Development of palliative care services in different countries
Nicoletta Mitrea looks at the different models of palliative care in Central Eastern Europe and how this is leading to better training for nurses – and improved treatment for patients.
Palliative care (PC) relieves suffering and improves quality of life for both patients and families throughout the trajectory of chronic progressive illnesses, through the end of life and beyond in the bereavement process.1
Worldwide, there is a significant need for PC:
- Of the 58 million people dying annually, it is estimated that at least 60% (35 million) will have a prolonged advanced illness and dying and would benefit from PC2
- With the rapidly aging world population and the associated increase of multiple ‘‘non-communicable’’ diseases, the need for PC will increase dramatically over the next 30 years3,4
- by 2025 there will be 1,200 million people 60 years of age or older; by 2050 the number will increase to 2,000 million.
- the incidence of cancer will more than double to an estimated incidence of 24 million new cancers per year by 2050.
- if preventative measures don’t work, annual mortality from AIDS will increase to four million in 2015 and six million by 2030.
WHO public health framework for PC
In the process of developing PC in Europe, a common used framework has been the WHO’s Model for Public Heath. According to this model there is a need for having in place, under the umbrella of specific policies transposed in national strategic plans, education in the field of PC for media and public, healthcare providers and trainees, PC experts, family caregivers, specialised services where those people can practice their specialty and gain each day more experience, and drugs available for the patient to have their suffering relieved and for professionals to have the major necessary tools to work with5.
Overview of development in different countries in Central Eastern Europe
The shared communist background had a direct influence on the development of PC services in these countries. The centralised system, including healthcare decision-making, is still in place today. As a result, some countries in the region, like Moldova6 and Russia7 , have taken a top-down approach in the development of their services by putting into place regulations for the development of services based more on international expertise than on the needs and realities of the country.
Bulgaria: Vratsa model
Vratsa, although not the largest city in the country, has made a significant contribution to the development of medicine in Bulgaria. Comprehensive Cancer Center – Vratsa (CCCV) is an important part of the specialised oncology network in this country. The PC team specialises in providing care for patients with uncontrolled symptoms, especially pain, and management of patients in crisis. In 2004, the PC team in CCCV became part of a joint international project between Bulgaria and Holland and, as a result of this project, a post-graduate education program for nurses in PC was developed and the department became a place for practical training for medical students, and also for a master’s degree in nursing. Since 2013 the PC Department in CCCV became the main organiser of courses for postgraduate training in PC for the country. The efforts of the PC team in the CCCV was rewarded with accreditation as a designated center for integration of oncology and PC by ESMO in 2011.
Ukraine: A win for PC
In order to prescribe morphine to a terminally ill cancer patient, a physician in the Ukraine needed a panel of three additional doctors to confirm this need. Doctors were only allowed to prescribe patients 50 milligrams of morphine per day – an arbitrary amount with no basis in medical evidence. Intensive advocacy efforts have been made. The short film “50 Milligrams Is Not Enough” was launched as part of a larger awareness campaign featuring a 27-year-old cancer patient in terrible pain whose mother went to extreme effort in order to get pain relief for her bed-ridden son. Finally, on 13 May 2013 the Cabinet of Ministers passed Decree #333, lifting burdensome procedures for prescribing and accessing opioids.
Education in PC
In Poland, Hungary and Romania, PC is recognised as a sub-specialty for doctors and nurses, whereas in the Czech Republic it is accredited only for doctors, and in Bulgaria and Greece only for nurses. There are more training programmes available for continuous medical education of doctors and nurses.
Romania: Education is a drive for change
PC education started in Romania with the opening in 1997 of the Princess Diana Study Center as part of Hospice Casa Sperantei – the pioneering PC service in the country, now the Center of Excellence for PC service development, education and advocacy for Central Eastern Europe8 . Since its founding, this education center has played a pivotal role in preparing the workforce in PC in Romania and in the region. Over 16,000 participants from 18 countries in the region have attended introductory courses, advanced training programmes and subspecialty programmes at the Center. The education centre works with over 100 accredited trainers from Romania and is partners with the University of Transylvania in running the multidisciplinary PC masters program since 2010. Since 2012 an online programme has been launched for general practitioners with the aim of spreading PC approaches within the community, and an information center offers access to written and video materials for lay caregivers.
- Internationally agreed frameworks and guidelines are important for orienting the providers and beneficiaries in the process of planning the development of PC;
- Each country finds its own way of establishing, developing, improving PC services, education and policies;
- Strong, opinionated leaders make the difference in the process of transferring the theory into reality.
Nicoletta Mitrea is Director of National Education and Development, Hospice Casa Sperantei, Romania.