POLISH EXPERIENCES IN PALLIATIVE - HOSPICE CARE

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POLISH EXPERIENCES IN PALLIATIVE - HOSPICE CARE

• Jacek Luczak,
• Katarzyna Kowalewska,
• Maciej Kluziak,
• Anna Szczerbak
• Palliative Medicine Chair and Department,
• Karol Marcinkowski Poznan University of Medical
  Sciences,
• Hospice Kutno
• Hospice Palium Resource and Training Centre

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HOW DID IT START?
In 1976, when Poland was still ruled by
communists, a group of parishioniers from the
Lords Ark church in Nowa Huta (near Cracow) led
by a journalist and a philosopher - Halina
Bortnowska, began to provide care for the dying
in a local hospital ? the first informal hospice
service in Eastern Europe (Clark 2002)
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SOLIDARITYFIRST NGOs HOSPICE

• SSolidarity(1980) paved the way to free civil
• Society development ie the freedom to
• unit into nongovermental organisation
• TThe first Polish NGO hospice The Society
• of the friends of the sick Hospice Krakow(81)
• inspired by St Christophers Hospice in London
• and its founder Dame Cicely Saunders

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HOSPICE /PALLIATIVE CARE IN POLAND
HISTORY 1976 the first group of hospice
volunteers in Eastern Europe - The New Arc
Church N. Huta, Binczyce 1978 the visit of
Dame Cicely Saunders (Cracow, Gdansk,Warsaw) 1981
- Society of Friends of the Ill - Hospice in
Cracow 1984 - First Home Hospice Pallotinum,
Gdansk 1987 - Pain Clinic and Palliative Home
Care Team in the Department of Oncology in
Poznan University of Medical Sciences, later
extended ? 7-bedded unit added ? evolved to the
PC Department of the University of Medical
Sciences. Academic link established with Sir
Michael Sobell House (Oxford, UK)
WHO- collaborating centre (since 1990), the
department is offering under- and postgraduate
education 1991- Palliative Care implemented to
the Ministry of Health Programme, new policy,
MoH and NGOs , development of H/PC - 81 units in
1993 ? 270 in 2002 1999 - Specialisation in
palliative medicine (doctors) and PC (nurses)
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• Poland
• 38,6 million inhabitants
• 3 85,853 deaths per year
• 322,520 - deaths from chronic illness
• 82,600 - deaths from cancer (data for 2000)
• 6 641 death from AIDS (1995-2002)

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EPIDEMIOLOGY (POLAND)
The number of patients (new diagnoses) with
cancer increasing 110,000 in 1996 ? 125,000
cases in 2002. Predominance () women breast
- 19, colorectal - 11, cervical - 8. lung - 8,
ovarian - 6 and uterine 6 men lung 29,
colorectal 17.7, gastric - 7, prostate - 5,
bladder - 5 and larynx - 5
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CANCER PAIN IN POLAND

• Of 125,000 of new diagnosed patients, 42,000 -
  only 30 - have curable cancer, 83,000 -
  incurable. Total number of patients with
  incurable cancer consists of 83,000 (above
  mentioned) 110,000 patients diagnosed as
  incurable during previous years. There is also
  another group of 200,000 patients with curable
  cancer (survivors). Altogether there are about
  435,000 cancer patients each year.
• Taking into consideration the 70 incidence of
  pain in incurable cancer and about 30 in
  actively treated patients, the number of
  patients with cancer pain in Poland each year
  reaches 150.000

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NATIONAL ASSOCIATIONS - NGO ORGANISATIONS
PROMOTING PAIN RELIEF AND HOSPICE /PC

• Forum of Independent Hospice Movement (ORFH
  1991,Warszawa), a meeting place for all
  independent hospices,
• National Council for Hospice and PC affiliated
  with the Ministry of Health (1993)
• national consultant(1994) and regional
  consultants in palliative medicine (1999)
• Polish Association for Palliative Care (1989
  Poznan), branches in 16 regions,
• Polish Palliative Medicine Association (2002)

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POLICY DEVELOPEMENT IN PC

• The first Pain Clinic with Palliative Care Home
  Service in Poland implemented to the statute of
  University Oncological Hospital in Poznan (1987)
• followed by a 7-bedded unit and creation of
  Palliative Care Department of Poznan University
  of Medical Sciences (co-operating with WHO- PC
  Centre in Oxford) and developing
• curricula in PC for medical students and
  basic/advanced training (since 1991)

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POLICY DEVELOPEMENT IN PC

• In 1991, the Ministry of Health and Social
  Welfare introduced a provisional programme to
  establish palliative care as part of national
  health care policy and also set up a body of
  PC/Hospice leaders
• Introducing to medical practice by PC Unit in
  Poznan in 1989
  1.Oral
  morphine aqueous solution easy to prepare
  2.A cheap approach -a syringe
  attached to a SC Butterfly needle with sufficient
  medication for 24 48h
• In 1994, the Ministry of Health and Social
  Welfare endorsed a booklet which contained
  information about cancer pain control, designed
  to improve the practice of pain control and to
  induce the correct use of medication. 150 000
  copies were distributed to doctors, nurses and
  pharmacists.

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REGULATIONS GOVERNING THE ESTABLISHMENT AND
FUNDING OF PALLIATIVE CARE UNITS

• According to the Health Care Units Act published
  on 14th October 1991 patients have the right to
  die peacefully and in dignity 19 art.5
• Health Care Units Act1991 mentioned PC units
  and hospices as medical service providers for the
  first time in Polish law,

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REGULATIONS GOVERNING THE ESTABLISHMENT AND
FUNDING OF PALLIATIVE CARE UNITS
Code of Medical Ethics (1993) doctors
obligation is to provide care for terminally ill
patients until the end of life and to relieve
pain and other distressing symptom in dying
patients. The NGO hospice/palliative care group
proposing to become an independent unit must
disburse its funds according to the Ministry of
Health regulations dated 8 May 1995. These
regulations govern the conditions of public
funding of independent health care units and also
the management of resources. M.P. no 29,341 )
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REGULATIONS GOVERNING THE ESTABLISHMENT AND
FUNDING OF PALLIATIVE CARE UNITS

• Amendment to the Universal Health Insurance Act
  1998 obligates Regional Health Funds to
  contract services provided by palliative/hospice
  care units as a separate and unique medical
  activity
• Standards in Palliative/Hospice Care (1999)
• MoH regulations (1999) introducing palliative
  medicine as a medical subspecialisation and
  palliative care as a nurse specialisation
• Palliative Medicine Clinics,Palliative Home Care
  Services and In-patient palliative care/hospice
  units included to the coded medical services
  according to
• the MOH regulations (2000,DzU.003037)

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REGULATIONS GOVERNING OPIOID AVAILABILITY

• Changes in Polish Farmakopea IV ed 1993 increase
  in maximal dosages of morphine in cancer pain
  single dose to 30 mg
• MOH regulations on max. doses of strong opioids
  allowed to prescribe by every doctor on single
  prescription
• from 100 to 300 mg of morphine1993
• to 4.0 (oral morphine formulations),2.4 g
  (injectable)-1997,
• 12 g(o.morphine),100mg TTS fentanyl,1999
• Fentanyl in ampoules unlimited (paid)2001
• Methadone oral unlimited(paid)2001

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MoH PROGRAM OF PAIN RELIEF AND PALLIATIVE CARE
- OPIOID AVAILABILITY ADRESSED!

• Cancer pain relief and palliative care are
  addressed in the Ministry of Health programme
  for development of hospice and palliative care in
  Poland prepared in 1998 by the National Council
  for Hospice and Palliative Care Services (an
  advisory body for the Ministry of Health)
• National Council for Hospice and Palliative Care
  was founded in 1993, it is working for improving
  the availability of opioids, in co-operation
  with the Ministry of Health.
• Weak and strong opioids are easy to prescribe and
  either free of charge(including immediate and
  modified release and injectable morphine) for
  cancer patients, or their price is reduced.

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NATIONAL PROGRAMS

• Since 1996 AIDS prevention, treatment and support
  are included in The National Program of
  Prevention of HIV Infections and Care Offered to
  People Living with HIV and AIDS, which was
  adopted by the Government and the Parliament
• National Cancer Program developed by Polish
  Union of Oncology includes cancer pain and
  palliative care issue(2002) is in the process of
  introducing to the Polish Health Low

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THE ROLE OF GOVERNMENT IN SPONSORING AND
ENDORSING THE TRAINING PROGRAMS IN CANCER PAIN
AND PC
Ministry of Health endorsed and sponsored
training programs in cancer pain and PC developed
by Poznan University of Medical
Sciences-Palliative Care Dpt (since 1991) linked
with WHO collaborating PC centre Sir Michael
Sobell House in Oxford, and Sections of
Palliative Medicine in Gdansk, Bydgoszcz,
Katowice.
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THE ROLE OF GOVERNMENT IN SPONSORING AND
ENDORSING THE TRAINING PROGRAMS IN CANCER PAIN
AND PC
Other PC and hospice centres, including Wroclaw,
Cracow (St. Lasarus Hospice) and Warsaw
(Intensive Pain Therapy ward and clinic at the
Oncological Centre) are accredited by Ministry
of Health as centres for education and training
for doctors specialising in palliative medicine
and nurses specialising in palliative care (1999,
program approved by Medical Postgraduate
Education Center).
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THE ROLE OF NGOs IN SPONSORING AND ENDORSING
THE TRAINING PROGRAMS IN CANCER PAIN AND PC
Other sources of funding include Stefan Batory
Fundation and Open Society Institute (George
Soros funding, Polish Hospices Fund and Polish
Association for Palliative Care
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THE SERVICES

• - domicillary palliative care services
• (including geriatric)
• - outpatients palliative medicine clinics
• - in-patient units (hospital based, free
  standing hospices)
• - hospital supporting palliative care team
• - day care services
• - paediatric palliative care - home hospice
• - lymphoedema clinics
• - decubitus ulcers clinics
• - bereavement services

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AVAILABILITY OF PC SERVICES, ACCESS TO SERVICES

•  Hospice and palliative care services in 2002
• 270 units altogether
• In-patient units number
  beds
• Non-public 34
  460
• Public 76
  808
• Total of 1,268 beds (800-1000 more needed)
  
  
  
• There are 155 palliative home care services (95
  non-public and 60 public),126 outpatient pall.
  medicine and pain clinics (52 nonpublic 74
  public), 9 lymphoedema clinics, 12 day care
  centers, 7 children home care hospices, and a
  few hospital supporting teams

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•  
• More than 55 of cancer patients died in
  hospitals, 12 died in hospices, about 30 died
  at home cared by hospice/PC services.
• About 40 of terminally ill cancer patients
  used hospice/PC services 
• Differences in distribution of hospice/PC
  services fewer in rural areas, more near/in
  urban centres (Warszawa, Bydgoszcz, Lublin) to
  the west (Poznan, Gdansk,Szczecin) and south
  (Kraków, Katowice, Wroclaw)

AVAILABILITY OF PC SERVICES, ACCESS TO SERVICES
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FUNDING OF SPECIALIST H/PC SERVICES

• Health care services in Poland are in transition
  switching from regional to National Health Fund,
  they are severely underpaid which is also the
  case of Specialist Hospice and Palliative Care
  Services
• (40-60 of cost is covered)
• The proposed coverage of funding for 2004 is as
  follows
• 35 per one day for one bed (in-patient
  service) - in Italy 300-400 , in Germany 260 !
• Home care funding 8 per one doctors home
  visit (in UK - 80 )

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FUNDING OF SPECIALIST H/PC SERVICES

• Palliative and hospice care services are still
  treated as the low paid long-term care health
  service but they differ significantly. Palliative
  and hospice care is a very specific, unique and
  specialized form of care and palliative
  treatment it is mentioned as a different medical
  activity in the Polish health law regulations
  (1998)

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UNIVERSITY DEPT. / SECTION
Palliative care department an independent
academic unit or a part of a clinical department
of other medical specialities (oncology, internal
medicine, anaesthesiology, family medicine). The
work of such a clinic is supervised by an
independent academic professor, a palliative
medicine specialist. Such institution carries out
palliative care services and deals with education
and distribution of information. Its activities
include scientific research and publishing.
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UNIVERSITY DEPT. / SECTION
Palliative care sections offer undergraduate and
postgraduate courses, as well as specialised
courses and training in all forms of palliative
care (in-patient care, palliative care ward, pain
clinic, home care team, day care centre,
bereavement group)
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PALLIATIVE MEDICINE
Palliative Medicine refers to that contribution
to the practice and study of palliative care
which is made by doctors. Doyle (1993) defines
palliative medicine as study and management of
patients with far advanced diseases for whom the
prognosis is limited and the focus of care is
quality of life. PM was recognized as a distinct
field of medicine in 1987 (UK), in Poland -1999.
There are more than 60 doctors specialists in
PM in Poland already and 50 more will have
completed training in 2004.
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ECEPT Eastern and Central Europe Palliative
Care Task Force

• An international association meant to group
  palliative care professionals from Eastern and
  Central Europe and Central Asia, the people who
  take leading part in the field of caring for the
  terminally ill in their countries.

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ECEPT
Website http//www.oncology.am.poznan.pl/ecept
Alternative (old) website http//free.med.
pl/ecept ECEPT is also serving as an
international organisation gathering PC/hospice
professionals and volunteers supporting the
development of a network between NGOs and public
health institutions, policy makers etc.
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PC RESOURCE AND TRAINING CENTRE
The Poznans Palliative Care Resource Training
Centre funded mainly by the OSI (G. Soros
Foundation) is providing facilities for
theoretical and practical training for palliative
care professionals from Poland and other
countries of the region. It serves as a source
of information and advice (both written and
audiovisual, but also by means of on-line
contact)
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TRAINING PROGRAM The packages
of 2 weeks free of charge, hands-on training in
interdisciplinary palliative care at Hospice
Palium in Poznan - offering training in variety
of PC forms pain clinic, 24-hours per day and 7
days a week accessible home care, in-patient
ward, hostel for children/adolescents, day care
centre, lymphoedema clinic and bereavement
service, using not only physicians as teachers,
but also nurses qualified in PC, psychologists,
social workers etc. To apply please contact
Ms. Anna Szczerbak, ECEPT CEO and PC
ResourceTraining Center Co-ordinator anna.szczerb
ak_at_oncology.am.poznan.pl website
http//www.oncology.am.poznan.pl/ecept