Publicly provided long term and palliative care for older persons in Montevideo

It is spring in Uruguay, and the air at Hospital Luis Piñeyro Del Campo, the only publicly funded home for older persons in Montevideo, is heavy with the scent of jacaranda trees planted throughout the spacious campus. Luis Piñeyro del Campo (1853-1909), for whom the home was named, was a constitutional lawyer, soldier, and founding father of the Uruguayan state. Educated by Jesuits, he was a key leader of the la Comisión Nacional de Caridad y Beneficencia Pública (National Charity and Public Welfare Commission). The Hospital for older persons we visited the other day is testimony to his prioritisation of the most vulnerable and the poor in Uruguayan society. 

I was in Uruguay for the World Health Organisation Global Conference on Non-Communicable Diseases, to advocate for the inclusion of palliative care in oral interventions and policy documents where appropriate, and to support our national partners in the Ministry of Health and the Uruguay Palliative Care Association. The President, Dr. Laura Ramos, a psychiatrist whose mission is to develop spiritual care for Uruguayans facing life-limiting illness,  arranged a visit for us to what Montevideans fondly call “Piñyero de Campo.”

Left to right — Dra. Laura Ramos, the author, Dra Sara Levy, and Dra Alejanda Ferarri

Laura’s colleague, geriatrician and palliative care Dr. Sara Levi, showed us around the campus, which used to be an asylum that was home to more than 1000 souls. It now has 216 beds, organised into five pavilions, depending on level of disability (including severe dementia) and care needs. Residents are mostly sixty-five and older, must be low-income, and with a diagnosis requiring residential care. The majority are “elder orphans,” with no family members to care for them at home. The exception are those who come for the daycare program while their family members work. 

We arrived just as lunch was ending and saw 45 residents in the “high dependence” ward, all in wheelchairs, some tied so they wouldn’t fall out, many with a sugary drinks and a banana in front of them. Some responded to greetings, but most were isolated in their own worlds.  Although it was as grim as the “memory care” wards in even the highest end “retirement homes” I have visited, the facility was airy and clean, and the staff seemed attentive and kind. Palliative patients are scattered throughout the pavilions until a dedicated ward is finished, hopefully early next year. 

IMG_8988We stopped by to check on Sarah, a103 year old patient in her last days, who was sleeping in the corner of one of the salas, or wards reserved for residents with mild disabilities. Doctor Sara told us how patients used to die here in terrible suffering until she was able to introduce palliative care in 2001. She recounts how when she first brought an ampoule of morphine in to the wards, she was greeted with horrified stares. Now the staff are trained to use morphine for patients with severe pain, and have overcome their initial opioidphobia.

IMG_8982Because the government of Uruguay recognises the right to healthcare, it provides its citizens with a basic package, which includes palliative care and controlled medicines, free of charge. A parallel system of private insurance offers a more comprehensive menu for those who can pay.  I have been privileged to go on home visits with doctors who provide both, and to visit the inpatient wards at the private hospitals, which provide excellent care to patients who cannot be managed at home.

IMG_8985Uruguay was one of the first countries to ratify the Inter-American Convention on Protecting the Rights of Older Persons, which recognises the government’s obligation to respect, protect and fulfill all the basic social, cultural, economic, and political rights of older persons, including the right to palliative care.  UN member states, through the Open Ended Working Group on Aging, have been debating whether or not to begin drafting a binding convention, similar to that protecting the rights of children, persons with disabilities, women, and indigenous groups, and will consider palliative and long term care in July 2018.  I hope Sara Levi will come from Montevideo to speak about those in her care at Piñyero del Campo.

Luis Piñyero del Campo would no doubt have approved of palliative care, a medical specialty that developed during the century after his death. His life and the hospital named for him, resonates with Pope Francis’ description of palliative care “an expression of the truly human attitude of taking care of one another, especially of those who suffer. It is a testimony that the human person is always precious, even if marked by illness and old age.”