Ksenia: Could you tell us how you got into medicine and palliative care?

Maral: I have always wanted to become a doctor. After graduating from medical school, I began working at a family medicine centre. Later, I was invited to explore something entirely new and still unfamiliar in our country at the time—palliative care.

By the end of 2013, we had formed a multidisciplinary team comprising two doctors and four nurses. By 2015, there were already three such teams. We operated as home-based outreach services, dividing the areas among us—one doctor and two nurses covered each district, while another team served a different one.

From late 2015 until nearly 2022, I worked in adult palliative home care services. Besides caring for patients, we also organised educational projects—delivering lectures for doctors—because having only five palliative care specialists for the entire Kyrgyzstan was not enough. It was crucial that local physicians at least understood the basics: how to recognise a palliative situation and how to manage pain, since it is the primary symptom in almost 90% of patients.

We trained quite a few colleagues in the regions, but it was still not enough. All projects related to palliative care were funded by the Soros Foundation, and thanks to its support, the home care teams could operate. When the Foundation closed the programme, the educational projects also came to an end.

There is very limited specialised information, and we often do not know where to find learning materials. Doctors in the regions usually lack access to the training they need because it simply does not exist. Unfortunately, palliative care is still not taught at the university level—that is, at the fundamental level. There are only a few short courses within postgraduate education or professional development programmes, and some training for nurses and residents. Still, these are small segments and clearly insufficient to fully prepare a specialist to work with palliative patients.

There is a shortage of palliative care specialists in Kyrgyzstan. The government is taking steps to address this. We have clinical protocols: the first ones were developed in 2013, the second edition was prepared in 2023 and implemented in 2024. Currently, along with working groups from various government sectors, we continue to develop regulations and bylaws. Fortunately, we have succeeded in establishing cooperation with ministries—there is communication, and some individuals recognise that palliative care is essential and a basic human need.

Ksenia: Can you remember your first steps and impressions when starting work in palliative care? How did you envision it at first, and how quickly did your expectations align with reality?

Maral: As a general practitioner, you usually don’t adopt a palliative mindset. Initially, I approached patients from the perspective of ‘we must treat and cure’.

It felt like I hadn’t been able to save them. The realisation that our aim is not to prolong life at all costs, but to improve its quality, came later. It was a gradual process—learning, understanding, and acceptance—not easy, but critical.

At that time, I received a great deal of support from my colleague, the director of our organisation. She provided me with textbooks and manuals on palliative care to help me start building at least some understanding. However, I still lacked a complete understanding.

Then Professor Davaasuren, a pioneer in palliative care from Mongolia, visited us. She led a five-day seminar that clarified many concepts and gave me real insight. I still remember those lectures, and I am deeply grateful to her. That was where I gained my first systematic understanding of palliative care.

Everything she discussed—including the medications she recommended—truly existed in our context, and we could put it into practice. For me, Professor Davaasuren became a genuine mentor. My colleague Naziko Karakchieva and I still see her as our teacher because she provided us with the foundation—an understanding of pain management, symptom control, and core approaches to palliative care. Textbooks are useful, but when you read them, questions naturally come up, so live discussion is essential. During her lectures, we received the answers and finally managed to link theory with practice. That was incredibly valuable.

After that, each patient and their family became a valuable learning experience, enriching our ‘knowledge bank’. Over time, we gained a genuine understanding of how to deliver palliative care.

Ksenia: Immersing yourself in palliative care imposes a significant emotional burden. How do you manage it, and what assists you?

Maral: Honestly, it’s very emotionally demanding. I now work at the First Children’s Hospice with a highly skilled team, including psychologists, which makes a big difference. Palliative care always requires teamwork. However, I still visit adult patients at their homes. People call and ask for help, and it’s impossible to refuse. Sometimes colleagues call for advice, and other times, family members of patients do. You support them by explaining things and occasionally visiting the patient to assist. Of course, I feel great satisfaction from my work, but I also experience burnout.

My colleague from the home care team and I shared a private joke: Friday was our unofficial resignation day. On Friday evenings, we’d say to each other, ‘That’s it, we’re done with palliative care, we’re quitting’. And then on Monday, we’d appear again as usual.

Ksenia: Why did you always come back?

Maral: Because patients would call, their relatives would call, someone would cry and ask for help. How could we leave them? My colleague has been working in oncology and palliative care for 30 years, and she keeps saying she’ll quit any day now.

The word ‘weekend’ has always been in quotation marks for us. When a patient is in severe pain or has a problematic symptom, it doesn’t matter whether it’s Saturday, Sunday, or a holiday—they call, and you can’t just ignore them. Very often, weekends became a series of calls and visits. So technically, we had days off, but in reality, we never did. And this went on for years.

Ksenia: Do you have any personal rituals or methods to deal with fatigue and emotional stress? Maybe your family helps?

Maral: Sometimes my colleague and I go somewhere by the water—we just sit in silence and relax. Sometimes we go for coffee together, just to sit, be close to each other, and take a breath.

Regarding family… our children rarely see us. I have a daughter. Once, I asked her, ‘Would you like to become a doctor?’ She looked at me and said, ‘No. Work around the clock for a small salary? No, thank you.’ She firmly decided she would never be a doctor.

Ksenia: How old is your daughter?

Maral: She’s 17 now.

Ksenia: Do you tell her about your work? Do you share stories about your patients?
Maral: Sometimes, yes. Once, something funny happened. At school, they had a topic about pain relief. My daughter—she was in 3rd or 4th grade then—suddenly started telling the teacher and classmates about morphine, tramadol, and fentanyl, including their side effects and how long they last. Of course, the teacher was shocked—a young child talking about opioid analgesics as if she were a medical student!
I was summoned to the school. The teachers and school management suspected there might be a drug issue in the family. I had to clarify that I am a doctor specialising in palliative care, and that my child simply overhears my conversations with patients and colleagues. I even brought my medical diploma to demonstrate it! After that, everyone relaxed.

Ksenia: I’m sure they’ll never forget what palliative care is now!

Maral: Sometimes you end up educating people in the most unexpected ways. You never know when this knowledge might be useful to someone.

Ksenia: How did you come to work at the First Children’s Hospice in Bishkek?

Maral: Earlier, I worked alongside the hospice—mainly with adult patients, though sometimes also with teenagers. Occasionally, I would consult colleagues from the hospice on pain management.

Then the Soros Foundation ceased funding home-based palliative services, and we found ourselves without work. I was offered a position back at a polyclinic, but I didn’t want to take it. That’s when Olga Trukhanova invited me to join the First Children’s Hospice as a doctor—and I’ve been working there for three years now.
Initially, I was hesitant to work with children. It’s a very specialised field, with its own nuances and challenges, and I’m not a paediatrician. Moreover, as a mother myself, I find that it also influences how I experience things. When you work with adults, they make their own decisions. But with children, decisions are made by the parents—you work closely not only with the patient but also with the entire family. That demands a particular approach. I had to start learning from scratch—reading, searching for materials, looking for answers—because there are hardly any ready-made resources available here.

It’s still the most emotionally challenging for me to work with the youngest patients, especially newborns.

Gradually, the fear faded. I became accustomed to it and grew to love this work. The hospice does important work, and I sincerely admire Olga Trukhanova and the entire team—both medical and non-medical staff. They are my role models.

But most of all, I am deeply moved by the mothers of our patients. These individuals are incredibly strong and deserving of the utmost respect. For example, there is Gulina—a wonderful wife, mother, and truly extraordinary woman. She now works with us, assisting other families, supporting parents, and sharing her experience. Although she does not have a medical background, she understands the processes so well that I sometimes think she could replace both a doctor and a nurse. She has learned to insert catheters for her children, care for tracheostomies and gastrostomies, and even insert feeding tubes—then goes on to teach other parents how to do the same. But the most important thing is that she knows how to support, guide, and simply be there. She is a person with a big heart, great empathy, and inner strength. I admire her patience and bravery. She works in our hospice, helping everyone in need, facing the pain of others, and sharing it with parents. She does this with genuine understanding, acceptance, and respect—as an equal, supporting and instructing them. It’s challenging work, but Gulina never gives up. People like her are the backbone of palliative care.

Ksenia: Does the hospice team include a psychologist?

Maral: Yes, it does, but in Kyrgyzstan, there is no specific ‘palliative psychologist’ specialisation, so our colleague had to learn on the job. It’s challenging for her. She is a very empathetic person who feels everything deeply. She can cry with mothers and children, sharing their emotions. It’s a type of work that requires complete emotional presence and compassion. Very few specialists like that exist, and we at the hospice are proud to have Olga in our team.

Ksenia: And you yourself—as a professional—have you ever consulted a psychologist?

Maral: You know, I have my own way. I relieve stress through karaoke. Even though I have no ear for music and no vocal talent whatsoever, karaoke helps me release emotions. It’s like the technique of ‘going into the mountains and screaming’—just in a more socially acceptable manner.

If I could sing well, nobody would come with me. But since we all sing quite badly, we support each other.

Of course, burnout still exists. It affects everyone who works with people, especially those in difficult life circumstances. It’s very demanding work. In palliative care, you can’t simply say, ‘My working day is over—don’t call me anymore’. Patients often go through a ‘roller coaster’: in the morning, they might feel well, by the afternoon, their condition suddenly worsens, and by evening, things stabilise again. When you receive a call at night—at four in the morning—from a distressed family saying, ‘He’s breathing differently than usual’, you can’t ignore it. You stay on the phone, talking, explaining what to do, how to help, how to comfort. And a few hours later, they call again to say, ‘He’s gone’.

That’s our job. Palliative care can’t be ‘from 8 to 6’. It’s a 24-hour responsibility. You can’t “leave your work at work.” But perhaps that’s how it should be—because if we ever learned to do that, we might also lose our empathy.

Ksenia: Could you tell us how the palliative care system is functioning in your country and what changes you hope to see in the coming years?

Maral: We’re doing our best, but palliative care in Kyrgyzstan is still in its early stages. Yes, there is progress, but we are moving slowly. Unfortunately, until someone personally faces this issue—especially if that person is a decision-maker—there is neither understanding of palliative care nor the willingness to learn more about it.

But gradually, the situation is evolving. We’re engaging in much awareness work, and some positive changes are emerging. At least now, the concept of ‘palliative care’ is officially recognised in legislation. That’s already a step forward. Progress is slow but steady.

Ksenia: You mentioned earlier that there are continuing education courses or even a master’s programme for doctors in palliative care in Kyrgyzstan. Could you tell us more about that?

Maral: Currently, we offer only continuing education courses, but we sincerely hope that the medical university will introduce a dedicated palliative care course in the future. Perhaps not a whole department, but a subject included in the final years, when students begin their clinical practice.

When young doctors first face a patient's death, they experience immense stress. Many find it challenging to cope and leave the profession. To prevent this, students need to be properly prepared—both morally and professionally. They should recognise that caring for a palliative patient is a normal aspect of medicine and that palliative care isn’t about curing but about enhancing quality of life. If this understanding were taught at university, it would be a major step forward.

The problem is that medical schools train health professionals to ‘save’—to diagnose, cure, and prolong life at any cost. But palliative care offers a different message: that death is a natural part of life, and a doctor’s role is to help a person face it with dignity, free from pain or suffering. If this were incorporated into basic medical education, it would be less traumatic for doctors — and much better for patients.

Ksenia: What do you think needs to happen in Kyrgyzstan for the situation to improve?

Maral: The leaders of medical institutions and decision-makers still don’t recognise that palliative care is essential. Across the world, it’s already a recognised medical speciality. In the UK, for instance, palliative medicine has been taught since the 1970s—there are separate programmes and departments. But here, there’s still nothing like that. We’re truly hopeful that one day we’ll have a proper course or programme too.
It’s also crucial that everyone in Kyrgyzstan understands that when their time comes, they won’t be alone or without support. There will be someone there to help them, to ensure they don’t suffer—especially not from pain.

People dislike contemplating death; they fear it, and that’s natural. However, awareness remains vital. People should recognise that if they face an incurable illness, there is support available. Death doesn’t have to mean solitude or suffering. I believe that’s very important.

Ksenia: If you could dispel one myth about palliative care, what would it be?

Maral: That’s a difficult question because there are so many myths! But the first one that comes to mind is that palliative care is only for cancer patients. Of course, that’s not true—it’s for people with all kinds of life-limiting illnesses.

The second myth is that palliative care is only provided in the last few weeks of life, when a person is already dying. That’s also false. And, of course, there’s the myth about morphine—that it’s the ‘last resort’, that it causes addiction or ‘hastens death’. None of that is true. Sometimes I have to explain to families, almost with a textbook in hand, how morphine really works: that it doesn’t cause dependence, and that increasing doses reflect disease progression, not drug addiction.

Ksenia: Everyone ought to have a copy of Twycross on their shelf.

Maral: That’s my favourite textbook. It’s the foundation of all palliative care. Every guideline, every training resource, somehow originates from it. I never had the chance to attend Robert Twycross’s lectures in person, but I’ve watched recordings—they’re fantastic. I really regret not seeing him speak live.

Ksenia: That means a lot to us because Robert Twycross was one of the co-founders of PACED. We hold great respect for his legacy and do our best to share his knowledge further. If you were mentoring young professionals who want to work in palliative care, what advice would you give?

Maral: First, I’d give them Twycross’s textbook—it’s the essential foundation you can’t progress without. I’d also advise them to learn English because most of the literature, research, and resources are published in English. My own English isn’t perfect, but it’s sufficient for work. I teach students from India and Pakistan, so I rely heavily on it.