PC centre.
Most patient had cancer. Among the reasons of admission, the first was nutritional support.

(Continued).
Supplementary Age, time to diagnosis and number of chemotherapy cycles affect the symptoms of the children. The number of symptoms increased with higher age, longer time to diagnosis and higher number of chemotherapy cycles. Children who had their treatment in the hospital experienced physical symptoms more frequently. The most frequent symptoms were low appetite, irritability and difficulty in concentration.

Söğütlü Çetin and Kuran Akburak [155]
Turkish Poster Cross-sectional Symptoms experienced by patients receiving chemotherapy and factors affecting these symptoms.
The symptoms of fatigue and anxiety were found to be significantly higher among inpatients. Whereas constipation, alopecia, mouth problems were more frequent among outpatients.
Akyüz [211] Turkish Poster Cross-sectional PC practices for cancer patients. It was aimed to explore pain status of patients and propose an algorithm for treatment approach in patients with advanced stage cancer who were followed up in hospital, and to emphasise the importance of questioning the patient's pain. In addition, this importance of the pain, even in inpatients, reveals the necessity of careful pain management in outpatient follow-up. Pain palliation, which is one of the cornerstones of palliative treatment, should always be kept in mind in the treatment of cancer patients.

(Continued).
Supplementary The median visual analogue scale pain levels of the patients were found to be 8.5 (7-10) before morphine sulphate administration and 6.5 (4-7) after morphine sulphate administration. It was determined that the relatives of the patients used religious coping strategies widely and thought that it was advantageous to benefit from religious coping strategies. Benefiting from religious coping strategies in the treatment process might produce positive results for relatives of patients.

(Continued).
Supplementary As a result of our cultural values, we are able to reduce mental/psychological health problems the most. It may be possible to anticipate that the level of burnout and the standard of living will improve as a result of social support from the environment of cancer patients.

Öksüzoğlu [336]
Turkish Thesis Cross-sectional To evaluate the relationship between depression-burnout level and maintenance period observed in caregivers of PC patients.
The rate of depression is higher in caregivers who care for parents or partner. It was understood that the personal success scores of the depressive cases were lower, extension of the maintenance period and the inability to obtain support from the family members facilitated the emergence of the burnout situation.

(Continued).
Supplementary PC is a maintenance that should not be ignored in the current health system. It is not possible for emergency services alone to undertake such care, but it is not possible to exclude emergency services from this care.

Filiz [341]
Turkish Thesis Cross-sectional To determine the satisfaction levels of the patients in the PC centre in the health centres in Ankara and the factors affecting this level of satisfaction.
Completely dependent patients and patients who have had previous experience of bed rest have higher satisfaction levels. Better physical conditions of PC clinics, comfortable single patient rooms and having materials that they may need, positively affect patient satisfaction. In addition, nursing care satisfaction levels of nurses with higher education level, nurses with more clinical experience, and PC clinics with higher number of nurses are higher.

Saygılı [342]
Turkish Thesis Cross-sectional To evaluate the cost effectiveness of the PC services received by cancer patients who need PC with three different service models.
Receiving usual care at the public hospital was more cost effective than receiving care at the Palliative Care Centre from the social perspective. From the patient's perspective, home health care services model was more cost effective than the usual care at the public hospital model and the Palliative Care Centre model. When the gains in terms of quality of life were evaluated from the patient's perspective, the most cost effective model became the home health care services model again. When the patient satisfaction level was evaluated from the patient's perspective, the most cost-effective method was found as the usual care at public hospital model. The most cost-effective model in terms of the satisfaction levels and the care burdens of the families was found as home health care services model.

Gürakan [343]
Turkish Thesis Interventional To investigate the impact of aromatherapy massage on pain and plasma beta-endorphin levels in palliative cancer patients.
Aromatherapy massage can decrease pain intensity and increase plasma beta-endorphin levels in palliative cancer patients.

Ahmed et l [13]
Turkish Thesis Cross-sectional To comment on the use of narcotic analgesics.
Cancer pain is still one of the most feared entities in cancer and about 75% of cancer patients with pain require treatment with opioids for severe pain.

(Continued).
Supplementary Nurses' most important difficulty in giving care to the dying patient was communication with patients and their relatives. Attitudes of nurses towards giving care to the dying patient were more positive (t = 4.900; p = 0.001). Good death score median of female nurses was higher male nurses (p = 0.001).
There was a negative weak correlation (r = −0,158; p = 0.011) between nurses' level of adopting principles about death with dignity and their perceptions about good death; a positive weak correlation between attitudes of nurses for giving care to the dying patient and psychosocial-spiritual (r = 0.124; p = 0.011) and self-control subscales (r = 0.172; p = 0.006) of death. In general, patients and nurses defined end-of-life care as a time when painless death is near, physical and psychological needs increase and team collaboration is absolutely necessary. Although nurses want to provide the necessary care, they are not able to do so due to excess workload.

(Continued).
Supplementary Continuity of home care is essential and should be available 24 hours including weekends and holidays. The person who wants to receive home care can apply to the health institution in person or by phone. The call centre interviews the person requesting services and provides the necessary information. The person who wants to receive care at home will be visited by a physician and nurse. The care needs of the person and home conditions will be determined and a home care treatment plan will be developed. If necessary, patient consultation will be provided with specialist physicians. The Ministry of Health will provide medical care, rehabilitation, social and psychological support services to those individuals and family members who need home health services through establishing home healthcare units within the affiliated health institutions.

Ministry of Health [39]
Turkish Directive -Applicatıon procedures and prıncıples of PC servıces.
The purpose of this directive is to early identification of pain and other symptoms in patients having life-threatening diseases and to provide medical, psychological, social and moral support to these patients and their family members.
To establish PC centres define their functioning and physical conditions, the minimum standard of equipment and personnel. To determine the procedures and principles regarding the duty, authority, and responsibilities of the pallıatıve care servıces.

(Continued).
Supplementary The purpose of this Regulation; to determine the procedures and principles for ensuring coordination between institutions and organisations related to the provision, referral and administration of home health services (medical care, rehabilitation, social and psychological support to patients and their family members) provided by the Ministry and its affiliated institutes.