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Slovenia
Vol. 24 No. 2 August 2002
Journal of Pain and Symptom Management
233
Original Article
Slovenia: Status of Palliative Care and Pain Relief Ur˘ska Lunder, MD, and Branka C˘erv, RN, BSc Palliative Care Development Institute, Ljubljana, Slovenia
Introduction Palliative care is developing in Slovenia and there are several factors contributing to its emergence. These include the initiatives of professionals, a social awareness of the needs of patients after a new independent state has been established, a decentralization of health and hospital resources, and support from a health administration or local community.
Demographic and Epidemiological Data and Provision of Health Services in Slovenia Slovenia is a Central European country (Figure 1) with approximately 2 million inhabitants. The life expectancy at birth is 71 years for men and 79 years for women.1 The three main causes of death in Slovenia are diseases of circulatory system (7512 in total in 2000), neoplasms (4829) and diseases of respiratory system (1481).2 Slovenia is a country with a middle-sized morbidity and mortality rate caused by cancer. There were 8411 new cases of cancer diagnosed in Slovenia in 1998 (4209 among men and 4202 among women). The leading cancer site for the male population is lung (19% out of all cancer sites) and for the female population is breast (21%).3 Approximately 48% of all deaths occur in hospitals and 52% occur at home. The financing of health care is based on a social security system, which covers practically the entire population.
Address reprint requests to: Ur˘ska Lunder, MD, Palliative Care Development Institute, Vegova 8, SI-Ljubljana 1000, Slovenia © U.S. Cancer Pain Relief Committee, 2002 Published by Elsevier, New York, New York
Pallitive Care in Slovenia: Present Initiatives The hospice movement, with home service and education programs, started in the middle of the 1990s in the capital city of Slovenia. This includes mostly nursing and volunteer activities. A physician is not yet involved in the care. New regional organizations in different parts of Slovenia are coming into action, particularly for education on psychosocial topics for volunteers and the public. A major institution for cancer patients in the country has established a consultant group for palliative care. In the last few years, regular education on different topics related to palliative care has become part of the curriculum for family medicine and oncology offered by the medical faculty. Occasional seminars also are organized for health care professionals and others involved in the emergence of palliative care in Slovenia.
Pain Relief and Opioid Availability In the beginning of the 1990s, there were some administrative barriers for patients who needed opioids for severe pain. With a newly established independent state, there was an urgent need to bring new laws and procedures for better opioid availability. Today, all substantial drugs for pain relief are available, with a normal procedure for prescribing. Guidelines for pain management for adult patients have been available for the last two years. Together with the guidelines, there was a successful educational campaign organized to train doctors and nurses all over the region on the basics of pain management. Figure 2 shows the rise of morphine consumption in Slovenia; 0885-3924/02/$–see front matter PII S0885-3924(02)00436-0
234
˘ erv Lunder and C
Fig. 1. Map of Europe indicating Slovenia’s location on the continent.
there was a sudden rise after 1998, most probably due to the activities listed above and new pain relief drugs available on the market. In 1999, when the highest consumption of opioids in Slovenia occurred, the comparison with the rest of Europe is encouraging (Figure 3).
Vol. 24 No. 2 August 2002
rule; our independence began only in 1991. This situation through the centuries contributed to the development of a closed national character. People are not used to discussing and solving their problems publicly. Our suicide rate is one of the highest in Europe. In the period of socialism, death was pushed into the sphere of the private, and the Church, which was competing for the public’s attention, would not enter the public sphere.4 There was no interest in the development of public institutions, like palliative care wards in hospitals or hospices. There was a strict hierarchical organization of the health care system, and a team work approach was not developed. Nursing, which is the most involved in the care of dying patients, still has little power because of its subordinate position within the health care system.5 Medical doctors, probably because of the lack of palliative care topics during study, do not feel comfortable in the area of palliation and rather emphasize the curative approach. Finally, there is a constant lack of financial support for the palliative care programs on the part of the young state. The positive starting point for palliative care development is the fact that more than half (52%) of population is dying at home.
Future Perspectives Historical, Cultural, and Economic Reasons for the Present Situation Possible reasons for present status of palliative care in Slovenia could be the historical development of Slovene society. There has been long subjugation of the country to another’s
Fig. 2. Consumption of morphine in Slovenia. (Source: Ministry of Health of Slovenia)
There should be a specific strategy to develop and combine well-planned resources with an emphasis on training. The planning and implementation of palliative care must be comprehensive, with measures taken in all health care settings. This should be adapted to the health and social system, and linked, from the beginning, to the relevant areas, particularly oncology, primary care, pediatrics, geriatrics, and neurology, in order to promote maximum integration. The development of palliative care is a public health policy matter and the health administration has to be involved from the beginning in order to promote quality and equity in the provision of palliative care, and to finance it as a part of the overall health care system. A newly established Palliative Care Development Institute prepares education and research, and is a liaison for different organizations and interests for the development of a national program of palliative care.
Vol. 24 No. 2 August 2002
Slovenia
235
Fig. 3. Opioid consumption in Slovenia (1999) in comparison to other European countries. (Source: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center.)
References 1. Primic-Z˘akelj M, C˘eh F, Pompe-Kirn V, S˘krk J, S˘tabuc B. Vec˘ znanja—manj bolezni: didaktic˘ ni komplet za uc˘ itelje [More knowledge—less illness: a didactic set for teachers]. Ljubljana: Zavod republike Slovenije za ˘solstvo, 2001:7. 2. Moravec-Burger D, Urdih-Lazar T. Zdravstveni statistic˘ ni letopis, Slovenija 2000 [Health statistics yearbook, Slovenia 2000]. Zdravstveno varstvo 2001; letn. 40; supl. 1: 43, 55, 57. 3. Pompe-Kirn V, et al. Incidenca raka v Sloveniji
1998. Poroc˘ ilo RR ˘st. 40 [Cancer incidence in Slovenia 1998: report no. 40]. Ljubljana: Onkolo˘ski in˘stitut, 2001:12. 4. Ker˘sevan M. Odnosi do mrtvih v socialistic˘ nih druz˘bah [Attitudes toward the dead in Socialist societies]. Anthropos 1981;4–6:265–276. 5. Pahor M. Nurses in Slovenia and professionalisation: one step forward, two backward. Paper presented at the 5th conference of the European Sociological Association “Visions and Divisions: Challenges to European Sociology” at Helsinki, August 28–September 1, 2001.
Journal of Pain and Symptom Management
233
Original Article
Slovenia: Status of Palliative Care and Pain Relief Ur˘ska Lunder, MD, and Branka C˘erv, RN, BSc Palliative Care Development Institute, Ljubljana, Slovenia
Introduction Palliative care is developing in Slovenia and there are several factors contributing to its emergence. These include the initiatives of professionals, a social awareness of the needs of patients after a new independent state has been established, a decentralization of health and hospital resources, and support from a health administration or local community.
Demographic and Epidemiological Data and Provision of Health Services in Slovenia Slovenia is a Central European country (Figure 1) with approximately 2 million inhabitants. The life expectancy at birth is 71 years for men and 79 years for women.1 The three main causes of death in Slovenia are diseases of circulatory system (7512 in total in 2000), neoplasms (4829) and diseases of respiratory system (1481).2 Slovenia is a country with a middle-sized morbidity and mortality rate caused by cancer. There were 8411 new cases of cancer diagnosed in Slovenia in 1998 (4209 among men and 4202 among women). The leading cancer site for the male population is lung (19% out of all cancer sites) and for the female population is breast (21%).3 Approximately 48% of all deaths occur in hospitals and 52% occur at home. The financing of health care is based on a social security system, which covers practically the entire population.
Address reprint requests to: Ur˘ska Lunder, MD, Palliative Care Development Institute, Vegova 8, SI-Ljubljana 1000, Slovenia © U.S. Cancer Pain Relief Committee, 2002 Published by Elsevier, New York, New York
Pallitive Care in Slovenia: Present Initiatives The hospice movement, with home service and education programs, started in the middle of the 1990s in the capital city of Slovenia. This includes mostly nursing and volunteer activities. A physician is not yet involved in the care. New regional organizations in different parts of Slovenia are coming into action, particularly for education on psychosocial topics for volunteers and the public. A major institution for cancer patients in the country has established a consultant group for palliative care. In the last few years, regular education on different topics related to palliative care has become part of the curriculum for family medicine and oncology offered by the medical faculty. Occasional seminars also are organized for health care professionals and others involved in the emergence of palliative care in Slovenia.
Pain Relief and Opioid Availability In the beginning of the 1990s, there were some administrative barriers for patients who needed opioids for severe pain. With a newly established independent state, there was an urgent need to bring new laws and procedures for better opioid availability. Today, all substantial drugs for pain relief are available, with a normal procedure for prescribing. Guidelines for pain management for adult patients have been available for the last two years. Together with the guidelines, there was a successful educational campaign organized to train doctors and nurses all over the region on the basics of pain management. Figure 2 shows the rise of morphine consumption in Slovenia; 0885-3924/02/$–see front matter PII S0885-3924(02)00436-0
234
˘ erv Lunder and C
Fig. 1. Map of Europe indicating Slovenia’s location on the continent.
there was a sudden rise after 1998, most probably due to the activities listed above and new pain relief drugs available on the market. In 1999, when the highest consumption of opioids in Slovenia occurred, the comparison with the rest of Europe is encouraging (Figure 3).
Vol. 24 No. 2 August 2002
rule; our independence began only in 1991. This situation through the centuries contributed to the development of a closed national character. People are not used to discussing and solving their problems publicly. Our suicide rate is one of the highest in Europe. In the period of socialism, death was pushed into the sphere of the private, and the Church, which was competing for the public’s attention, would not enter the public sphere.4 There was no interest in the development of public institutions, like palliative care wards in hospitals or hospices. There was a strict hierarchical organization of the health care system, and a team work approach was not developed. Nursing, which is the most involved in the care of dying patients, still has little power because of its subordinate position within the health care system.5 Medical doctors, probably because of the lack of palliative care topics during study, do not feel comfortable in the area of palliation and rather emphasize the curative approach. Finally, there is a constant lack of financial support for the palliative care programs on the part of the young state. The positive starting point for palliative care development is the fact that more than half (52%) of population is dying at home.
Future Perspectives Historical, Cultural, and Economic Reasons for the Present Situation Possible reasons for present status of palliative care in Slovenia could be the historical development of Slovene society. There has been long subjugation of the country to another’s
Fig. 2. Consumption of morphine in Slovenia. (Source: Ministry of Health of Slovenia)
There should be a specific strategy to develop and combine well-planned resources with an emphasis on training. The planning and implementation of palliative care must be comprehensive, with measures taken in all health care settings. This should be adapted to the health and social system, and linked, from the beginning, to the relevant areas, particularly oncology, primary care, pediatrics, geriatrics, and neurology, in order to promote maximum integration. The development of palliative care is a public health policy matter and the health administration has to be involved from the beginning in order to promote quality and equity in the provision of palliative care, and to finance it as a part of the overall health care system. A newly established Palliative Care Development Institute prepares education and research, and is a liaison for different organizations and interests for the development of a national program of palliative care.
Vol. 24 No. 2 August 2002
Slovenia
235
Fig. 3. Opioid consumption in Slovenia (1999) in comparison to other European countries. (Source: Pain & Policy Studies Group, University of Wisconsin/WHO Collaborating Center.)
References 1. Primic-Z˘akelj M, C˘eh F, Pompe-Kirn V, S˘krk J, S˘tabuc B. Vec˘ znanja—manj bolezni: didaktic˘ ni komplet za uc˘ itelje [More knowledge—less illness: a didactic set for teachers]. Ljubljana: Zavod republike Slovenije za ˘solstvo, 2001:7. 2. Moravec-Burger D, Urdih-Lazar T. Zdravstveni statistic˘ ni letopis, Slovenija 2000 [Health statistics yearbook, Slovenia 2000]. Zdravstveno varstvo 2001; letn. 40; supl. 1: 43, 55, 57. 3. Pompe-Kirn V, et al. Incidenca raka v Sloveniji
1998. Poroc˘ ilo RR ˘st. 40 [Cancer incidence in Slovenia 1998: report no. 40]. Ljubljana: Onkolo˘ski in˘stitut, 2001:12. 4. Ker˘sevan M. Odnosi do mrtvih v socialistic˘ nih druz˘bah [Attitudes toward the dead in Socialist societies]. Anthropos 1981;4–6:265–276. 5. Pahor M. Nurses in Slovenia and professionalisation: one step forward, two backward. Paper presented at the 5th conference of the European Sociological Association “Visions and Divisions: Challenges to European Sociology” at Helsinki, August 28–September 1, 2001.