Intended for healthcare professionals

Opinion Last Orders

Rachel Clarke: Ukraine—how do you live in the face of death?

BMJ 2022; 379 doi: (Published 26 October 2022) Cite this as: BMJ 2022;379:o2525
  1. Rachel Clarke, specialty doctor in palliative medicine
  1. Oxfordshire
  1. rtsclarke{at}
    Follow Rachel on Twitter @doctor_oxford

For her first six months of work as a doctor in the small Ukrainian town of Sambir, Olena Parijchuk was paid precisely nothing. She and a small group of fellow physicians had an audacious plan—to transform a dilapidated tuberculosis sanitorium on the town’s periphery into a 30 bed hospice. They toiled and painted and sawed and heaved, doctors-turned-labourers with more grit than sense. “Some of my colleagues in Kyiv told me I was mad,” Olena tells me, smiling broadly. “And maybe I was.”

That was six years ago. Today, the white walls of the Mother Theresa Hospice dazzle with refracted autumn sunshine. Olena is keen to take me inside, but she can’t resist first showing off the hospice gardens. She gestures eagerly to a field bisected by spindly fruit trees. “Look! When the war began, President Zelensky told us to grow fruit, to grow vegetables. This field has every species of fruit grown in Ukraine. It is . . . ” She stops, struggling to finish the sentence. “It is our victory garden.”

I came to Ukraine earlier this month alongside the renowned neurosurgeon and author Henry Marsh, who, until retiring two years ago, spent over three decades visiting the country to operate pro bono and train local surgeons. Even before Russia invaded, Ukraine’s GDP was a mere £4000 per capita, compared with the UK’s £32 000. Publicly funded healthcare is desperately patchy, and palliative care scarcely exists at all. There are only 10 state hospices for a population of over 40 million. Local doctors were eager for some support and training in palliative care, which I was only too delighted to provide.

But how do you live in the face of death? How do you muster the strength to go on? These questions frame every aspect of my work in palliative care, yet for Olena—who strives to help people die with dignity, even as Putin aims to slaughter them—they are unimaginably pertinent. Inside her hospice, I meet a woman who spent a month trapped at home alone after falling and fracturing her neck of femur, as both of her daughters had gone to fight on the front line. Patients with end stage cancer have been transported hundreds of miles west to this hospice from the horrors of Kharkiv and Mariupol—names now synonymous with war crimes—because terminal cancer care was simply impossible there. Olena shows me a photo of a young man with a tracheostomy and a crater where half of his skull should be. Evacuated from Kharkiv after a Russian bombing, he died in Sambir under her care.

Olena, like every other Ukrainian I met on my trip, is extraordinarily brave and resourceful. But she has no choice. Everyone here is fighting for their very life. Provision of tender palliative care is simultaneously an act of defiance, of resolve—and what it must cost her is vast. I can’t shake Samuel Beckett’s words from my head: “You must go on. I can’t go on. I’ll go on.”