Roman: How would you describe your professional journey in palliative care—from working as a nurse to leading a palliative care department at the National Oncology Centre and serving as an advisor to the Ministry of Health?

Marius: My introduction to palliative care started in Norway in 2010. At that time, I was working in community support services, assisting patients returning home after hospital stays. Many of these patients had cancer and needed palliative care. That was when I truly realised its importance. Most of these patients were going home to die, surrounded by their loved ones—this was common practice in Norway then. It had a deep impact on me, and I began to explore palliative care more thoroughly.

I enrolled in a two-year programme at the European Palliative Care Academy at the University of Cologne, organised in collaboration with King’s College and other institutions. That was where my professional journey in palliative care truly began.

While still studying, I returned to Lithuania and began working in mobile services, eventually becoming the head of a home-based palliative care department. After graduating from the Academy, I started studying Lithuanian palliative care legislation in detail and was quite outspoken in my criticism of the Ministry of Health. One day, I received a call from the Deputy Minister, who invited me to talk. She said, ‘If you think you can do better, come and work with us.’ Initially, I refused, but eventually I agreed. That is how I became an advisor to the Minister of Health on long-term care.

I have my doubts about this, but that is how the system is currently set up.

During my work, I observed that many palliative care patients had cognitive and neurodegenerative conditions. This piqued my interest, and on the recommendation of colleagues, I applied for a one-year programme in brain health at the Global Brain Health Institute at Trinity College Dublin. I was unsure about being accepted—COVID had just started, it was in a different country, and the competition was tough. Nevertheless, I secured funding, passed the selection process, and completed the programme. Ultimately, I realised my professional focus was on palliative care for oncology patients rather than work related to neurodegenerative and cognitive disorders.

After leaving the Ministry, I spent some time consulting for private companies. Later, I received a call from the National Oncology Centre, which was establishing a new palliative care department and was seeking someone with experience in both oncology and palliative care. That is how I came to my current position.

Roman: So, is your advice to colleagues in other countries: if you want to become a ministerial advisor, start by criticising the Ministry of Health?

Marius: Criticism is one thing. What truly counts is that it offers concrete evidence and proposals.

For me, this work marked a significant turning point in my career. Up to that point, I knew the system as a practitioner, but I did not fully grasp it from the perspective of organisation and financing.

We started developing new quality standards for Lithuania. For example, it was previously common for long-term care facilities to house 3 or 4 people in a single room. And this was not only the case in palliative care but across the entire system. After collaborating with colleagues in Scandinavia, we gained a clearer understanding of what suitable infrastructure should look like, how many professionals are necessary, and how to organise the care environment for people with serious illnesses. It is crucial to base your actions not just on reading and analysis but on genuine understanding.

And once you reach that level of understanding, it no longer matters which country you are referring to—Lithuania, the United Kingdom, India, or the Philippines. The fundamental principles are the same everywhere.

Roman: You’ve mentioned adopting the long-term care strategy as a key milestone. What other important achievements or turning points would you highlight in recent years within the fields of long-term care, palliative care, or oncology in Lithuania?

Marius: One of the most notable achievements has been changing the principle of access to palliative care. Previously, access to palliative care in Lithuania was strictly linked to ICD codes: if a patient had a specific diagnosis, they were entitled to palliative care. We succeeded in moving away from this approach and shifting the focus to evaluating the patient’s actual condition rather than a formal diagnosis.

This facilitated the successful introduction of early palliative care. Previously, palliative care was mainly regarded as end-of-life support. Now, we can offer palliative care at earlier stages and combine it with active treatments, such as chemotherapy, radiotherapy, and immunotherapy.

They may recover, go into remission, and no longer need palliative care—and that is a positive outcome. In my view, this is one of our most important achievements.

The second major focus has been organising inpatient palliative care. Previously, palliative care beds were located in nursing homes, usually one or two per facility. There were only two or three hospices in the entire country, which did not meet the actual demand. We realised that this model was inefficient. In a single municipality, there could be five to seven institutions with only a few palliative beds each, and doctors had to constantly move between them. Knowledge and expertise were fragmented.

Funding was provided at the national level, with municipalities responsible for choosing the institution to host the unit. The main requirement was modern infrastructure: single rooms, private bathrooms, family spaces, and facilities to keep relatives close. This marked the beginning of our systematic capacity-building efforts.

The next vital step was developing home-based palliative care teams. Home medical services have been available in all municipalities across Lithuania since 2018–2019. Every primary healthcare provider is legally required to have a contract with a home care service provider, without exception. We adopted the same principle for palliative care. A mobile medical team consists of a nurse, a nursing assistant, a physiotherapist, and an occupational therapist. We also included a physician, a psychologist, and a social worker as mandatory members of the palliative care team.

To work in a palliative care team in Lithuania, all professionals must complete mandatory training: a one-week course plus practical training. This applies to all disciplines. Physicians must complete additional programmes, including 200 hours focused on pain management, while nurses must complete an additional 36 hours if they aim to work in pain management.

As a result, we ensured nationwide access to palliative care. In small municipalities with populations of around 3,000 people, it does not make sense to establish a separate team, so one team may serve two or three municipalities. However, in every municipality, it is clear where patients should be referred and where help can be found.

Roman: Is this sufficient to claim that Lithuania now possesses a well-developed palliative care system, or are there still gaps that require attention?

Marius: ‘Sufficient’ is rarely enough, especially in larger cities. People continue to relocate from smaller towns to bigger cities—mainly younger generations—and they often bring their parents along. Consequently, in Vilnius, Kaunas, and other major cities, there are not always enough palliative care beds.

We do have home-based care, which is fully funded by the state and available to everyone who pays taxes, regardless of how long or how intensively they need it. Mobile palliative care teams operate from morning until evening. Night visits are not yet in place, but we have already received recommendations from the Ministry of Health on organising night-time mobile teams, and I believe this will eventually become mandatory.

I'm unsure where this perception originates. It might stem from fear of the dying process or difficulty in accepting what is happening. People feel afraid, and as a result, they opt for institutional care—even though we have both the capacity and the resources to deliver high-quality care at home. This increases demand for inpatient beds, which then become inadequate. However, this is not the path we should be pursuing.

Of course, we also need to keep developing home-based care, especially by strengthening the nursing workforce. Doctors are important for adjusting treatments and managing symptoms, but it is the nurse who provides daily care, who is present, and who observes the patient and family over time. This is a key factor.

Another significant challenge is persuading the National Health Insurance Fund to cover nighttime visits. This is a tough discussion. Insurance organisations tend to focus only on immediate costs and estimate how many millions of nights' visits will be needed. They overlook how much money can be saved by preventing emergency department visits at night, where palliative patients undergo unnecessary tests at the expense of the insurance system. For politicians, it is simpler today to concentrate on the figures in a spreadsheet. The fact that these investments could pay off in two or three years is often seen as irrelevant—by then, they might no longer be in office. Nonetheless, we are heading in the right direction. Slowly, but progress is being made.

Roman: Is my understanding correct that palliative care in Lithuania is completely funded and provided by the state?

Marius: There are private providers, but they operate within the national system. They deliver the same services, adhere to the same standards, and receive the same funding conditions. They do not charge patients any extra fees. Occasionally, a local provider or a municipal structure might opt not to deliver these services, and in such cases, the service is transferred to a private provider. However, for the patient, there is no difference. Only the provider changes, while the service itself, its quality, and its funding stay the same.

Roman: How is palliative care education structured? What is the ‘typical pathway’ to becoming a certified physician or nurse in palliative care?

Marius: Palliative care is included in the curricula of medical and nursing education in Lithuania, so students receive basic training already at university. After that, they are required to complete additional palliative care courses that last one week, or 36 hours. There is also a requirement to regularly update this knowledge with a further 8 hours at specified intervals.

We are currently considering increasing the mandatory training to approximately 100 hours—about a month’s duration. For specialised pain education, nurses need to complete an extra 36 hours, while physicians must undertake an additional 200 hours. At present, there is no master’s or doctoral programme specifically dedicated to palliative care in Lithuania.

Many young professionals are attracted to home-based palliative care because independence matters to them. In Lithuania, a nurse manages their own patient list. For example, you might have 50 patients and decide when and whom to visit. The main condition is that care is provided punctually. This level of autonomy is very motivating.

Interestingly, we do not experience a shortage of nurses in mobile services—neither in the capital nor in rural areas. The shortages are more apparent in inpatient facilities and nursing homes.

Another observation is that people who have experienced serious illness within their family are often more willing to work in palliative care, provided enough time has passed. There was a case of a woman who had worked in food delivery; after her husband died of cancer, she decided to train as a nurse to work with palliative care patients. These stories are uncommon but powerful. And when someone shares such an experience in a classroom, it can be deeply inspiring to others.

Roman: Is there adequate access to opioids in Lithuania? Are professionals in both mobile teams and inpatient facilities permitted to prescribe them? How does this operate in practice?

Marius: Primary care physicians can both continue prescriptions started in university hospitals and make their own prescribing choices. Palliative care physicians, of course, are fully authorised to prescribe opioids.

However, when we look at opioid consumption data, we are still lagging behind. There are ongoing fears, stigma, and misperceptions. I would suggest this is more common among older generations of doctors and in rural areas. If you examine prescribing maps, you can clearly see that opioids are prescribed less frequently in remote regions, most likely due to fears of addiction.

That is exactly why we place such a strong emphasis on education. Every year, we organise the Baltic Conference on Palliative Care, where we consistently discuss opioid prescribing, medication use, fentanyl patches, and related topics.

Overall, access to opioids in Lithuania aligns with typical European standards for palliative care.

Sometimes I think this might be one of the reasons why families are hesitant to care for patients at home: if a local doctor prescribes inadequate pain relief, the patient suffers. In hospital settings, symptom management is usually much more effective.

We also run an excellent course in collaboration with Georg Bollig, one of the founders of the international Last Aid initiative. This initiative promotes the concept of ‘last aid’—teaching society how to care for dying people, much like how first aid teaches how to care for the living. The course consists of four 45-minute modules. It covers topics from spiritual care and nutrition to the physical symptoms of dying. The course is free and aimed at the general public. There is a version designed for children, delivered in schools and nurseries, and a version for adults—targeted at firefighters, students, and anyone interested. Currently, more than 200 people in Lithuania have completed the course. I believe this is a very significant contribution to enhancing death literacy within society.

Roman: How do you handle such a demanding workload? Where do you source resources, support, and inspiration?

Marius: Honestly, I don’t really believe in stories about perfectly balanced lives combined with successful careers. That is quite rare. I am deeply passionate about palliative care. When I work on projects, I often come home at 11 p.m. or even midnight—that is just how it happens. I never really reflected on this until you asked the question. From the outside, one might say that I sacrifice my personal life. But I have never experienced it as a sacrifice or felt unhappy about it.

I once knew a professor from Kaunas who published one or two books on palliative care each year. That was remarkable. He had no family, no children, not even a dog, but he was fully dedicated to his work. I believe it was more than just a job for him; it was his passion. When you find something you truly love and going to work doesn't feel like a burden, then you know you are in the right place. I know many doctors who stay with their patients beyond working hours and even after retirement.