Pain and Palliative Medicine Project (PPMP), funded by the TEMPUS programme of the European Union, has been established with a goal of sharing knowledge and experience from countries in which palliative care is already substantially developed to partner countries whose palliative care encountered more problems. Croatia as partner country, has tried to improve national palliative care systems through education of medical and non-medical personnel.
Protocols of collaboration and training courses in pain management and palliative medicine at the Universities of Florence and Lyon, including options of collaboration with some university and clinical institutions in Croatia have been presented.
After their two-year project, the Croatian team has noted significant progress in the fields of education, infrastructure and legislative support for development of palliative care. These results show the need for improving Croatian palliative care system as well as possible solutions for overcoming obstacles derived from nation’s traditional views on the treatment of the terminally ill.Bol i palijativna medicina (PPMP) je projekt u okviru TEMPUS programa Europske Unije s ciljem prenošenja znanja i iskustava zemalja, u kojima je palijativna skrb dobro razvijena, zemljama u kojima je palijativna skrb manje aktivna. Hrvatska, kao zemlja partner, nastoji poboljšati nacionalni program palijativne skrbi kroz edukaciju medicinskog i ne-medicinskog osoblja.
Prikazani su protokoli suradnje i tečajeva o boli i palijativnoj medicine na Sveučilištima u Firenci i Lyonu, kao i na nekim sveučilišnim i kliničkim institucijama u Hrvatskoj.
Nakon dvogodišnjeg projekta hrvatski tim zabilježio je značajni napredak u poljima edukacije, infrastrukture i zakonske potpore razvoju palijativne skrbi. Ovi rezultati su pokazali potrebu za daljnjim poboljšavanjem hrvatske palijativne skrbi kao i moguća rješenja za prevladavanje prepreka koje proizlaze iz tradicionalnih pogleda društva na skrb terminalno bolesnih

Benko, Marta

Butković, Diana

DeGaudio, Raffaele

Jadrijević, Filip

Matolić, Martina

Rogošić, Srđan

Stepan, Jasminka

English

Hrčak - Portal of scientific journals of Croatia

55ARTICLE Libri Oncol., Vol. 38 (2010), No 1-3, 55 – 59PAIN AND PALLIATIVE MEDICINE – TEMPUS PROJECT IN CROATIAJASMINKA STEPAN1, DIANA BUTKOVI]2, SR\AN ROGO[I]1, MARTA BENKO1, FILIP JADRIJEVI]1, MARTINA MATOLI]2 and RAFFAELE DE GAUDIO31Department of Hematology and Oncology, Children’s Hospital Zagreb, “Sestre milosrdnice” University Hospital, Zagreb, Croatia2Department of Anestesiology, Reanimatology and Intensive Care, Children’s Hospital Zagreb, “Sestre milosrdnice” University Hospital, Zagreb, Croatia3Critical Care Department, Section of Anesthesiology and IC, University of Florence, Florence, ItalySummaryPain and Palliative Medicine Project (PPMP), funded by the TEMPUS programme of the European Union, has been established with a goal of sharing knowledge and experience from countries in which palliative care is already substan-tially developed to partner countries whose palliative care encountered more problems. Croatia as partner country, has tried to improve national palliative care systems through education of medical and non-medical personnel.Protocols of collaboration and training courses in pain management and palliative medicine at the Universities of Flor-ence and Lyon, including options of collaboration with some university and clinical institutions in Croatia have been pre-sented.After their two-year project, the Croatian team has noted significant progress in the fields of education, infrastructure and legislative support for development of palliative care. These results show the need for improving Croatian palliative care system as well as possible solutions for overcoming obstacles derived from nation’s traditional views on the treatment of the terminally ill.KEYWORDS: palliative care, pain, interdisciplinarityBOL I PALIJATIVNA MEDICINA – TEMPUS PROJEKT U HRVATSKOJSa`etakBol i palijativna medicina (PPMP) je projekt u okviru TEMPUS programa Europske Unije s ciljem preno{enja znanja i iskustava zemalja, u kojima je palijativna skrb dobro razvijena, zemljama u kojima je palijativna skrb manje aktivna. Hrvat-ska, kao zemlja partner, nastoji pobolj{ati nacionalni program palijativne skrbi kroz edukaciju medicinskog i ne-medicin-skog osoblja.Prikazani su protokoli suradnje i te~ajeva o boli i palijativnoj medicine na Sveu~ili{tima u Firenci i Lyonu, kao i na nekim sveu~ili{nim i klini~kim institucijama u Hrvatskoj.Nakon dvogodi{njeg projekta hrvatski tim zabilje`io je zna~ajni napredak u poljima edukacije, infrastrukture i zakon-ske potpore razvoju palijativne skrbi. Ovi rezultati su pokazali potrebu za daljnjim pobolj{avanjem hrvatske palijativne skrbi kao i mogu}a rje{enja za prevladavanje prepreka koje proizlaze iz tradicionalnih pogleda dru{tva na skrb terminalno bolesnih.KLJU^NE RIJE^I: palijativna skrb, bol, interdisciplinarnostLibri Oncol., Vol. 38 (2010), No 1–3, 55 – 5956INTRODUCTIONThe TEMPUS programme (Trans-European Mobility Programme for University Studies) is a European Union (EU) program designed to en-courage the collaboration between institutions of the EU Members States and their partner countries with a goal of modernizing higher education and promoting specific project goals primarily through university cooperation (1).In 2007, the TEMPUS programme approved a project on the topic of pain management and palliative medicine called Palliative and Pain Medicine Project (PPMP). The University of Flor-ence and University of Lyon have been given a two-year grant (2007-2009) to lead the project with a goal of imparting knowledge and experience from countries in which palliative care has already been substantially developed to partner countries with much less active palliative care. These part-ner countries were recognized in Croatia and Ser-bia, with the University of Zagreb School of Medi-cine, represented by the Zagreb Children’s Hospi-tal, and the University of Belgrade School of Medicine, as their consortium members (2).The principal goals of this project were to im-prove the existing and create new and better con-ditions for the development of palliative medicine and pain management in Croatia. This was meant to be done by means of undergraduate and post-graduate education and training, ensuring better infrastructure and influencing positive legislative changes.Palliative medicine in Croatia attracted very little attention of both medical and general audi-ence. Several attempts to form institutionalized palliative care in Croatia, thanks to the leadership of Professor Anica Ju{i}, resulted in positive legis-lative changes in 2003, regulating infrastructural and personnel requirements for providing pallia-tive care in primary healthcare (3). In this project a Croatian consortium mem-ber, represented by the Zagreb Children’s Hospi-tal, has made significant efforts in advancing pal-liative care in Croatia and resolving some of many obstacles preventing the Croatian palliative care system from fully taking its role. In this report we will try to present the betterment of Croatian pal-liative care as a result of the PPMP project con-ducted over two years.METHODSAs a Croatian consortium member we have organized five two-day courses in the Zagreb Children’s Hospital for 45 doctors of various spe-cialties from all parts of Croatia. Invitations to the courses were open to the public, the courses were free and the only requirements for application were a medical degree and knowledge of English. The courses were held by local and international lecturers from grant-holder institutions, the Uni-versity of Florence and the University of Lyon. Upon completion of all five courses, participants were invited to apply for a one-month course on palliative and pain medicine at the Universities of Florence and Lyon. Applicants were chosen on the basis of their curriculum vitae, written exam testing their knowledge of pain and palliative medicine, their motivation letter as well as their course attendance records. Fifteen candidates of various specialties were chosen for the task. Fol-lowing the completion of the one-month course in referral centers in Italy and France, applicants have been granted a certificate of competence in pain management and palliative care. As such, they have joined our project as basic medical per-sonnel certified to be included in the PPMP and continue further education on the issue in their primary institutions throughout the country.Education and dissemination were also con-ducted through undergraduate and postgraduate courses in the School of Medicine, School of Ap-plied Health Sciences, Faculty of Theology, Law School (Social Services Studies), Faculty of Educa-tion and Rehabilitation Sciences (Department for Motoric Disturbances, Chronic Diseases and Art Therapies/Croatian Psychosocial Oncology Asso-ciation) at the University of Zagreb, as well as at the Zagreb Children’s Hospital and Zagreb Uni-versity Hospital Center. General public was also educated through media exposure.RESULTSEducation and trainingAll 15 candidates selected for the course on pain and palliative medicine have successfully mas-tered topics in the areas of pain management, health issues of the terminally ill, psychological approach to the patient and their families and cur-57Libri Oncol., Vol. 38 (2010), No 1–3, 55 – 59rent ethical guidelines. Candidates were of differ-ent medical specialties and have continued the education and promotion of the issue at their pri-mary institutions (Table 1).Undergraduate and postgraduate courses at the University of Zagreb have been held for many participants. Postgraduate courses have offered targeted instructions to various medical personnel of different specialties, mostly anesthesiologists, neurologists, pediatricians, children surgeons, on-cologists and general practitioners.InfrastructureAs a result of education and dissemination of the project’s agenda we have achieved substantial results with increasing number of both adult and pediatric palliative care units.In December 2008, the Committee for Pallia-tive Care and Team for Palliative Care visited the Zagreb Children’s Hospital as the first Croatian inpatient palliative care unit. Both the Committee and the Team consist of pediatric oncologist, pedi-atric surgeon, anesthesiologist (as a pain special-ist), psychologist, nurse and physiotherapist, all of them unified in a goal to provide the best care for children in terminal phases of chronic lethal dis-eases.All actions have been implemented in coordi-nation with the Hospital’s Ethics Committee.The Palliative Committee helps patients and their families in their transition from curative to palliative treatment, enabling a better quality of life and better communication between attending physicians and the family.Table 1. NUMBER OF CANDIDATES ATTENDING THE COURSE ON PAIN AND PALLIATIVE MEDICINE AT THE UNIVERSITY OF FLORENCE AND THE UNIVERSITY OF LYON, SORTED ACCORDING TO THEIR SPECIALTIES.Candidate’s specialty Number of candidatesAnesthesiologist 9Neurologist 2Pediatrician 2General practitioner/Emergency room attending2Total 15Through the Pain and Palliative Medicine Project (PPMP), the Croatian consortium member has established a good collaboration with the con-sortium member represented by the School of Medicine, University of Belgrade. Cooperation with the University of Tuzla in Bosnia and Herze-govina has also been established.Continuous education has been implemented through the third phase in a form of e-learning where participant contributed to the growing base of knowledge.Table 3. CROATIAN PALLIATIVE CARE SYSTEM AFTER IMPLEMENTATION OF TEMPUS PPMP.HospicesInpatient palliative care unitsConsultant teams in hospitalsHome care teams -Mobile unitsDay care centresBereavement support teamsNumbers of bed allocated to palliative care Adult 0 0 5 5 0 2 6Pediatric 0 1 1 1 0 1 2Total 0 0 6 6 0 3 8Table 2. CROATIAN PALLIATIVE CARE SYSTEM BEFORE IMPLEMENTATION OF TEMPUS PPMP (ACCORDING TO PALLIATIVE CARE FACTS IN EUROPE QUESTIONNAIRE 2005).HospicesInpatient palliative care unitsConsultant teams in hospitalsHome care teams -Mobile unitsDay care centersBereavement support teamsNumbers of bed allocated to palliative careAdult 0 0 0 3 0 2 0Pediatric 0 0 0 0 0 1 0Total 0 0 0 3 0 2 0Libri Oncol., Vol. 38 (2010), No 1–3, 55 – 5958The Palliative Team can be contacted by pho-ne on a 24/7 principle when a child is nursed at home. Symptom Control Protocols have been made, primarily for pain management but also for other complications of the terminally ill, such as gastrointestinal, neurological, respiratory and skin conditions. Psychological and spiritual help is also included and continues in the period of mo-urning. Contacts with primary care physicians, county hospitals, social workers and priests in the residential area of the patient have also been dee-med necessary.Upon completion of their training, our candi-dates continued to advocate the need of palliative care at their primary institutions which has resulted in forming six consultant palliative teams in hospi-tals, six homecare palliative teams (mobile teams) and eight beds allocated to palliative care in hospi-tals throughout the country (Table 2, Table 3).LegislationThrough education of a wider public, media dissemination of the issue and vigorous advocacy of the need for legislative support of our project’s cause, we have obtained a unanimous approval from the Croatian Parliament set forth the Resolu-tion on Malignant Diseases. The Resolution clearly defines palliative medicine as a crucial component in cancer treatment. We also witnessed a change in the Healthcare Law in 2009 and 2010 where there was a first legal mention of an institution for palliative care as a separate entity, in contrast to the previous mention of the primary care level alone (4, 5).DiscussionPalliative care, by the definition of the World Health Organization (WHO), is “an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual” (6).Since 1994, efforts to form a palliative care sys-tem in Croatia have been shown through a variety of congresses, symposia and seminars. Several non-governmental organizations have made every at-tempt at founding proper institutions in the field of palliative care. These efforts resulted in a change of the Healthcare Law in 2003 clearly defining the need and requirements for founding palliative care at the primary healthcare level (3, 7, 8).Despite the positive indicators, no actual in-stitutional changes have been made. The Croatian palliative care level is still considered to be very low. General public as well as healthcare provid-ers have supported and expressed the need to form such care in an increasingly aging popula-tion of Croatia (9). However, the needs for this sort of care have not had an impact on actions at government levels.The financial aspect of the problem is most likely the one to be blamed for such an outcome. Financing from the country’s budget has always been challenging, but even private donations have been discouraged due to long-lasting procedures of forming Foundations which would manage such private funds. Although based on our expe-rience, we believe that our society’s attitude to-ward life and dying is also of great significance when choosing the modality of organizing pallia-tive care, not just financial aspects of the problem. Our culture and tradition of nursing the dying at home is likely to play an important role when es-tablishing proper palliative care. Experience tells us that patients and their families have troubles accepting the concept of institutionalized transi-tioning from curative to palliative care outside the hospital.With our project we have tried to raise public and healthcare providers’ awareness of the issue. We have managed to give institutionalized educa-tion to 15 doctors to promote the goal throughout the country. Our efforts in educating and promot-ing the goal have also been visible through dozens of post-graduate courses as well as several under-graduate courses at the University of Zagreb.Results of increased infrastructural and per-sonnel resources, in our still very poorly organized palliative care, are encouraging. The formation of the very first hospital palliative care unit, six hos-pital-based consultant palliative teams, six homec-are palliative teams (mobile teams) and eight hos-pital beds allocated to palliative care, is a good step toward a goal of well-organized care of the terminally ill.Therefore, education and initiatives at na-tional levels to further develop palliative care in Croatia have been pinpointed as our future goals. 59Libri Oncol., Vol. 38 (2010), No 1–3, 55 – 59We believe that doctors, nursing staff, volunteers and general public should all be involved in this education. Additional collaboration between in-stitutions in Croatia, but also at regional and inter-national levels is planned as we believe that the solutions to the problems of palliative care in the region might be of the same nature as in Croatia. Special emphasis should be on collaboration be-tween the four universities with possible expan-sion to more members.It is our conviction that by sharing the model of Palliative Care Committee and Palliative Care Team with all Croatian hospitals, we might work toward advancing the palliative care in Croatia while at the same time respecting the tradition and specific local customs on the care of the dying. Institutional palliative care should not only be viewed in a form of hospices. Our belief is that when taking into consideration Croatian tradi-tional views of the topic, a better solution for pal-liative care system might be found in increasing the number of hospital beds allocated for pallia-tive care and day care hospitals.Furthermore, by establishing a good collabo-ration between the School of Medicine, Law School, Faculty of Education and Rehabilitation Sciences, Theological Faculty, Croatian Associa-tion of Psychosocial Oncology and other institu-tions we might provide a regulatory role for coor-dination of any future actions for the improvement of palliative care at a national level. We believe that coordination should be maintained through the Croatian Medical Association and its subdivi-sions. With such an experience we might also en-courage neighboring countries of similar cultural heritage to develop their palliative care to a higher level.REFERENCES 1. About Tempus IV (2007-2013) [accessed 17 Nov 2010] Available from: http://eacea.ec.europa.eu/tempus/programme/about_tempus_en.php 2. Palliative and Pain Medicine Project Goals [accessed 17 Nov 2010] Available from: http://www.palliative-4pain.org/goals.htm 3. Ju{i} A. [The hospice movement in Croatia--short re-view] [Article in Croatian] Acta Med Croatica. 2009; 63: 335-40. 4. Zakon o zdravstvenoj za{titi [In Croatian]. Narodne novine 2009;150. 5. Dopuna Zakona o zdravstvenoj za{titi [In Croatian]. Narodne novine 2010;71. 6. WHO Definition of Palliative Care, accessed 17 Nov 2010, Available from: http://www.who.int/cancer/palliative/definition/en/ 7. Ju{i} A. Palliative medicine’s first steps in Croatia. In: Saunders C, Kasternbaum R, editors. Hospice care on the international Scene. New York: Springer; 1997. p 125-9. 8. Zakon o zdravstvenoj za{titi [In Croatian]. Narodne novine. 2003; 121. 9. Brklja~i} M, Mavrinac M, Sorta-Bilajac I et al. An in-creasing older population dictates the need to orga-nize palliative care and establish hospices. Coll An-tropol. 2009; 33: 473-80.10. World Health Organization. Cancer Pain Relief and Palliative Care in Children, Geneva, WHO, 199811. Oxford Textbook of Palliative Medicine, 2nd Ed,Oxford University Press 2006Author’s address: Jasminka Stepan, M.D., Ph.D., Depart-ment of Hematology and Oncology, Children’s Hospital Zagreb, ’Sestre milosrdnice’ University Hospital, Klai}eva 16, 10000 Zagreb, Croatia

Bol i palijativna medicina – tempus projekt u Hrvatskoj

Bol i palijativna medicina – tempus projekt u Hrvatskoj

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