Palliative Care in the Health System of Iran: A Review of the Present Status and the Future Challenges

A model for integrating palliative care into Eastern Mediterranean health systems with a primary care approach

BACKGROUND AND AIMS

Palliative care in the Eastern Mediterranean Region (EMR) faces challenges despite the high number of patients in need. To provide accessible, affordable, and timely services, it is crucial to adopt a suitable care model. World health organization (WHO) recommends integrating palliative care with primary health care (PHC). Given the unique conditions of EMR countries, there is a need to design a model tailored to these contexts.

METHODS

This study is a multi-method research project conducted through several sub-studies, including a literature review, policy analysis, expert opinion (Delphi Method), dimension-specific analysis, model development, and its validation and refinement (Delphi Method). Drawing from the WHO model, six dimensions: policy, drug availability, education, community integration, service delivery, and research were considered to developing the model and implementation requirements. Within each dimension, evidence-based solutions tailored to the region's context were explored.

RESULTS

A successful palliative care model requires, in the policy dimension, oversight by the Ministry of Health (MOH). Having a focal-person or working group within the MOH is crucial for policy-making, formulation, and approval of clinical guidelines, as well as addressing care challenges. It is essential to provide access to morphine and other essential medications, along with facilitating the administration and consumption of morphine at home. Conducting empowerment courses for care providers, can address various challenges. Community involvement through volunteers, charities, and non-governmental organizations (NGOs) is also important. To ensure service provision, monitoring and evaluating systems are crucial, along with striving for service continuity through an appropriate payment system. Lastly, research is necessary for needs assessment, evidence-based practice, and designing evaluation indicators. The proposed model relies on community health workers, especially nurses, as multitasking professionals available for community palliative care. In the presented model, special attention has been given to networking, collaboration, and the use of digital health technologies to support nurses.

CONCLUSION

The model proposed for integrating palliative care into PHC should serve as a framework that enhances access to available and affordable services for countries in the region. While this model was developed based on the overall conditions of the region, each country can tailor it to its unique strengths and opportunities.

Motivations behind end-of-life care: a qualitative study of Iranian nurses' experiences

BACKGROUND

Providing high-quality end-of-life care is currently a paramount health priority. Given that the standard of care is intrinsically linked to nurses' motivations, it is becoming too imperative to explore the contributing factors Consequently, this study was undertaken to elucidate the experiences of Iranian nurses regarding their motivation for delivering end-of-life care.

METHODS

This research is a qualitative, descriptive inquiry employing conventional content analysis, carried out at two governmental hospitals in Gorgan, northern Iran, from February to July 2023. 12 nurses were purposefully selected to participate in the study, ensuring maximal diversity. The data were collected through semi structured interviews and analyzed using Graneheim and Lundman's five-step method. The coding process was facilitated by the useof MAXQDA version 10 software. To establish rigor, the four criteria outlined by Guba and Lincoln were applied.

RESULTS

the participants included eight women and four men with an average age of 39.6 ± 6.31 years. The data analysis yielded five main categories and fifteen subcategories. The main categories were: "The Foundations of professional care in nursing", "Core Drivers in Optimal End-of-Life Care", "Family Involvement in End-of-Life Care", "Incorporating Spiritualism in Care" and "Dominant motivational Issues Within the Caregiving Atmosphere".

CONCLUSIONS

This study delineates the experiences that influence the provision of end-of-life care from the perspective of Iranian nurses. Innate traits such as empathy and a passion for nursing, in addition to nurses' moral compass and spiritual beliefs, serve as pivotal motivational stimuli. Leveraging these findings can be instrumental in shaping healthcare practices and policies to enhance the quality of end-of-life care.

Future scenarios of palliative care in health system of Iran: a multi-method study

Background

Paying attention to palliative care has accelerated in Iran in the last 10 years. Considering the trend of aging, increasing burden of chronic diseases and increasing health costs, planning and development of palliative care is necessary in the future. This study was conducted with the aim of explaining the alternative scenarios of palliative care in the health system of Iran until the horizon of 2030.

Methods

This study was a multi-method scenario planning with a qualitative using multiple methods design, which was conducted in 3 phases in 2018-2020. In the first phase, a list of driving forces was extracted using qualitative interviews and literature review. In the second phase, all factors identified in the previous phase were examined in terms of degree of uncertainty and cross-impact analysis, and two key uncertainties were extracted. In the third phase, based on two key uncertainties, four future scenarios of palliative care were formulated, validated and scenario strategies were presented.

Results

The results indicate two uncertainties, including "governance of palliative care in the health system" and "acceptance of palliative care by society," based on which, four scenarios with the names "climbing to the top," "excruciating climb," "edge of the abyss" and "The bottom of the valley" were compiled.

Conclusion

The development of palliative care in health system of Iran is faced with serious uncertainties that it is necessary to focus the developmental activities of palliative care on the two axes of acceptance by society and need for coherent governance by considering all the dimensions and influential components by ministry of health. The application of the results of this research can provide reasonable options for effective interventions and implementation of this category of services to the beneficiaries of palliative care.

Exploring the Challenges in Palliative Care As Perceived by the Saudi Physicians: A Cross-Sectional Study

BACKGROUND

Palliative care is essential for managing patients with life-limiting illnesses. In Saudi Arabia, providing effective palliative care is uniquely challenging due to cultural, religious, and social factors. Despite healthcare advancements, there is a gap in understanding the challenges faced by physicians in palliative care within this context.

AIMS

This study aimed to explore the challenges encountered in palliative care as perceived by physicians in Riyadh, Saudi Arabia.

METHODS

A cross-sectional survey was conducted using an electronic questionnaire distributed among physicians involved in palliative care at the specified healthcare institutions. The questionnaire assessed their perceptions of the challenges in palliative care and the influence of their socio-demographic backgrounds on these perceptions. Data were analyzed using the Statistical Package for the Social Sciences (SPSS).

RESULTS

The age distribution of the enrolled physicians showed that a majority were between 20-40 years old (48.48%, n = 96). Male physicians accounted for 64.65% (n = 128), and females for 35.35% (n = 70). Various specialties were represented, with critical care (15.66%, n = 31) and radiation oncology (16.67%, n = 33) being the most common. Major challenges identified included limited outpatient and inpatient services (54.55%, n = 108), restricted access to allied healthcare professionals (60.61%, n = 120), ethical dilemmas due to triaging (63.13%, n = 125), lack of telemedicine facilities (57.07%, n = 113), and the impact of the COVID-19 pandemic on pain and palliative care research (60.1%, n = 119). Strategies adopted to mitigate these challenges included creating triage systems (54.55%, n = 108), using telemedicine (60.61%, n = 120), advanced care planning (63.13%, n = 125), and providing necessary personal protective equipment (PPE) (60.1%, n = 119).

CONCLUSION

This study highlights significant barriers in palliative care, such as limited services, ethical dilemmas, and lack of telemedicine facilities. Addressing these challenges requires ethical support for healthcare providers, integration of telemedicine, continuous education, and improved access to multidisciplinary care teams, which are crucial for enhancing palliative care quality and ensuring comprehensive patient support.

Psychometric properties of Persian version of advance care planning questionnaire among older adults in Iran

INTRODUCTION

Advanced age is associated with life-threatening conditions at the end of life. Many of these persons at the end of their lives cannot make decisions because of the variable consciousness. They are able to make decisions and identify their care priorities, in a process called advanced care planning. So, an instrument is required for investigating ACP of the elderly population. This study was performed to determine the psychometric properties of the Persian version of the advanced care planning questionnaire(ACPQ) in elderly population referring to Tehran.

METHOD

This methodological study was performed in five hospitals in 2021-2022. A total of 390 eligible elderlies were included. The psychometric assessment including translation, face validity, content validity were performed Alsothe exploratory factor analysis and confirmatory factor analysis were assessed. Reliability were done by internal consistency by assessing Cronbach alpha and stability was performed using test-retest.

RESULTS

The face validity of the instrument was performed with minor changes. The content validity index for all of the items was above 0.79. In EFA four factors was extracted also CFA showed that the four-factor model has a good fit of the data (RMSEA: 0.04; NFI: 0.97 CFI: 0.99; IFI: 0.99; RFI: 0.96; AGFI: 0.87; GFI 0/90; standardized RMR: 0.02). Cronbach alpha and ICC were 0.72-0.94 and 0.85-0.96, respectively.

CONCLUSION

The Persian version of the advance care planning questionnaire has desirable psychometric properties for measuring the advanced care planning of the elderly population. In addition, healthcare providers in Iran can employ this questionnaire in their practice and research.

Systematic Review on Barriers to Access Opioid Analgesics for Cancer Pain Management from the Health Worker Perspective

The increasing incidence of oncological diseases creates a corresponding need for effective cancer pain management (CPM). The lack of access to and availability of opioid analgesics in most countries leads to avoidable suffering. This systematic review aims to identify barriers to accessing opioids, as described in literature that reflects the perspective of health-care workers. A systematic literature search was performed in May 2018 and updated in December 2022, using search terms related to "cancer pain," "opioid analgesics," "access," and "health-care personnel." Medline, Embase, and PsycInfo were searched. Forty-two studies met the inclusion criteria. Principal barriers that have hindered licit access to medical opioids include regulatory, systemic, educational, patient-related, and societal. These barriers are rooted in a lack of adequate education about the importance and significance of appropriate CPM. Barriers were often mutually reinforcing. A interdisciplinary approach is required to overcome them. This research contributes to the important global health issue of unduly limited access to opioid analgesics. It provides interdisciplinary solutions in terms of guidelines to ensure that governments respect, protect, and fulfill the right to the highest attainable standard of health, which includes the relief of severe pain.

Palliative care delivery models: a systematic scoping review protocol

AIM

This scoping review will map out the evidence for palliative care delivery models in hospitals and the challenges of their application in practice from 2012 to 2022. A list of the predetermined MeSH terms will be used to search electronic databases for the relevant literature in English or Persian.

METHOD

The Joanna Briggs Institute Reviewer's guideline will be used to qualitatively appraise the identified reports and to assess their scientific rigour. Information about the introduced models will be summarised in extraction sheets and a narrative synthesis of the retrieved data will be performed and tabulated for benchmarking analysis. The findings will be applicable for evidence-informed policy-making in health systems and in response to palliative care unmet needs. The study results could also be accommodated in decision-making processes for the adoption of an integrated PalC model to achieve enhanced organisational performance in clinical settings.

Caregivers' Knowledge of and Attitude towards Palliative Care in Iran

BACKGROUND

Addressing the palliative care needs requires clinicians to have sufficient knowledge of and positive attitudes toward palliative care. The study aimed to determine nurses' and physicians' knowledge of and attitudes towards palliative care in Iran.

METHODS

This descriptive cross-sectional study was conducted in 2021 on 493 physicians and nurses, selected through convenience sampling. Three online questionnaires addressing caregivers' demographic and professional's questionnaire, Health Care Providers' Attitude toward PC Questionnaire, and Health Care Providers' Knowledge of PC Questionnaire were used. The data was analyzed in SPSS using correlational and descriptive statistics and regression analysis.

RESULTS

The mean score of attitude towards palliative care was 142.03 ± 11.35 and the mean score of palliative care knowledge, 19.47 ± 2.62. Considering the regression coefficients between these two mean scores (P-value = 0.001, b = 1.304), it can be inferred that knowledge is a good predictor of attitude. In addition, the mean scores of knowledge and attitude have a significant relationship with age, female gender, holding a master's or PhD degree, the need for formal education in the field of palliative care and the need to take a palliative care course.

CONCLUSIONS

The present study showed that Iranian nurses and physicians have a moderate level of knowledge and attitude towards palliative care. It is necessary to take measures in order to improve knowledge and attitude by holding retraining courses, theoretical and clinical training sessions and relevant seminars in short term, and also by integrating related topics into nursing and medical curriculums in long term.

Experiences and perception of character strengths among patients with breast cancer in China: a qualitative study

OBJECTIVE

To explore the patients' experiences on character strengths that Chinese patients experience after the diagnosis of breast cancer.

DESIGN

A qualitative, exploratory study using semistructured interviews based on the patients' lived experience after being diagnosed with breast cancer. Ethics approval was granted. Interviews were audiorecorded and transcribed verbatim. Values in Action Classification of Strengths provided conceptual framework for analysing strengths. Directed content analysis based on the classification of strengths and framework analysis were used to analyse transcribed data. The Standards for Reporting Qualitative Research guideline was followed.

SETTING

The Second Affiliated Hospital of Zhengzhou University and Henan Provincial Cancer Hospital in China.

PARTICIPANTS

Adult patients over 18 years, diagnosed with breast cancer between October 2019 and December 2020 were recruited. We used purposive sample method to collected data from 24 participants diagnosed with breast cancer.

RESULTS

Six themes (virtues) emerged from our analysis. In addition, two new subthemes (character strengths) emerged in this study, selflessness and pragmatism, respectively. Patients with breast cancer described a large repertoire of character strengths they used or wished for during survivorship, including gratitude, hope, humility, kindness, humour, honesty and forgiveness. Cultural values (eg, collectivism, familyism, Confucianism and Buddhist beliefs) helped structure the experiences of Chinese patients' character strengths. Patients wanted their character strengths to be more noticed, appreciated and encouraged by others and reported their psychological trajectory of using personal strengths.

CONCLUSION

The findings indicated that patients with breast cancer believing character strengths are important to them. Medical staff should pay more attention to motivating and cultivating character strengths of patients with breast cancer. Attention to make strength-based practices workable in clinical health promotion programmes is necessary. The healthcare system should develop tailored individualised psychological services that specifically address patients' needs for the application of personalised character strengths.

TRIAL REGISTRATION NUMBER

NCT04219267, Pre-results.

Association between quality of life, sleep quality and mental disorders in Iranian older adults

Aging as a major challenge can affect the development and growth of countries all around the world. This study aimed to identify the subgroups of the elderly based on the quality of life (Qol), sleep quality, and common mental disorders and assess the role of demographic characteristics on the membership of participants in each latent class. This cross-sectional study was conducted on 1064 people over the age of 60 years. The sample was selected through cluster sampling in northern Iran. All participants completed six sets of checklists and questionnaires. Data analysis was performed using latent class analysis. Three latent classes were identified; namely, (1) healthy (66.8%), (2) anxious and with poor sleep quality (28.6%), and unhealthy (4.6%). Being Female significantly increased the odds of membership in classes 2 and 3 compared to class 1. Furthermore, living in urban areas increased the odds of belonging to class 2 and class 3 compared to class 1. Illiteracy was also shown to increase the odds of being in class 3 in comparison to class 1. Results from the present indicate that the co-occurrence of health problems in 33.2% of the elderly was observed in various forms. The results of this study can be used in prioritizing health programs for the elderly and emphasizing high-risk groups.

Preferred place of death and end-of-life care for adult cancer patients in Iran: A cross-sectional study

Background

More than 50,000 deaths in terms of cancer occur annually in Iranian hospitals. Determining the preferred place of end-of-life care and death for cancer patients in Iran is a quality marker for good end-of-life care and good death. The purpose of this study was to determine the preferred place of end-of-life care and death in cancer patients.

Method

In 2021, the current descriptive cross-sectional investigation was carried out. Using the convenience sample approach, patients were chosen from three Tehran referral hospitals (the capital of Iran). A researcher-made questionnaire with three parts for demographic data, clinical features, and two questions on the choice of the desired location for end-of-life care and the death of cancer patients served as the data collecting instrument. Data were analyzed using SPSS software version 18. The relationship between the two variables preferred place for end-of-life care and death and other variables was investigated using chi-square, Fisher exact test, and multiple logistic regression.

Result

The mean age of patients participating in the study was 50.21 ± 13.91. Three hundred ninety (69.6%) of the patients chose home, and 170 (30.4%) patients chose the hospital as the preferred place of end-of-life care. Choosing the home as a preferred place for end-of-life care had a significant relationship with type of care (OR = .613 [95% CI: 0.383–0.982], P = .042), level of education (OR = 2.61 [95% CI: 1.29–5.24], P = 0.007), type of cancer (OR = 1.70 [1.01–2.89], P = .049), and income level (Mediate: (OR: 3.27 (1.49, 7.14), P = .003) and Low: (OR: 3.38 (1.52–7.52), P = .003). Also, 415 (75.2%) patients chose home and 137 (24.8%) patients chose hospital as their preferred place of death. Choosing the home as a preferred place of death had a significant relationship with marriage (OR = 1.62 [95% CI: 1.02–2.57], P = .039) and time to diagnostic disease less than 6 months (OR = 1.62 [95% CI: 0.265–0.765], P = .002).

Conclusion

The findings of the current research indicate that the majority of cancer patients selected their homes as the preferred location for end-of-life care and final disposition. Researchers advise paying more attention to patients’ wishes near the end of life in light of the findings of the current study. This will be achieved by strengthening the home care system using creating appropriate infrastructure, insurance coverage, designing executive instructions, and integration of palliative care in home care services.

Psychometric Properties of the Persian Version of Palliative Care Outcome Scale (POS) in Adult Patients With Cancer

Background

Measuring the outcomes of palliative care plays an important role to improve the quality, efficiency, and availability of these services in patients with cancer. Using valid, reliable, and culturally appropriate tools has a considerable role to measure these outcomes. This study aimed to assess the psychometric properties of the translated version of the Palliative care Outcome Scale (POS).

Methods

This methodological study was conducted in two outpatient clinics related to Shohada Tajrish and Baqiyatallah hospitals in Tehran in 2019-2020. The translation was done using the Forward-Backward approach after gaining permission from the developer. Face validity was tested with 10 patients with cancer through cognitive interviewing, as well as content validity with four experts. Construct validity was performed by (n = 203) exploratory factor analysis and confirmation (N = 150). To assess the reliability, internal consistency was assessed by using Cronbach's alpha coefficient, and relative stability was assessed using the interclass correlation coefficient (ICC). Furthermore, interpretability and ceiling and floor effects were assessed.

Results

A total of 353 patients with cancer under palliative care were included in the study. Then, three psychological (30%), physical (12.25%), and social factors (12.08%) with a cumulative variance of 54.34% were extracted in exploratory factor analysis. Confirmatory factor analysis showed that the model has a good fit of information. Cronbach's alpha coefficient for scale was 0.719. Furthermore, the ICC was 0.812. The scale was interpretable, and ceiling and floor effects were 0%.

Conclusion

Persian version of the POS was evaluated as a valid and reliable tool. Therefore, it can be used by the clinician to monitor the consequences of palliative care in Iranian cancer patients.

Developing a Model for the Establishment of the Hospice Care Delivery System for Iranian Adult Patients With Cancer

Introduction

Making appropriate plans for the provision of hospice care is considered a perceived need in the Iranian health system. The current study aimed to develop a model for establishing hospice care delivery system for the adult patients with cancer.

Materials and Methods

This study is part (data of the third and fourth phases) of a larger study that has been done in four phases. This Health System Policy Research (HSPR) utilized a mixed qualitative-quantitative approach. At the first phase, a qualitative study was conducted which explained the care needs and the requirements for establishing this system from the stakeholders' perspective (directed content analysis). The second phase aimed to examine the current situation of hospice care delivery in Iran and identify and determine the similarities and differences among them in the selected countries (comparative study). At the third phase, the main areas of the model and the related indicators were extracted and prioritized by consulting with experts (Delphi survey). Then the model was formulated. At the fourth phase, the proposed model was validated and finalized in terms of importance, scientific acceptability, and feasibility.

Results

Based on the developed model the first and the most important step in establishing the hospice care delivery system is laying the groundwork in the health system which requires focusing on policymaking. It is necessary to establish hospice centers and implement public awareness raising programs, train, and supply expert manpower, strengthen family physician and referral process, formulate clinical guidelines, encourage the private sector and NGOs(Non-Governmental Organizations (NGOs).) to invest, develop end-of-life and hospice care service packages, and create quality care indicators. The proposed model had moderate feasibility.

Conclusion

This model was developed based on the current Iranian healthcare structure and the needs of terminally ill cancer patients. It can be used as a model tailored to the current state of the health system and community in Iran. It is suggested to use this model as a pilot at the regional level.

IRAN National Cancer Control Program (IrNCCP): Goals, Strategies, and Programs

Background

Annually, over 131000 new cases of cancer have been identified in Iran, with an increasing trend that is predicted to grow by 40% by 2025. The most important contributing factors to this increase are the improvement of the health service delivery system, increased life expectancy, and the aging of the population. The aim of this study was to develop Iran's "National Cancer Control Program" (IrNCCP).

Methods

The present study is a cross-sectional study that was conducted in 2013 using the method of reviewing studies and documents and focused group discussions and a panel of experts. In this study, the available evidence related to cancer status and its care in Iran and other countries, as well as national and international upstream documents, were reviewed and analyzed. Then, by analyzing the current situation in Iran and other countries and conducting stakeholder analysis with the strategic planning approach, the IrNCCP was developed with a 12-year horizon consisting of goals, strategies, programs, and performance indicators.

Results

This program has 4 main components, including Prevention, Early Detection, Diagnosis and Treatment, and Supportive and Palliative care, as well as 7 supporting components including Governance and policy-making, Cancer Research, Developing facilities, equipment, and service delivery network, Providing and managing human resources, Providing and managing financial resources, Cancer information system management and registry, and Participation of NGOs, charities, and the private sector.

Conclusion

Iran's National Cancer Control Program has been developed comprehensively with cross-sectoral cooperation and stakeholder participation. However, like any long-term health intervention, strengthening its governance structure both in terms of implementation and achievement of expected goals and evaluation and modification during the implementation of the program is essential.

Current State of Palliative Care in Iran and Related Issues: A Narrative Review

BACKGROUND

Palliative research studies seem to be limited and disperse in Iran. The present study was therefore conducted to review and categorize the Palliative Care (PC) studies performed in Iran in terms of the research type, the type/focus of PC, the measured outcomes in interventional palliative studies and their related results, the disease type, and their geographical distribution.

MATERIALS AND METHODS

This narrative review was conducted in 2021 in which both Iranian and international databases including PubMed, Scopus, Web of science, CINAHL, ProQuest, Magiran, SID, Noormags, ISC were searched. The inclusion criteria were original articles conducted in Iran and results published in Persian or English journals ab initio in which PC was assessed as a variable (dependent or independent) or the main concept.

RESULTS

A total of 1096 articles were identified from which only 44 articles were reviewed. The research studies were mainly focused on cancer and majority conducted in Tehran. Majority of studies were quantitative-interventional leading to a variety of positive changes in dependent variables, including reduce in pain severity, change in life pattern, a good response to therapy, increase life expectancy, improve in dysphagia, improve quality of life, reduce patients' metastasis, and increase in nurses' self-efficacy.

CONCLUSIONS

The PC studies distributed across different fields and cities in Iran resulted to a number of positive outcomes for patients. More focused and robust research studies with different patients need to be conducted in this emerging field in Iran.

Assessing the compliance of educational curricula of selected disciplines with the content standards of cancer-related palliative care

BACKGROUND

Management of cancer complications requires the provision of palliative care as a comprehensive care by the main and trained members of this method of care. The aim of the present study was to assess the compliance of educational curricula of selected disciplines with the content standards of cancer-related palliative care.

MATERIALS AND METHODS

In this descriptive-comparative study, the content standards of palliative care for nurses, physicians, and social workers were identified based on the World Health Organization guideline and Oxford Textbook of Palliative Nursing. For this purpose, a separate checklist was prepared for the disciplines with different dimensions. Then the face and content validity of the checklists were checked. Finally, we examined the coordination between selected curricula available on the website of Education Deputy of the Ministry of Health, Treatment and Medical Education with the dimensions of the checklists.

RESULTS

All three curricula in most domains were relevant with the content standards, but there was the biggest education need in the areas related to the dimensions of "planning and educational," "educating physician in palliative care," and "considering patient preferences" in these disciplines.

CONCLUSIONS

To meet the educational needs, it is suggested to change some course topics, hold training courses, or joint workshops.

Transitional Cancer Care Program from Hospital to Home in the Health Care System of Iran

OBJECTIVES

Transitional care program refers to the health care continuity during transferring from one health care setting to another or to home. This is an essential program for cancer patients and reduces the risk of unnecessary hospital admissions as well as the complications of the disease. The aim of this study was to develop a transitional cancer care program from hospital to home in the health care system of Iran.

METHODS

This study is a health policy and system research. It was conducted in four stages from October 2019 to January 2020. The first stage was a qualitative study. The qualitative data were collected through semi-structured interviews with 24 participants and a focus group with eight experts. In the second stage, a literature review of transitional care models was carried out. The initial version of the transitional cancer care program was developed based on the qualitative results and the literature review in the third stage. The validity and feasibility of the program were assessed using the Delphi study in the fourth stage.

RESULTS

Six major categories were extracted from the qualitative results, consisting of "integrated services for the continuity of care", "holistic care", "care standardization", "the use of telemedicine", "the transparency of rules" and "the care process provision". Using these results and extracted the three common models of transitional care, the initial program was developed in three phases of pre-discharge, post-discharge, and transitional care with six protocols. The content validity of the program (98.7%) and its feasibility (95.8%) were approved by experts in the Delphi rounds.

CONCLUSIONS

It is necessary to revise hospitals' discharge program, and home health care center's plan for admission and delivering health care services for cancer patients. Also, a pilot program is necessary to find the system advantages and disadvantages.<br />.