- Email: [email protected]
Palliative care for heart failure in Greece
European Geriatric Medicine 2 (2011) 44–45
The same patient in various European countries
Palliative care for heart failure in Greece G. Spatharakis * Public Primary Health Care Center for Itea, 7, Epaminonda Papalexandri street, 332 00 Itea, Phokida, Greece
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 October 2010 Accepted 1 November 2010 Available online 8 December 2010
While few palliative care units are available for cancer patients in big cities of Greece, this specialized care is generally unavailable for non-cancer patients. No protocols are in use and the use of advance directives and discussions around euthanasia still represents a taboo subject for Greek families. Patients will receive standard hospital care but not necessarily psychological or social support. Terminal patients will rather finish their life in a hospital bed, a tendency that has accentuated these last decades. The family is generally present and regulates hospital admittance, home care and end-of-life decisions. The presence of well-trained and multi-professional teams is very scarce and expensive. Informal carers guided by the family often assume the basic care while medical care is provided in hospitals on an outpatient base or through house calls of privately installed doctors of different specialties. Very few geriatricians are available in Greece. ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Palliative care Heart failure Elderly Health services Greece
A brief discussion based on the questions posed in the case vignette is presented for Greece. 1. Would a patient like this receive palliative care, or is palliative care reserved for cancer patients? Who will care for him? How will this be decided? Are objective criteria used to define final stages of non-cancer diseases amenable to end-oflife care? If a patient like the one described above is living in his home in Greece, it is almost certain that he will not have the possibility to receive any kind of formal palliative care. Palliative care in Greece is mostly intended for cancer patients and at a minor degree for terminal patients with neurodegenerative diseases (Alzheimer’s disease, Parkinson’s disease). When living at home, close relatives like the spouse or children will take care of the elderly patient with heart failure. Additionally to that, specialized palliative care groups that provide home care are very scarce and mainly based in the private sector, making them very costly and unapproachable for most middle and low-income patients. Even under these conditions, this kind of services is only available in the two big cities of the country, namely Athens and Thessaloniki. Informal female carers with no specific training (many times of foreign origin, from eastern European countries, mostly of the
DOI of original article: 10.1016/j.eurger.2010.11.001 * Tel.: +302265351007; fax: +302265032268. E-mail address: [email protected].
old USSR) will cover the needs in basic and instrumental activities of daily living. This is decided mainly based on the availability and disposition of members of the close family and in accordance to the financial status of the family. The family will call a specialist doctor, mostly a neurologist and a cardiologist, in order to provide a prescription and/or directives for home management. The presence of a psychologist is difficult to get, either because of their small number or mainly because of the lack of experience in dealing with elderly patients. Social workers’ home visits are extremely rare in Greece and happen only when problems like poverty, abuse or inability for placement arise within the family. No criteria or protocols exist concerning the definition of the final stages of the non-cancer terminal elderly patient [1].
2. What kind of supportive treatment is offered? Which drugs used for symptom control? Are guidelines used for care? Is there any system to assess quality of end-of-life care of cardiac patients? The supportive treatment that will be offered is not standardized. There are no guidelines in use. If a doctor specialized in palliative care is available, protocols used in other European countries may be applied, adapted according to family wishes and available technical resources. Diuretics and oxygen therapy constitute the main procedures used. If at home hospitalization is available, drugs like milrinone in continuous perfusion can be also used to treat the cardiac symptoms. For the control of delirium traditionally haloperidol is used, although in recent
1878-7649/$ – see front matter ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. doi:10.1016/j.eurger.2010.11.002
G. Spatharakis / European Geriatric Medicine 2 (2011) 44–45
years the use of modern antipsychotics like risperidone is increasing. 3. What is the usual attitude of health care providers (physicians, nurses, aides) and caregivers/family members towards these patients? How are care decisions made? Although the possibility of writing ‘‘Advance Directives’’ exists legally since the nineties in Greece, its applicability is limited by the fact that it demands a notary act that has to be deposited in advance. Given the nature of Greek people this possibility is unknown and practically never used. Thus, the family is usually taking decisions about maintaining or withholding treatments and on the general management of patients. Nurses and aides usually express their concerns, but will bend to family decisions. The attitude of the physician is mostly remote and defensive, centred on the medical problems per se rather than in life decisions for the patient [2,3]. Usually, when final stages approach, patients will be hospitalized and possibly end their lives in the hospital [4]. The whole family takes these decisions, when all its members are present and interested, or they will be taken and conducted by the one(s) that has/have the immediate care burden and usually, also, access to the patients’ financial resources. Conflicts of interest generally do not arise, as the non-interested family members usually feel relieved because somebody else has taken the burden of these difficult and complex decisions [5]. Euthanasia and other end-oflife issues are generally not discussed, as they are considered ethically unacceptable (due among others to orthodox religious beliefs) and psychologically painful [6,1]. 4. How is care provided in the hospital and after hospital discharge? How is follow-up performed? Are there mechanisms that may avoid hospital admissions without reducing standards of care? In Greece, there are no specialized geriatric units, as geriatrics is not recognized as a medical specialty or subspecialty. Palliative care beds, but not units (with a few exceptions) exist mainly in oncological hospitals and/or departments. Moreover, very few doctors in Greece are specialized in geriatrics and/or paliative care
45
(exacts figures are unavailable and unknown). Consequently, patients like the one described above will be admitted to a general internal medicine wards and receive standard care, under the instructions of neurologists, psychiatrists and cardiologists. The quality of care is usually good, and even intensive care can be assigned to these patients, although they are generally full and it is not easy to have a bed available when needed. There is no shortage of medicines, but the overall care is mostly medical/pharmacological based, with no patient-centred care or psychological support of the patient and the family. Follow-up is mainly performed at the hospital on an outpatient basis. Unfortunately, patients come to their appointments at the clinic and may wait in the corridors for some hours before entering into a short (a few minutes) visit with the physician. Unfortunately, again there are no protocols or measures and mechanisms that may avoid hospital admissions without reducing standards of care [1]. After hospital discharge, care is again mostly provided and coordinated by the family, as described above.
Conflict of interest statement Nothing declared. References [1] Parpa E, Mystakidou K, Tsilika E, Sakkas P, Patiraki E, Pistevou-Gombaki K, et al. Attitudes of health care professionals, relatives of advanced cancer patients and public towards euthanasia and physician assisted suicide. Health Policy 2010;97(2–3):160–5. [2] Myrianthefs P, Batistaki C, Baltopoulos G. Cardiopulmonary resuscitation in end-stage cancer patients. J BUON 2010;15(1):25–8. [3] Mystakidou K, Tsilika E, Parpa E, Katsouda E, Vlahos L. Patterns and barriers in information disclosure between health care professionals and relatives with cancer patients in Greek society. Eur J Cancer Care (Engl) 2005;14(2):175–81. [4] Mystakidou K, Parpa E, Tsilika E, Galanos A, Patiraki E, Tsiatas M, et al. Where do cancer patients die in Greece? A population-based study on the place of death in 1993 and 2003. J Pain Symptom Manage 2009;38(2):309–14. [5] Tsigaroppoulos T, Mazaris E, Chatzidarellis E, Skolarikos A, Varkarakis I, Deliveliotis C. Problems faced by relatives caring for cancer patients at home. Int J Nurs Pract 2009;15(1):1–6. [6] Mystakidou K, Parpa E, Tsilika E, Katsouda E, Vlahos L. The evolution of euthanasia and its perceptions in Greek culture and civilization. Perspect Biol Med 2005;48(1):95–104.
The same patient in various European countries
Palliative care for heart failure in Greece G. Spatharakis * Public Primary Health Care Center for Itea, 7, Epaminonda Papalexandri street, 332 00 Itea, Phokida, Greece
A R T I C L E I N F O
A B S T R A C T
Article history: Received 19 October 2010 Accepted 1 November 2010 Available online 8 December 2010
While few palliative care units are available for cancer patients in big cities of Greece, this specialized care is generally unavailable for non-cancer patients. No protocols are in use and the use of advance directives and discussions around euthanasia still represents a taboo subject for Greek families. Patients will receive standard hospital care but not necessarily psychological or social support. Terminal patients will rather finish their life in a hospital bed, a tendency that has accentuated these last decades. The family is generally present and regulates hospital admittance, home care and end-of-life decisions. The presence of well-trained and multi-professional teams is very scarce and expensive. Informal carers guided by the family often assume the basic care while medical care is provided in hospitals on an outpatient base or through house calls of privately installed doctors of different specialties. Very few geriatricians are available in Greece. ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved.
Keywords: Palliative care Heart failure Elderly Health services Greece
A brief discussion based on the questions posed in the case vignette is presented for Greece. 1. Would a patient like this receive palliative care, or is palliative care reserved for cancer patients? Who will care for him? How will this be decided? Are objective criteria used to define final stages of non-cancer diseases amenable to end-oflife care? If a patient like the one described above is living in his home in Greece, it is almost certain that he will not have the possibility to receive any kind of formal palliative care. Palliative care in Greece is mostly intended for cancer patients and at a minor degree for terminal patients with neurodegenerative diseases (Alzheimer’s disease, Parkinson’s disease). When living at home, close relatives like the spouse or children will take care of the elderly patient with heart failure. Additionally to that, specialized palliative care groups that provide home care are very scarce and mainly based in the private sector, making them very costly and unapproachable for most middle and low-income patients. Even under these conditions, this kind of services is only available in the two big cities of the country, namely Athens and Thessaloniki. Informal female carers with no specific training (many times of foreign origin, from eastern European countries, mostly of the
DOI of original article: 10.1016/j.eurger.2010.11.001 * Tel.: +302265351007; fax: +302265032268. E-mail address: [email protected].
old USSR) will cover the needs in basic and instrumental activities of daily living. This is decided mainly based on the availability and disposition of members of the close family and in accordance to the financial status of the family. The family will call a specialist doctor, mostly a neurologist and a cardiologist, in order to provide a prescription and/or directives for home management. The presence of a psychologist is difficult to get, either because of their small number or mainly because of the lack of experience in dealing with elderly patients. Social workers’ home visits are extremely rare in Greece and happen only when problems like poverty, abuse or inability for placement arise within the family. No criteria or protocols exist concerning the definition of the final stages of the non-cancer terminal elderly patient [1].
2. What kind of supportive treatment is offered? Which drugs used for symptom control? Are guidelines used for care? Is there any system to assess quality of end-of-life care of cardiac patients? The supportive treatment that will be offered is not standardized. There are no guidelines in use. If a doctor specialized in palliative care is available, protocols used in other European countries may be applied, adapted according to family wishes and available technical resources. Diuretics and oxygen therapy constitute the main procedures used. If at home hospitalization is available, drugs like milrinone in continuous perfusion can be also used to treat the cardiac symptoms. For the control of delirium traditionally haloperidol is used, although in recent
1878-7649/$ – see front matter ß 2010 Elsevier Masson SAS and European Union Geriatric Medicine Society. All rights reserved. doi:10.1016/j.eurger.2010.11.002
G. Spatharakis / European Geriatric Medicine 2 (2011) 44–45
years the use of modern antipsychotics like risperidone is increasing. 3. What is the usual attitude of health care providers (physicians, nurses, aides) and caregivers/family members towards these patients? How are care decisions made? Although the possibility of writing ‘‘Advance Directives’’ exists legally since the nineties in Greece, its applicability is limited by the fact that it demands a notary act that has to be deposited in advance. Given the nature of Greek people this possibility is unknown and practically never used. Thus, the family is usually taking decisions about maintaining or withholding treatments and on the general management of patients. Nurses and aides usually express their concerns, but will bend to family decisions. The attitude of the physician is mostly remote and defensive, centred on the medical problems per se rather than in life decisions for the patient [2,3]. Usually, when final stages approach, patients will be hospitalized and possibly end their lives in the hospital [4]. The whole family takes these decisions, when all its members are present and interested, or they will be taken and conducted by the one(s) that has/have the immediate care burden and usually, also, access to the patients’ financial resources. Conflicts of interest generally do not arise, as the non-interested family members usually feel relieved because somebody else has taken the burden of these difficult and complex decisions [5]. Euthanasia and other end-oflife issues are generally not discussed, as they are considered ethically unacceptable (due among others to orthodox religious beliefs) and psychologically painful [6,1]. 4. How is care provided in the hospital and after hospital discharge? How is follow-up performed? Are there mechanisms that may avoid hospital admissions without reducing standards of care? In Greece, there are no specialized geriatric units, as geriatrics is not recognized as a medical specialty or subspecialty. Palliative care beds, but not units (with a few exceptions) exist mainly in oncological hospitals and/or departments. Moreover, very few doctors in Greece are specialized in geriatrics and/or paliative care
45
(exacts figures are unavailable and unknown). Consequently, patients like the one described above will be admitted to a general internal medicine wards and receive standard care, under the instructions of neurologists, psychiatrists and cardiologists. The quality of care is usually good, and even intensive care can be assigned to these patients, although they are generally full and it is not easy to have a bed available when needed. There is no shortage of medicines, but the overall care is mostly medical/pharmacological based, with no patient-centred care or psychological support of the patient and the family. Follow-up is mainly performed at the hospital on an outpatient basis. Unfortunately, patients come to their appointments at the clinic and may wait in the corridors for some hours before entering into a short (a few minutes) visit with the physician. Unfortunately, again there are no protocols or measures and mechanisms that may avoid hospital admissions without reducing standards of care [1]. After hospital discharge, care is again mostly provided and coordinated by the family, as described above.
Conflict of interest statement Nothing declared. References [1] Parpa E, Mystakidou K, Tsilika E, Sakkas P, Patiraki E, Pistevou-Gombaki K, et al. Attitudes of health care professionals, relatives of advanced cancer patients and public towards euthanasia and physician assisted suicide. Health Policy 2010;97(2–3):160–5. [2] Myrianthefs P, Batistaki C, Baltopoulos G. Cardiopulmonary resuscitation in end-stage cancer patients. J BUON 2010;15(1):25–8. [3] Mystakidou K, Tsilika E, Parpa E, Katsouda E, Vlahos L. Patterns and barriers in information disclosure between health care professionals and relatives with cancer patients in Greek society. Eur J Cancer Care (Engl) 2005;14(2):175–81. [4] Mystakidou K, Parpa E, Tsilika E, Galanos A, Patiraki E, Tsiatas M, et al. Where do cancer patients die in Greece? A population-based study on the place of death in 1993 and 2003. J Pain Symptom Manage 2009;38(2):309–14. [5] Tsigaroppoulos T, Mazaris E, Chatzidarellis E, Skolarikos A, Varkarakis I, Deliveliotis C. Problems faced by relatives caring for cancer patients at home. Int J Nurs Pract 2009;15(1):1–6. [6] Mystakidou K, Parpa E, Tsilika E, Katsouda E, Vlahos L. The evolution of euthanasia and its perceptions in Greek culture and civilization. Perspect Biol Med 2005;48(1):95–104.