Conference on Palliative Care

A scientific practical conference "Palliative care. Modern experience of the Russian Orthodox Church" took place on December 14-15, 2018 in Moscow, in the Central Clinical Hospital of St. Alexiy. It was jointly organized by the Central Clinical Hospital, Resource Center for Palliative Care of St. Dimitry Sisterhood, Department for Church Charity and Social Service and Russia Round Table / DECR. The conference evaluated almost three decades long experience of Church's palliative activity and was timed to the 115th anniversary of the hospital.

The conference was attended by 160 participants - heads of public health institutions, ministries and agencies, representatives of Holy Synod departments, dioceses of the Russian Orthodox Church - spiritual fathers of sisterhoods, heads of social departments. Among the conference participants were sisters of mercy from different regions of Russia, mainly from those that are actively developing palliative care for people living with HIV/AIDS (PLWHA): Moscow, Khabarovsk, St. Petersburg, Ufa, Arkhangelsk, as well as members of the Union of Orthodox Sisterhoods of Belarus.

The conference was opened by Bishop Panteleimon of Orekhovo-Zuevo, Chairman of the Department for Church Charity and Social Service, the Vice-Chairman of the Board of Trustees of St. Alexiy Hospital. He said: "For the last two years, our hospital has been returning to its original activity: the hospital has been initially established for terminally ill people. Now it has a large palliative ward, which is unique - people from all over the country are being treated here. As soon as the Church was given the opportunity to go to medical institutions and help those in need, first of all came priests, sisters of mercy and doctors that wanted to help people with serious illnesses. And today the Church has 25 years of experience in providing palliative care."

The head physician of St. Alexiy Hospital Zarov A.Yu. in his speech noted that this year the hospital celebrates its 115th anniversary. Today it is the largest medical institution of the Russian Orthodox Church. In this multidisciplinary medical clinic for 280 beds, people from all regions of Russia are treated, regardless of their confession. For all patients, examination and treatment are provided free of charge. The hospital has a palliative unit for 65 beds, in which 90 employees, sisters of mercy and volunteers work. The hospital has a mobile palliative care medical service. Telling about the history of the hospital, he noted that it was established in 1903 for incurable patients, and later a poorhouse was opened there. As such, the hospital existed until 1918, after which it was closed by the Soviet authorities. In 2016, almost a hundred years after the closure of the hospital, the palliative unit reopened. "Opening of the palliative department was a major event in the life of the hospital. Apart from the palliative ward, we have a multifield hospital, open new departments, but it is the palliative care that is the main mission of St. Alexiy Hospital, "A.Yu. Zarov noted.

Ye. V. Polevichenko, Dr. habil. med., chief external expert in children's palliative care, Ministry of Health of the Russian Federation, Professor of Oncology, Hematology and Radiation Therapy Department of the Pediatric Faculty at the Pirogov Russian National Research Medical University, Board member of the Association of professional participants in hospice care spoke in her report "Palliative care as an ethical obligation of modern medicine," about principles of providing palliative care for children; the importance of psychological, spiritual and religious support for parents, their dying children and medical staff; how to talk with believers and nonbelievers about the approaching death. She noted that all parents of terminally ill children ask the same questions: "Why does God let it happen? Why does it happen to me and to my child? Why live? What do I really believe in? We often did wrong; we are punished; How can I fix this? How to believe in life after death? What is it like? Will I receive forgiveness? "

"For me, as a doctor, this is a "marker" for spiritual support, a proof that spiritual processes inside a person turned on. The doctor does not need to rush to answer these questions himself. It is necessary to find a person who can provide spiritual support better than me. It is almost always possible to find such a person is, because all palliative departments and hospices cooperate with priests"? - Ye. V. Polevichenko said.

She also noted that "bans on talking about imminent death and a poor prognosis of the disease lead to isolation and loneliness. The more openly you can discuss the bad prognosis of the disease, the less do the relatives suffer over the passing away of the loved one. "

Dying people being on death's doorstep also often ask the same questions: "Am I going to die? When do I die? Will it hurt? Will I suffer? Why me? What will happen after I die? Do I need to do something? What will happen to my loved ones? Am I a burden? Will I have time to do something for the last time? Can I change something? Can I remain myself?"

Ye. V. Polevichenko stressed: "Not only answers to these questions need to be found, but also solutions: you need to understand what members of the palliative team or who from outside will be able to quench their thirst and answer these questions that seem to have no answer. "

Experts give some advice on how to talk with a dying child: first of all, you need to remove the ban on talking about death, existing in some traditions; do not play the game "I know that you know that I know"; At the same time, "it is necessary to have a special tact in order to say what is happening, and at the same time not to scare the child and not to destabilize his relatives. This requires special skill. "

One needs to take into account that the medical staff has a "self-defense mechanism" - a distancing tactic: pretending a heavy work load, which allows to reduce the time of contact with the patient; superficial, non-empathic listening or comments like " there's no money, but you hang in there!"

Dr. V. Polevichenko told about the new initiative of the Moscow Health Committee - on perinatal palliative care as an alternative to euthanasia of the newborn babies, prohibited by law in Russia (Federal Law No. 323), but already introduced in some European countries.

A woman carrying a low viable child undergoes a perinatal case conference, at which doctors most often incline her to abortion. The model of perinatal palliative care implies the inclusion in the team of experts conducting a case conference, a specialist in palliative care for children and a clergy. This model assumes that after the birth of a child with disabilities, palliative care will be provided to the family. "Parents can give birth to a week baby, care for him, bury him, move beyond and be parents for a new child, while not feeling guilty for their whole life, understand that they did not kill anyone, served their mother duty for a child who for some reason was born sick. This is the palliative care path."

To prevent emotional burnout and rehabilitate staff working in the palliative services, spiritual support is needed - not only confessional, but spiritual support in a wider sense. "This is the most important screw on which all other rehabilitation components are screwed."

She drew the participants' attention to the fact that the website of the Association of professional participants in hospice care (http://www.pro-hospice.ru) offers many interesting materials, and among the experts of the Association there are a lot of aware people, who are ready to cooperate.

On behalf of the Moscow City Health Department, specialist of the Public Relations Office Mr. I Sun Cher made said a word of greeting. He thanked the Russian Orthodox Church for cooperation, noting that there are more than 200 temples on the territory of the city's medical organizations, where patients and their relatives can receive spiritual help. Medical workers also receive great spiritual support. The Church makes an immense contribution to prevention of abortions, to provision of palliative care.

"We understand how important it is for a person to have ae healthy body and healty soul. Only by joint efforts can we achieve the desired results, "said the representative of the Health Department.

The head physician of the Moscow Infectious Clinical Hospital (ICH No.2) Krasnova S.V. made a presentation on the cooperation of the hospital with St. Dimitry Sisterhood.

"Our interaction started over 10 years ago. We have a common cause and we have remarkable results. Today we can't imagine our hospital without sisters of mercy and volunteers who work with us on a daily basis. Your work is important not only for patients, but also for employees," - Svetlana Vasilyevna emphasized.

The peculiarity of ICH No.2 is that people with HIV infection are being treated here: 400 out of 810 beds in the hospital are there for patients with HIV. The city AIDS center is situated on the hospital territory. "Given the special attitude towards this disease in society, hospital patients are in great need of spiritual help," - she said.

ICH No.2 and sisterhood have been cooperating since 2007. The purpose of this collaboration is charitable care for seriously ill patients in the terminal stage and for patients without family care. Today, 6 sisters of mercy and 24 volunteers care for patients in 4 wards of the hospital, provide them with social and spiritual assistance. Volunteers take courses in the basics of nursing care and palliative care at St. Dimitry School of Sisters of Mercy, and then improve their skills in trainings, have introductory training in the hospital, work closely with senior nurses and doctors.

Especially important is the assistance of volunteers in the children's department that has 20 beds for children with HIV infection, where orphans often stay. Sisters of mercy, who have pedagogical training, work with children every day. The main task of the volunteers in the hospital is to reduce the hospital syndrome in orphans. Some kids were born with a drug "withdrawal" syndrom. Volunteers take care of young patients, take them in their arms, feed them, make light gymnastics. For older children, volunteers read books, play, draw, talk on various topics. Sisters of mercy also communicate with mothers of young patients who also have HIV-positive status and who have many problems. Children born at the hospital are transferred to a specialized orphanage, where sisters of mercy also accompany them; mothers with children, if necessary, are taken to the Crisis Center.

Sisters of mercy help patients prepare for Church sacraments, accompany them to services in the St. Panteleimon Church on the hospital territory. A priest visits sick patients in the wards, administers sacraments for those who cannot come to the Church. "Our patients need daily communication: answering their questions from a Christian point of view, helping them to accept their difficult situation is as important as bandaging. Hospital staff do not have the time or appropriate training. So this is done by sisters of mercy, "- said the head physician of the hospital.

From 2007 to 2018 3,850 patients of the hospital received medical and social care; 230 patients were referred to social adaptation and rehabilitation centers; 360 patients re-established contact with relatives and were sent home, thanks to the help of volunteers and sisters of mercy. 13 patients and their families are currently receiving targeted assistance. 1,550 patients attended the hospital Church since the opening of in 2014 and up to 2018, they were accompanied by volunteers. Since opening of the children's department in 2016 and until 2018, 20 children from 7 months to 2 years old received help from volunteers and sisters of mercy.

"The participation of sisters of mercy is very significant for us, and their work proves: together we can do a lot," emphasized S. Krasnova concluding his speech.

Specialist on epidemiological issues of the Central Research Institute of Epidemiology of Rospotrebnadzor Dementieva L.A. made a presentation on "HIV infection in Russia. Challenges in help and support". At the beginning of her speech, she noted that the Russian Orthodox Church makes a great contribution to helping people with HIV infection, this ministry is very much in demand in the society. It is difficult to overestimate the importance of the Concept of participation of the Russian Orthodox Church in overcoming spread of HIV / AIDS adopted in 2004, as a document expressing the position of the Church on this issue. Speaking about the HIV / AIDS situation, she noted that there are 36.9 million people in the world living with HIV and a similar number of people has already died from this disease. Thanks to the efforts of specialists, the number of new infections is gradually decreasing (in 2017 - 1.8 million people). The world's epidemic is slowing down, partly due to the fact that over 70% of HIV-infected people are already receiving therapy that prolongs their life.

According to personalized statistics, about 998,000 prs. live with HIV in the Russian Federation. There is a government strategy to counteract the spread of HIV in the period up to 2020, within which a number of government ministries and agencies are actively involved in the fight against AIDS.

In recent years, the country has seen a positive shift in the fight against HIV infection in many areas: coverage of HIV testing (carried out not only in medical institutions, but also during various anti-AIDS campaigns) has increased 1.3 times compared to 2015 and amounted in 2018 to 38.39 million people (37% of country's population). The coverage of patients with antiretroviral therapy (ART) has increased: today 430.000 patients receive ART, i.e. 58,9% of those registered at dispensary (in 2006 14,000 people received ART). More drugs for HIV treatment (over 60%) are now produced in Russia, thereby reducing the cost of treatment. New factories for the production of ART drugs have been built; New Russian test systems for HIV have been created. The increase rate in HIV infection incidence in the country is going down from 13.4% in 2012 to 2.2% in 2017; in 2018 the growth rate was 2.0% (about 90.000 new cases were detected). The proportion of people infected with HIV by injecting drug use decreased from 56.1% (2012) to 42.5% (2018). This, in particular, is associated with a change in the structure of drug use: a decrease in the proportion of opioids (down to 30%) and an increase in the consumption of new synthetic drugs. The proportion of adolescents and young people among newly diagnosed PLWHA decreased from 70% in 2001 to 1.1% in 2017. The proportion of sexual transmission is growing: among those newly diagnosed in 2018, 54,8% were infected during heterosexual contacts (in 2017 - 53.5%, 2016 - 48.7%). HIV infection is most widely spread in Ural and Siberia regions.

Great success was achieved in preventing vertical HIV transmission: it is less than 1%. Since the beginning of HIV infection registration in Russia, 189.504 children have been born to HIV-infected mothers, this number increases annually by 15.000 - 20.000 prs. Gradually, a cohort of children born with HIV infection is growing in society; today they count almost 11.000 prs. These children, especially in teenage, seriously suffer because of their diagnosis. They need spiritual, social, psychological help.

More and more new cases of infection are detected among people aged 30-40 years. The trend of "aging" of HIV infection is also observed in other countries. In Russia, more than 7% of newly detected cases in the past year are people over 50 years old. Older people find it to learn about their illness, they often get depressed, they need psychological support.

The average age of death of HIV-infected is 39 years. The main cause of death is tuberculosis: 24,8% of PLHA have died of it, 3,4% died from drug overdose, 1,8% suicided, the number of people with cancer increases. Dementieva L.A. especially stressed that HIV-infected people need palliative care. It is especially disturbing that many young women aged 30-35 are leaving this life, probably also due to the loss of hope for the future. They need spiritual help from the Church. It is also worrying that the girls now become infected at a younger age than men.

"Today we know a lot about this disease, but we still cannot stop its spread. Probably, for this for this we need spiritual formation, we need to work more with the family, " - said Larisa Aleksandrovna.

She stressed that any health worker and sister of mercy may encounter HIV infection in their work, therefore infectious safety is very important in hospitals. There are few registered cases of occupational infection, but there are cases of HIV transmission from one patient to another due to the wrong actions of health workers.

In conclusion, L. A. Dementieva expressed her hope for the continuation of mutually beneficial cooperation between state and religious organizations in the prevention of HIV infection and assistance to people affected by this disease.

Nelyubova M.B., a DECR staff member made a presentation on "Church and palliative care - a 25 years long journey". She noted that over the past 25 years, considerable experience has been accumulated in various areas of diaconal work, including in the field of christian medical ministry, which is highly in demand in society and in the Church. Back in the period of restoration of Church related social service in the 1990s, care provision was one of the first areas of Church diakonia. Several sisterhoods and Orthodox charitable organizations, mainly in Moscow, St. Petersburg and Novosibirsk, played a leading role in the process of formation and development of Church medical ministry in those years. Among them are the St. Dimitry Sisterhood and the Marfo-Maria Sisterhood in Moscow, St. Elizabeth Sisterhood in the Novosibirsk Akademgorodok, St. Elizabeth Community in St. Petersburg.

"From the very beginning, the care provided by the Orthodox sisters of mercy was complex: it combined medical care, social assistance, spiritual support and help to the patient's family. In fact, this was a model of palliative care in the broad sense, in the sense of a later interpretation of this concept by WHO, as a comprehensive assistance to the patient and his relatives throughout the entire period of incurable disease. At the same time, the very word "palliative" in relation to the work of sisterhoods began to be used relatively recently.... Back in the 1990s, when in our country the concept of palliative care was used mainly in relation to oncology patients and hospices, Orthodox sisterhoods have already applied this concept to a wider range of patients, including patients with multiple sclerosis, gerontological diseases, Alzheimer's disease, post-stroke conditions, etc. ... The care model created by nurses is quite universal: it is applicable both to adults with various diseases and also to children ".

Formation of palliative care as a field for involvement of communities of mercy occurred gradually. Sisterhoods developed their own experience, studied the experience of foreign partners. Since the beginning of the 1990s, many training courses for sisters of mercy have been conducted by Russian and foreign specialists, sisters attended trainings in different countries. Interregional interaction and exchange of experience within Russia was also established. Many remarkable methodical manuals and textbooks on palliative care have been written and published.

An important milestone in the development of palliative care by Church specialists was establishing of the Resource Training and Methodological Center for Palliative Care, which has two main fields of activity: provision of practical nursing care for patients and training for palliative care. The Center made a significant contribution to the further development of this area.

Thanks to his efforts, a serious educational and methodical base has been created: manuals, training programs. Volunteer training courses are run, field seminars are held in various dioceses, where local sisterhoods and secular partner organizations are trained.

At the end of her speech, M.B. Nelyubova noted that at present moment, serious instruments have already been developed to support charitable palliative ministry: educational institutions and courses, action plans, methodological aids and curricula. Society and the state have changed their attitude towards this ministry: mistrust has gone, instead, respect and willingness to cooperate have come. The most important thing is that with the hands and hearts of sisters and brothers of mercy, many thousands of people suffering from distress and pain, received comfort, help, healing from anguish of body and mind.

O.Yu. Egorova, project director in the Orthodox Service of Mercy presented a report on "Orthodox Sisterhoods of Mercy in palliative care" and told about the history of the Association of Sisterhoods of Charity of the Russian Orthodox Church, which was established in 2005, and today unites 300 communities in Russia. In Moscow today there are 18 sisterhoods, 60 groups of mercy at Orthodox Churches, 6 homes for elderly. She noted that the conference brought together representatives from several Russian dioceses - Arkhangelsk, St. Petersburg, Ufa, Khabarovsk, Khanty-Mansiysk - in which sisterhoods are most active in the field of palliative care, as well as members of the Union of Orthodox sisterhoods of Belarus, with whom the Association works closely together. Sisterhoods consider it their important task to spread merciful attitude of patients among health workers. Today, many graduates of the St. Dimitry School of Sisters of Mercy who work in leadership positions in Church and state hospitals also deal with this challenge.

Olga Egorova told about the Orthodox Service for Palliative Care for HIV-Infected, which operates under ICH No.2 and is a model project that can be replicated in other hospitals and regions.

She also reported that the All-Russian Occupational Classification (Order of Rosstandart from 12.12.2014, No. 2020) included the profession "medical nurse of mercy", but there are no instructions on how it should be realized. To promote this important profession, additional efforts are needed from the state health authorities.

Priest Alexiy Lebedev, spiritual father of the St. Petersburg St. Elizabeth Diocesan Sisterhood of Mercy, made a presentation on "Experience of Church and Volunteer Services of the St. Petersburg Diocese in Palliative Medicine". He noted that in the northern capital there are 19 sisterhoods, which have about 300 sisters of mercy and 200 volunteers. All of them provide spiritual, social and psychological assistance to their patients. 17 communities serve in palliative care institutions. Two communities - St. George and Mother of God ikon of Tikhvin - have a different ministry: one of them takes care of the memorials, preserving the memory of the fallen soldiers, care the veterans of the Great Patriotic War; another community carries out social service at the parish. Much attention is paid to the education of sisters of mercy and volunteers: the Diocesan School of Sisters of Mercy has been active for 4 years. Under the agreement between the sisterhood, hospice and medical college, courses for junior nurses are run, after which students receive state certificates in the specialty "assistant nurse of palliative care" and diocesan certificates of graduation from the school of nurses. From 2019, a branch of the School of Nursing will start off at the Military Medical Academy. The diocese has established a sisterhood council, which includes spiritual fathers and senior sisters of the communities of mercy. At annual council meetings, its members meet new communities, priests and sisters share experiences of palliative ministry. Every year, the Diocese holds a Forum of Mercy, in which not only Church workers participate, but also leaders of relevant municipal institutions. The first hospice in Russia in Lakhta has been operating since 1990, Orthodox volunteers work here: they regularly visit patients on holidays, arrange concerts. Seminary students complete here a social internship: they visit patients, communicate with them, give solace. "Palliative medicine for dying people shall give love. Not only for the patient, but all of us need love. If there is no love in a person, there is no person in him either", - said Fr Alexiy in conclusion.

Archpriest Alexiy Denisov, Head of the Department of Medical Social Service and Charity of the Arkhangelsk Diocese, spiritual father of the diocesan sisterhood of mercy, presented the report on the "Experience of cooperation of the Arkhangelsk and Kholmogory diocese with health care institutions in the organization of palliative care".

He noted that the St. Alexandra Feodorovna Romanova diocesan sisterhood in Arkhangelsk has been operating since 2002, it has currently 109 members, including 48 active members, 17 candidates, 4 permanent volunteers. Sisters of mercy assist about 6.000 patients per year. The cooperation with state institutions in the social sphere started from the time, when the department for medical and social ministry and philanthropy of the Arkhangelsk diocese has been established in 1992. In 2000, with the blessing of the Bishop Tikhon of Arkhangelsk, the regional NGO "Rassvet" has been established to develop social charitable ministry. Some"Rassvet" projects aimed at revival of sisterhoods movement. In this work, the diocese closely cooperated with the sisterhoods and Church related NGOs in Moscow and St. Petersburg, and with the hospice in Lakhta.

The first "core group" of the sisterhood was made of 20 Bible courses students from the Holy Trinity Church. They have been trained for nursing at the city medical college, with which a cooperation agreement has been concluded. The college has developed a special program for 72 hours sisters, and also regularly conducts advanced training courses for them. For the past five years, volunteers from among the medical college students have attended hospital service along with the sisters of mercy, which was credited as internship. At the request of the sisterhood the college teachers on a voluntary basis hold seminars on various aspects of palliative care. The experience of the Moscow and St. Petersburg sisterhoods prompted the signing of a cooperation agreement between "Rassvet" and the city hospital in Arkhangelsk, in which the sisters initialle were working in 2 departments. Now they are working in 11 departments of hospitals in Arkhangelsk, Severodvinsk and Novodvinsk. Coordinators were appointed from among the nurses of these hospitals who supervise the work of the sisters of mercy. Studying the experience of sisterhoods from other regions helped to avoid some difficulties in relations between sisters and hospital staff, sisters try to be sensitive not only to patients, but also to hospital staff. "Today, both patients and medical staff are waiting for us in hospitals. Waiting not only for free hands, diapers, etc., but also for a warm relationship. They expect us to help in what the hospital staff do not have enough time for: to wash, to shave, to talk, to spoon-feed. Attimes we need to counsel, comfort, support the patient and his family. Sometimes we spend more time with the family members, than with the patient: we teach them to care for a bed ridden patient, this helps them to cope with helplessness and fear of the loved one's illness. An important aspect of cooperation with public health institutions is holding of joint seminars and conferences: a number of activities were held under the Ministry of Health program in 2015, in 2015-2017 3 training seminars on palliative care were organized by the St. Dimitriy Sisterhood. The Arkhangelsk sisterhood actively cooperates with the Northern State Medical University, whose teachers are members of the regional Society of Orthodox doctors. Over the years of the existence of the Diocesan Medical and Social Department, close and effective cooperation has been established with many health institutions. Quite a number of the have opened chapels and prayer rooms.

I. V. Myslevtsev, head of the day patient facility at St. Alexiy Hospital, in his presentation "Use of venous port systems for parenteral support in a palliative ward" told about the work of the new department for patients with cancer. Up to 20 prs. a day can receive here free treatment, including chemotherapy in a day-care hospital mode. The facility is designed for patients who can come for treatment by themselves. Igor Myslevtsev spoke about the advantages of the venous port system used here for chemotherapy.

N. Yu. Shaitanova, Chief Palliative Care Specialist, Ministry of Health of the Arkhangelsk Region, Head of the Palliative Care Unit of the Arkhangelsk City Clinical Hospital No. 6, made a presentation on "Organization of Palliative Care in the Arkhangelsk Region. Results, problems, prospects". She spoke about how Russian legislation defines the concept of palliative care, its purpose, various categories of palliative patients; she spoke about the composition of an interdisciplinary team providing palliative care.

She noted that, in line with the definition provided by WHO, palliative care is an approach that improves the quality of life of patients and their families, who are facing the problem of a fatal disease. The support system for patient's relatives is designed to help them cope with the tragic situation, mainly using psychological counseling. However, in Russian regulatory acts there is no concept of "assistance to relatives". Research proofs that the patient's relatives develop chronic distress. Often, the sickness of a person causes serious health problems in his relatives. Without adequate support, the mortality rate among relatives of a cancer patient increases by 40%. The health care system of the Arkhangelsk region paid in recent years much attention to the development of palliative medicine. In Arkhangelsk, the number of palliative beds in hospitals increased from 54 in 2013 to 152 in 2018.

According to foreign researchers, from 37,4 to 89% of all dying patients need palliative care. In Russia, one-third of palliative patients are people with oncological diseases, and two-thirds - with other diseases.

Shaitanova N.Yu. focused on the question of meeting spiritual needs of ta patient, which is an integral part of the palliative care. "The term 'spiritual' refers to person's life values. This is a universal concept. Spiritual questions of a patient are related to his personal search for meaning and purpose. It is religion that helps a person in his search of meaning."

She also spoke about the cooperation of medical institutions of the Arkhangelsk region with St. Alexandra sisterhood.

Doctor Suvorov A.Y., head of the Organizational and methodological department of accounting and medical statistics of the Federal Center for Cerebrovascular Pathology and Stroke, Ministry of Health of Russia, associate professor of the Department of medical rehabilitation at the Pirogov Russian National Research Medical University, Ministry of Health of Russia, made a presentation on "Palliative ward. Care and rehabilitation".

He noted that the first definition of medical rehabilitation was given by the World Health Organization in 1980: "Medical rehabilitation is an active process, targeted to restore all of the patient's capabilities that were lost due to injury, illness or disease or, if unrealistic, to achieve the optimal realization of the patient's physical, mental and social capabilities, his most adequate integration in society."

In our country, the respective definition has been formulated only in 2011 (Russian Federal Law No 323, Article 40): "Medical rehabilitation is a complex of medical, psychological activities targeted to restore the body's functional reserves, to improve quality of life, to maintain patient's performance and integrate him into society". It did not mention the active process (as in the WHO's definition), that would presuppose that the patient helps the nursing staff in care manipulations (he rolls over, lifts up, etc.), because meanwhile doctors already understood that kinesitherapy procedures are very important even for the immobilized, i.e. passive patients.

The law determines that medical rehabilitation has 3 stages: the first is an acute condition of a disease or injury; the second is the early recovery period or late rehabilitation period or the period of residual disease; the third - early and late rehabilitation periods, period of residual disease.

Already at the first stage, a decision is made whether the patient will be transferred to the second and third stages of medical rehabilitation or will be referred to palliative care or to the nursing care unit. The criterion for decision is the rehabilitation potential, i.e. the prospect of restoration of functions, confirmed by the medical diagnostic results.

Speaking about the development of palliative medicine in Russia, the speaker noted: "When palliative medicine only appeared in our country, it targeted cancer patients and was aimed at relieving pain and alleviating other severe manifestations of the disease. Nobody thought about the quality of life, which is an integral part of palliative medicine." In 2012, the "Procedure for the provision of palliative care to the adult population" (Order of the Ministry of Health of the Russian Federation No. 1343n, 12.12.2012) was adopted, which referred to long-term care for incurable [not only oncological] patients, but also for the provision of psycho-social care. Already in 2015, the new "Procedure for the provision of palliative medical care to the adult population" (Order of MH RF No. 187n, 04.14.2015) was approved, in which, among the palliative patients, "patients with severe irreversible effects of cerebral circulatory disorders in need of symptomatic treatment and nursing during medical care."

Activation of patients is an extremely important component of the palliative department's work at a medical institution, otherwise the risk of immobilization syndrome - a complex of multiple organ associated with the non-physiological limitation of the patient's motor and cognitive activity, - would be high. The incidence of immobilization syndrome in patients with acute cerebral imparity reaches 65-80%, and in patients of intensive care units with longer than 48 hours stay- 55-98%. A medical institution must be staffed with appropriate nursing personnel, that must be proficient in the correct positioning and movement of immobile patients, passive joint gymnastics, position therapy, etc.

Comparing medical rehabilitation and palliative care, the speaker noted that in the first case, for a period determined by specialists for rehabilitation, a certain result should be obtained, i.e. there should be an improvement in the patient's condition.

It is generally assumed that condition of palliative patients with their incurable diseases cannot improve. However, the incurable patients can stabilize, and their condition can improve, such a patient can go into rehabilitation. "Palliative medicine is not a death sentence. It is extremely important to properly manage a palliative patient and ensure his competent activation," - concluded A.Yu. Suvorov. He also presented a methodological guide "Basics of correct positioning and movement of a patient with focal brain damage" (A. Yu. Suvorov. - Moscow: RCT Sovero Press, 2014).

Priest Alexiy Konstantinov, rector of the Sts Peter and Paul Church in Salym, Metropolia of Khanty-Mansiysk made a presentation on "Interaction between state and the diocesan department of social service and charity - example of palliative service of Sts Peter and Paul Church, Salym". He spoke about the sisterhood established at his Church, and about the ministry of the sisters of mercy in the palliative care unit, which was opened in 2015 in the Nefteyugansk region on the basis of the Salym regional hospital. The sisterhood has eight sisters who have received special training and provide spiritual and psychological support to patients of the palliative ward, they also assist in providing care.

V.P. Tikhonova, the senior sister of St. Elizabeth sisterhood of the Khabarovsk diocese, spoke about the experience of sisters of mercy and volunteers in providing palliative care. The sisterhood has 7 sisters of mercy and 30 volunteers, 12 nurse's stations are operating permanently. The sisters provide care for lonely old and disabled people at home.

In 2016, the small nursing care center "Martha and Mary home for elderly" was opened, which provides 24-hour care for lonely elderly people with disabilities. About 300 prs. are volunteering here. Students of the social work department of the Khabarovsk College of Technology have here a pre-graduation practical training.

The sisterhood assists the Regional Clinical Center of Oncology on a weekly basis. It has an agreement with the department of palliative care. Worship services are celebrated every Saturday, sisters of mercy prepare patients for Church sacraments, volunteers carry out missionary work.

The diocesan social department organizes the work of volunteers: for everyone who wants to work, the most suitable activity is selected. Most often, volunteers choose to help children, families, participate in campaigns, fundraising and collecting humanitarian aid. Less often - helping the homeless, visiting and caring for elderly and seriously ill people. The work of volunteers is very important both for the patients (care, attention, communication, etc.), and for the sisters of mercy - without volunteers they would not be able to provide assistance on such scale and in such diversity to their patients. The volunteers themselves also gain a lot for themselves: "A volunteer who regularly participates in the process of organizing assistance for seriously ill patients comes in touch with pain and suffering. These sufferings motivate not only the patients, but also the volunteers themselves toward spiritual rethinking of life. Many of them have wrong or distorted ideas about suffering, diseases and their causes, about death and meaning of life ... As practice shows, the quality of care provided to the patient by the volunteer depends on how well he has solved the question of the meaning of life... It has always been believed that a person's attitude to death is an indicator of his spiritual maturity. Volunteers who help seriously ill people more often think about death. It is through the care of such people that they get answers to very important life questions that concern themselves. Experience shows that correct understanding, positive answers to questions about death allow volunteers to treat their patients with love, tenderness and patience. And vice versa. If a volunteer shows neglect to these issues, it affects his attitude towards the sick - he demonstrates lack of consideration and attention to people," - noted Tikhonova V.P.

Sisters of mercy Dorofeeva E.Yu. and Lebedeva E. B. held for the conference participants a master class on the movement, positioning and care of the patients with limited mobility.

Norwegian expert Per Halvor Lunde conducted a master class on use of sliding equipment for the care of a patient with limited mobility. Sheets made of sliding fabric is a relatively new invention, they are not used as bedding, but as a device for moving a bed ridden patient. They allow caregiver of the patient and sisters of mercy to move even heavy patients without significant physical effort.

At the end of the conference, its participants adopted a final document, in which, in particular, they formulated proposals for further development of Church activities in palliative care.