BUCHAREST -- The pain was unbearable, says Ion Andrei when describing the 13 days he spent in the intensive care unit (ICU). It was so excruciating, he says, that he couldn't even move.
The 72-year-old had gone for a routine checkup at the hospital after complaining of abdominal pain. The news wasn't good: Andrei was diagnosed with cancer and the recommended course of action was palliative care -- the branch of medicine that focuses on symptom relief rather than the treatment of the underlying disease.
After recovering from surgery, Andrei was admitted to a different facility, Casa Sperantei, a private palliative-care unit in Romania's capital.
It was a night-and-day difference between the care at Casa Sperantei and in the state ICU, Andrei says from the lakeside facility, which is surrounded by weeping willow trees.
At the state hospital, there simply weren't enough staff, he explained: "It wasn't that they didn't want to [help], they just couldn't." At Casa Sperantei, he added, "there is almost a nurse for every patient."
Dying well is not easy in Romania, and facilities like Casa Sperantei --which also offers subsidized and pro bono care -- are rare. With insufficient state funding and a lack of trained staff, most Romanians spend their final days in the ICU or on regular hospital wards. And with an aging population and increasing rates of chronic diseases, the need for high-quality palliative care in Romania has never been more urgent.
Hospital Scandal
The state of critical and palliative care has recently been thrust into the public spotlight following a scandal at the St. Pantelimon Emergency Hospital in Bucharest, where two doctors have been accused by prosecutors of causing the death of a critically ill 54-year-old patient by deliberately reducing their medication.
"Palliative care in Romania is like a preschool child," said Aurelia Feraru, the head of the Oncology Department at Bucharest's St. Luke's Hospital for Chronic Disease.
While working as a doctor in Ireland for several years, Feraru got firsthand experience of how other countries approach palliative care. "There is a lot of emphasis on [patients'] independence. In Romania, when we talk about a terminally ill patient, we think of a patient in bed, who is in a lot of pain and is permanently dependent on someone. The end for Romanian patients is not exactly dignified," she said, carefully choosing her words.
Romania is not alone in having inadequate palliative care. According to the World Health Organization, 56.8 million people -- including 25.7 million in their last year of life -- need palliative care. But only about 14 percent of people get it. In a recent study in the Journal Of Pain And Symptom Management, Romania ranked 41st out of 81 countries in palliative-care provision.
According to a 2019 government report, Romania could provide hospital beds for only 36 percent of the 5,530 patients in need of end-of-life care. Of the 176,156 people who needed palliative care annually, only 19 percent of patients received it. Twelve out of Romania's 41 counties don't have any palliative facilities at all.
The Health Ministry disputes these numbers and says that the situation is not so dire. In a September 4 statement, Health Minister Alexandru Rafila, who declined an interview with RFE/RL, said that the situation had since improved and that Romania needs approximately 4,000 palliative-care beds. "We currently have 3,300," Rafila said.
Not Enough Drugs
But speaking to Romanian doctors, the extent of the problem is clear: palliative care is severely underfunded and understaffed.
Daiana Jianu, the medical director at St. Luke's Hospital in the capital, says her hospital with 311 beds has a total of 14 nurses, working in shifts on both regular and palliative-care wards. That's totally insufficient, she adds.
It isn't just the number of staff but their training, says a senior manager at a hospital in Barlad in northeastern Romania "The problem is that there is a lack of specialized doctors," said the manager, who did not want to be identified.
According to the government's 2019 report, there were only 610 doctors in Romania with an additional qualification in palliative care, just over half the required amount.
Drugs commonly used in end-of-life care are also in short supply. Oncology head Feraru notes that while Romania only has two types of opioids available -- fentanyl patches and morphine -- Ireland has nine varieties of morphine alone.
This has all meant that an increasing number of patients and relatives are choosing to pay for private care. But facilities such as Casa Sperantei -- which can cost up to 2,000 lei ($420) a day -- are unaffordable for the vast majority of Romanians.
On September 4, Prime Minister Marcel Ciolacu announced a plan to make improvements in the field, covering inpatient, home, and outpatient services, but the details remain scarce.
Conversations No One Wants To Have
As medical staff are keen to point out, there is more to good palliative care than drugs, equipment, and staff. It is also about providing emotional support to patients and their families.
Cristina Ion, a clinical psychologist, has been working at Casa Sperantei for almost two years now. "Patients want to feel close to someone. They need acceptance, because sometimes it is difficult for them to come to terms with the past and especially the future," Ion said.
"We take the time to talk to patients," said Dan Malciolu, a doctor at Casa Sperantei, and "ask them what is troubling them both in body and soul. And then we try to draw up an intervention plan to [help them]."
For medical staff, sometimes the hardest part is having to explain to concerned relatives that their loved ones are nearing the end. "Family members come and ask us what we are going to do to cure the patient," Malciolu said. "The answer is usually a few seconds of silence, and [then we say] that we will do everything possible to alleviate the patient's suffering."
There is a peaceful silence down near the lake at Casa Sperantei, and the air seems cleaner and fresher than in the rest of the capital.
Patient Andrei is in a good mood. Apart from numerous doctors and nurses, he has seen a physiotherapist and a psychologist, he says. He's even been doing some gymnastics.
When asked why he is so happy, he smiles and says he was remembering his younger days, when he was working at the Interior Ministry, liaising with the rescue and emergency services.
"That's just how I've always been," he said. "My colleagues...called me 'The Joker.' Because if I'm glum, do I gain anything?"
