Background: Specialist palliative care is being increasingly recognised and developed to improve end-of-life care in many developed countries. However, only a small proportion of the total number of patients with incurable, progressive diseases actually has direct contact with specialist palliative care practitioners. Using the German situation as an example, the main purpose of this paper is to argue that the emphasis on specialist palliative care services without a similar encouragement of primary palliative care will deliver a constrained service

A Kruse

A Waller

Geoffrey K Mitchell

IJ Higginson

K Thomas

M Schumacher

N Schneider

N Small

Nils Schneider

Palliative Care Australia

R Charlton

R Harding

R Voltz

SA Murray

SC Murray

Scott A Murray

T Brueckner

T Schindler

World Health Organization Regional Office for Europe

English

PubMed

Schneider, Nils

Mitchell, Geoffrey K.

Murray, Scott A.

University of Queensland eSpace

Palliative care in urgent need of recognition and development in general practice: the example of Germany

Springer - Publisher Connector

DEBATE Open Access
Palliative care in urgent need of recognition
and development in general practice:
the example of Germany
Nils Schneider1*, Geoffrey K Mitchell2, Scott A Murray3
Abstract
Background: Specialist palliative care is being increasingly recognised and developed to improve end-of-life care
in many developed countries. However, only a small proportion of the total number of patients with incurable,
progressive diseases actually has direct contact with specialist palliative care practitioners. Using the German
situation as an example, the main purpose of this paper is to argue that the emphasis on specialist palliative care
services without a similar encouragement of primary palliative care will deliver a constrained service.
Discussion: For the vast majority of people with incurable, progressive diseases, good palliative care delivered by
General Practitioners and community nurses, with access to specialist support when needed, is the optimal
response. In Germany, specialist palliative care in the community was established in the 2007 health care reforms.
However actual and potential delivery of palliative care by general practitioners and community based nurses has
been sorely neglected. The time-consuming care of palliative patients and their families is currently far from
accurately reflected in German, indeed most European primary care payment systems. However, it is not just a
question of adequate financial compensation but also of the recognition of the fundamental value of this intense
form of holistic family medicine.
Summary: It is imperative palliative care carried out by community nurses and general practitioners is better
recognised by health professionals, health insurers, government and the scientific community as a central part of
the delivery of health care for people in the last phase of life. Health systems should be arranged so that this
critical role of general practice and primary care is intentionally fostered. Palliative care carried out by generalists
needs an identity at an academic and practical level, developing in concert with specialist palliative care.
Background
Delivering appropriate care for people with incurable
progressive diseases in the last phase of life is an impor-
tant, but largely neglected, role of the health system in
many countries [1,2]. In recent years deficits in this field
have increasingly come to the attention of the public,
politicians and professionals, as have insistent demands
for the development of palliative care.
Measured in terms of the number of palliative care
units, hospices and outpatient palliative care services
(palliative care teams), specialist palliative care has
grown considerably. However, according to expert
estimates, the need remains far from met [3]. This is
particularly true for care in the community. Although
most people want to die at home, only about 30% are
successful in doing so, with the majority dying in hospi-
tals or in nursing homes [1,4].
In Germany, for example, in order to enable more
people to spend the last phase of their lives at home,
avoid unnecessary hospital admissions and improve
patients’ quality of life, legislators established specialist
palliative care in the community (spezialisierte ambu-
lante Palliativversorgung, SAPV) as part of the 2007
health care reforms (§ 37b of German Social Security
Code V), with varying degrees of specialist support, ran-
ging from one-off consultations to full palliative care
provided by a specialist team. By the end of 2009,
approximately 50 SAPV contracts between the Statutory
* Correspondence: schneider.nils@mh-hannover.de
1End-of-life Care Research Group, Institute of Epidemiology, Social Medicine
and Health System Research, Hannover Medical School, Hannover, Germany
Full list of author information is available at the end of the article
Schneider et al. BMC Family Practice 2010, 11:66
http://www.biomedcentral.com/1471-2296/11/66
© 2010 Schneider et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.
Health Insurance and service providers had been agreed
nationwide [5]. The movement to implementation is in
practice sluggish, however, and is complicated by unan-
swered questions regarding requirements, content and
structural design, and by problems in quality assurance
and resource distribution. These implementation pro-
blems should not detract from the promising potential
SAPV has in bringing about sustainable improvement
through innovative approaches to caring for the
seriously and terminally ill. The introduction of SAPV is
in line with the international trend towards specialist
palliative care services for patients with particularly high
care needs [1,2].
Discussion
The fact should not be overlooked that even if specialist
palliative care became fully available in the future, only a
relatively small proportion of the total number of patients
with incurable, progressive diseases will benefit from this
care. It is estimated that 10% of the incurable, seriously
ill and dying need some form of specialist palliative care
[6]. The vast majority of those affected do not require
specialised care, but can be adequately treated within
primary care, some with varying degrees of specialist
support. Internationally, the phrase ‘primary palliative
care’ is generally used as a generic term for the activities
of GPs and home care nursing services in this field [7].
Potential of GPs
General practitioners have the potential and ability to
provide end-of-life care for most patients, given ade-
quate training, resources and, when needed, specialist
advice [8,9]. The introduction of SAPV meets require-
ments for specialist advice, and the majority of family
doctors welcome this opportunity: in a survey of GPs in
Lower Saxony, 56% indicated the likelihood that they
would, in relevant cases, consult SAPV teams as “defi-
nite” or “probable”, and the same number could imagine
themselves sharing the delivery of patient care with an
SAPV team. Only a minority of 15% can imagine
entirely handing over the care of their palliative patients
[10]. These results underline the self-perception of gen-
eral practitioners that they support their patients con-
tinuously through various stages of life, assisting in a
variety of care situations right up until death.
The level of family doctors’ commitment to seriously ill
and dying patients in their practices is also demonstrated
by the fact that around half of GPs indicate that they are,
regardless of the official rules of the physicians’ emer-
gency service, always available [i.e. around the clock] to
their palliative patients - sometimes personally, some-
times through informal arrangements with colleagues.
This willingness seems to become more pronounced as
the patient’s death comes closer [11].
For patients and relatives, the family doctor is the pri-
mary contact, including - and especially - in the case of
an incurable, progressive disease [12]. The doctor-
patient relationship, ideally developed over years,
together with the focus on whole patient care with a
biopsychosocial approach which is characteristic of the
general practice, means that family doctors have the
inestimable advantage of knowing palliative patients
even before the onset of the incurable disease, and so
proactively influence the care provided. This is an
advantage GPs have over specialist palliative care physi-
cians, who have a relatively late first contact with
patients and relatives.
Different illness trajectories
Forty-two per cent of people die aged between 60 and
80, and 44% die at over 80 years of age. With advancing
age, cardiovascular disease as a principal cause of death
is more relevant than malignant neoplasm [13,14].
Elderly people with dementia, frailty or multiple chronic
conditions formulate the largest group of patients in
GPs’ practices, responsible for around 35% of deaths,
and an even greater percentage of the need for palliative
care as their illness trajectories of decline are relatively
long [15].
As in other European countries, hospices, palliative care
units and palliative care teams in Germany focus on care
for cancer patients. In 2008, 90% of the patients cared for
by hospices and palliative care units, and 74% cared for by
palliative care teams in the community suffered from
cancer. Only approximately 20% had cardiovascular dis-
eases as the leading diagnosis [16]. A number of factors
have contributed to this, such as institutional affiliations
and financial incentives. One significant reason may be
found in the fact that remaining life expectancy and the
course of the disease are often relatively easier to estimate
in cancer patients than in patients with other incurable,
progressive diseases, and so organisation of, and therefore
access to specialized care is, comparatively, easier to
arrange.
So far three distinct illness trajectories have been
described for people with incurable, progressive chronic
illnesses: a trajectory with steady progression and usually
a clear terminal phase (mostly cancer); a trajectory (for
example, respiratory and heart failure) with gradual
decline, punctuated by episodes of acute deterioration
and some recovery, with more sudden, seemingly unex-
pected death; and a trajectory of prolonged frailty, poor
function, and gradual decline (typical of frail elderly
people or people with dementia) [17]. Thus in Germany
as in the UK, the palliative care needs of non-cancer
patients are often not adequately recognized [e.g.
[7,18,19]]. WHO advocacy for better palliative care for
older people [20] is a wake up call for groundbreaking
Schneider et al. BMC Family Practice 2010, 11:66
http://www.biomedcentral.com/1471-2296/11/66
Page 2 of 5
action that general practitioners are well placed to take
forward internationally.
Increased demand for primary palliative care
In order to meet these challenges, the development of
existing specialist palliative care is an important step.
The debate will however fall short of the issue if, as is
frequently the case, it focuses almost exclusively on spe-
cialist care. For the vast majority of people in the final
phase of life with incurable, progressive diseases, good
primary care delivered by GPs and community nurses,
i.e. primary palliative care, is the optimal response [7].
In politics, public and professional circles, however, this
aspect has been sorely neglected.
Beneficial as the introduction of specialist palliative
care in the community (SAPV) in Germany was, the
failure to encourage primary palliative care at the same
time remains baffling. The time-consuming care of
palliative patients and their families is currently far from
accurately reflected in the primary care compensation
Figure 1 Seamless transition between specialist and generalist
palliative care services according to intensity of need. [23]
Figure 2 Organisation of health system to facilitate needs-based palliative care. [23]
Schneider et al. BMC Family Practice 2010, 11:66
http://www.biomedcentral.com/1471-2296/11/66
Page 3 of 5
system. The same holds for the numerous home visits
that are often required, or for the willingness of many
primary care doctors to be, for the sake of their patients,
available outside of, and in addition to, their official
practice times and emergency duties. This is not just a
question of adequate financial compensation, but also of
the recognition of requirements in health care delivery,
and patients’ needs, and of the fundamental value of this
intense form of holistic family medicine.
Transition between primary and specialist palliative care
An ideal health system for managing palliative care
would see a seamless transition between primary and
specialist palliative care, and provision of support in the
form of access to evidence based guidelines, supported
by specialist involvement ranging from one-off consulta-
tions to full referral. In effect, the care of the patient is
shared between the two, with the primary care team
usually determining when and how much support is
required.
In Australia, for example, much work has been done to
facilitate needs-based palliative care delivery to ensure that
patients receive the right level of care at the right time
[21,22]. A schematic representation of this model devel-
oped by Australian policy makers is shown in Figures 1
and 2 [23].
In Britain, which has long-established and well devel-
oped specialist palliative care services, a general prac-
tice-based system of routinely identifying patients who
could die, and developing care plans for these people on
an individual basis is encouraged by formal financial
support by the National Health Service [24,25].
In Germany, specialist palliative care in the commu-
nity (SAPV) as established with the 2007 health care
reforms provides the appropriate legal and system
requirements for smooth transition between primary
and specialist palliative care [10]. It is much to be hoped
that further refinement of the implementation into prac-
tice will facilitate and support appropriate primary pal-
liative care.
Summary
It is imperative that in Germany as well as in other
developed nations primary palliative care is better recog-
nised by health professionals, health insurers, govern-
ment and the scientific community as a central part of
the delivery of health care for people in the last phase of
life. This needs to include academic and conceptual
development of the field with appropriate research activ-
ities, in order to better determine requirements of edu-
cation of professionals, and provision of patient and
carer-centred care in the community. Primary palliative
care needs a parallel research and development with
specialist palliative care to permit universal access to
end of life care.
Author details
1End-of-life Care Research Group, Institute of Epidemiology, Social Medicine
and Health System Research, Hannover Medical School, Hannover, Germany.
2Discipline of General Practice, University of Queensland School of Medicine,
Queensland, Australia. 3Primary Palliative Care Research Group, Centre for
Populations Health Sciences, The University of Edinburgh, Edinburgh, UK.
Authors’ contributions
NS conceived the idea for the paper and drafted the manuscript. GM and
SM made substantial contributions to conception and equally helped to
draft the manuscript. All authors read and approved the final manuscript.
Competing interests
The authors are all general practitioners and belong to the International
Primary Palliative Care Research Group http://www.uq.edu.au/primarypallcare.
Received: 14 July 2010 Accepted: 15 September 2010
Published: 15 September 2010
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Background: Specialist palliative care is being increasingly recognised and developed to improve end-of-life care in many developed countries. However, only a small proportion of the total number of patients with incurable, progressive diseases actually has direct contact with specialist palliative care practitioners. Using the German situation as an example, the main purpose of this paper is to argue that the emphasis on specialist palliative care services without a similar encouragement of primary palliative care will deliver a constrained service.Discussion: For the vast majority of people with incurable, progressive diseases, good palliative care delivered by General Practitioners and community nurses, with access to specialist support when needed, is the optimal response. In Germany, specialist palliative care in the community was established in the 2007 health care reforms. However actual and potential delivery of palliative care by general practitioners and community based nurses has been sorely neglected. The time-consuming care of palliative patients and their families is currently far from accurately reflected in German, indeed most European primary care payment systems. However, it is not just a question of adequate financial compensation but also of the recognition of the fundamental value of this intense form of holistic family medicine.Summary: It is imperative palliative care carried out by community nurses and general practitioners is better recognised by health professionals, health insurers, government and the scientific community as a central part of the delivery of health care for people in the last phase of life. Health systems should be arranged so that this critical role of general practice and primary care is intentionally fostered. Palliative care carried out by generalists needs an identity at an academic and practical level, developing in concert with specialist palliative care.</p

Edinburgh Research Explorer

Abstract Background Specialist palliative care is being increasingly recognised and developed to improve end-of-life care in many developed countries. However, only a small proportion of the total number of patients with incurable, progressive diseases actually has direct contact with specialist palliative care practitioners. Using the German situation as an example, the main purpose of this paper is to argue that the emphasis on specialist palliative care services without a similar encouragement of primary palliative care will deliver a constrained service. Discussion For the vast majority of people with incurable, progressive diseases, good palliative care delivered by General Practitioners and community nurses, with access to specialist support when needed, is the optimal response. In Germany, specialist palliative care in the community was established in the 2007 health care reforms. However actual and potential delivery of palliative care by general practitioners and community based nurses has been sorely neglected. The time-consuming care of palliative patients and their families is currently far from accurately reflected in German, indeed most European primary care payment systems. However, it is not just a question of adequate financial compensation but also of the recognition of the fundamental value of this intense form of holistic family medicine. Summary It is imperative palliative care carried out by community nurses and general practitioners is better recognised by health professionals, health insurers, government and the scientific community as a central part of the delivery of health care for people in the last phase of life. Health systems should be arranged so that this critical role of general practice and primary care is intentionally fostered. Palliative care carried out by generalists needs an identity at an academic and practical level, developing in concert with specialist palliative care.</p

Schneider Nils

Mitchell Geoffrey K

Murray Scott A

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DEBATE Open AccessPalliative care in urgent need of recognitionand development in general practice:the example of GermanyNils Schneider1*, Geoffrey K Mitchell2, Scott A Murray3AbstractBackground: Specialist palliative care is being increasingly recognised and developed to improve end-of-life carein many developed countries. However, only a small proportion of the total number of patients with incurable,progressive diseases actually has direct contact with specialist palliative care practitioners. Using the Germansituation as an example, the main purpose of this paper is to argue that the emphasis on specialist palliative careservices without a similar encouragement of primary palliative care will deliver a constrained service.Discussion: For the vast majority of people with incurable, progressive diseases, good palliative care delivered byGeneral Practitioners and community nurses, with access to specialist support when needed, is the optimalresponse. In Germany, specialist palliative care in the community was established in the 2007 health care reforms.However actual and potential delivery of palliative care by general practitioners and community based nurses hasbeen sorely neglected. The time-consuming care of palliative patients and their families is currently far fromaccurately reflected in German, indeed most European primary care payment systems. However, it is not just aquestion of adequate financial compensation but also of the recognition of the fundamental value of this intenseform of holistic family medicine.Summary: It is imperative palliative care carried out by community nurses and general practitioners is betterrecognised by health professionals, health insurers, government and the scientific community as a central part ofthe delivery of health care for people in the last phase of life. Health systems should be arranged so that thiscritical role of general practice and primary care is intentionally fostered. Palliative care carried out by generalistsneeds an identity at an academic and practical level, developing in concert with specialist palliative care.BackgroundDelivering appropriate care for people with incurableprogressive diseases in the last phase of life is an impor-tant, but largely neglected, role of the health system inmany countries [1,2]. In recent years deficits in this fieldhave increasingly come to the attention of the public,politicians and professionals, as have insistent demandsfor the development of palliative care.Measured in terms of the number of palliative careunits, hospices and outpatient palliative care services(palliative care teams), specialist palliative care hasgrown considerably. However, according to expertestimates, the need remains far from met [3]. This isparticularly true for care in the community. Althoughmost people want to die at home, only about 30% aresuccessful in doing so, with the majority dying in hospi-tals or in nursing homes [1,4].In Germany, for example, in order to enable morepeople to spend the last phase of their lives at home,avoid unnecessary hospital admissions and improvepatients’ quality of life, legislators established specialistpalliative care in the community (spezialisierte ambu-lante Palliativversorgung, SAPV) as part of the 2007health care reforms (§ 37b of German Social SecurityCode V), with varying degrees of specialist support, ran-ging from one-off consultations to full palliative careprovided by a specialist team. By the end of 2009,approximately 50 SAPV contracts between the Statutory* Correspondence: schneider.nils@mh-hannover.de1End-of-life Care Research Group, Institute of Epidemiology, Social Medicineand Health System Research, Hannover Medical School, Hannover, GermanyFull list of author information is available at the end of the articleSchneider et al. BMC Family Practice 2010, 11:66http://www.biomedcentral.com/1471-2296/11/66© 2010 Schneider et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the CreativeCommons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, andreproduction in any medium, provided the original work is properly cited.Health Insurance and service providers had been agreednationwide [5]. The movement to implementation is inpractice sluggish, however, and is complicated by unan-swered questions regarding requirements, content andstructural design, and by problems in quality assuranceand resource distribution. These implementation pro-blems should not detract from the promising potentialSAPV has in bringing about sustainable improvementthrough innovative approaches to caring for theseriously and terminally ill. The introduction of SAPV isin line with the international trend towards specialistpalliative care services for patients with particularly highcare needs [1,2].DiscussionThe fact should not be overlooked that even if specialistpalliative care became fully available in the future, only arelatively small proportion of the total number of patientswith incurable, progressive diseases will benefit from thiscare. It is estimated that 10% of the incurable, seriouslyill and dying need some form of specialist palliative care[6]. The vast majority of those affected do not requirespecialised care, but can be adequately treated withinprimary care, some with varying degrees of specialistsupport. Internationally, the phrase ‘primary palliativecare’ is generally used as a generic term for the activitiesof GPs and home care nursing services in this field [7].Potential of GPsGeneral practitioners have the potential and ability toprovide end-of-life care for most patients, given ade-quate training, resources and, when needed, specialistadvice [8,9]. The introduction of SAPV meets require-ments for specialist advice, and the majority of familydoctors welcome this opportunity: in a survey of GPs inLower Saxony, 56% indicated the likelihood that theywould, in relevant cases, consult SAPV teams as “defi-nite” or “probable”, and the same number could imaginethemselves sharing the delivery of patient care with anSAPV team. Only a minority of 15% can imagineentirely handing over the care of their palliative patients[10]. These results underline the self-perception of gen-eral practitioners that they support their patients con-tinuously through various stages of life, assisting in avariety of care situations right up until death.The level of family doctors’ commitment to seriously illand dying patients in their practices is also demonstratedby the fact that around half of GPs indicate that they are,regardless of the official rules of the physicians’ emer-gency service, always available [i.e. around the clock] totheir palliative patients - sometimes personally, some-times through informal arrangements with colleagues.This willingness seems to become more pronounced asthe patient’s death comes closer [11].For patients and relatives, the family doctor is the pri-mary contact, including - and especially - in the case ofan incurable, progressive disease [12]. The doctor-patient relationship, ideally developed over years,together with the focus on whole patient care with abiopsychosocial approach which is characteristic of thegeneral practice, means that family doctors have theinestimable advantage of knowing palliative patientseven before the onset of the incurable disease, and soproactively influence the care provided. This is anadvantage GPs have over specialist palliative care physi-cians, who have a relatively late first contact withpatients and relatives.Different illness trajectoriesForty-two per cent of people die aged between 60 and80, and 44% die at over 80 years of age. With advancingage, cardiovascular disease as a principal cause of deathis more relevant than malignant neoplasm [13,14].Elderly people with dementia, frailty or multiple chronicconditions formulate the largest group of patients inGPs’ practices, responsible for around 35% of deaths,and an even greater percentage of the need for palliativecare as their illness trajectories of decline are relativelylong [15].As in other European countries, hospices, palliative careunits and palliative care teams in Germany focus on carefor cancer patients. In 2008, 90% of the patients cared forby hospices and palliative care units, and 74% cared for bypalliative care teams in the community suffered fromcancer. Only approximately 20% had cardiovascular dis-eases as the leading diagnosis [16]. A number of factorshave contributed to this, such as institutional affiliationsand financial incentives. One significant reason may befound in the fact that remaining life expectancy and thecourse of the disease are often relatively easier to estimatein cancer patients than in patients with other incurable,progressive diseases, and so organisation of, and thereforeaccess to specialized care is, comparatively, easier toarrange.So far three distinct illness trajectories have beendescribed for people with incurable, progressive chronicillnesses: a trajectory with steady progression and usuallya clear terminal phase (mostly cancer); a trajectory (forexample, respiratory and heart failure) with gradualdecline, punctuated by episodes of acute deteriorationand some recovery, with more sudden, seemingly unex-pected death; and a trajectory of prolonged frailty, poorfunction, and gradual decline (typical of frail elderlypeople or people with dementia) [17]. Thus in Germanyas in the UK, the palliative care needs of non-cancerpatients are often not adequately recognized [e.g.[7,18,19]]. WHO advocacy for better palliative care forolder people [20] is a wake up call for groundbreakingSchneider et al. BMC Family Practice 2010, 11:66http://www.biomedcentral.com/1471-2296/11/66Page 2 of 5action that general practitioners are well placed to takeforward internationally.Increased demand for primary palliative careIn order to meet these challenges, the development ofexisting specialist palliative care is an important step.The debate will however fall short of the issue if, as isfrequently the case, it focuses almost exclusively on spe-cialist care. For the vast majority of people in the finalphase of life with incurable, progressive diseases, goodprimary care delivered by GPs and community nurses,i.e. primary palliative care, is the optimal response [7].In politics, public and professional circles, however, thisaspect has been sorely neglected.Beneficial as the introduction of specialist palliativecare in the community (SAPV) in Germany was, thefailure to encourage primary palliative care at the sametime remains baffling. The time-consuming care ofpalliative patients and their families is currently far fromaccurately reflected in the primary care compensationFigure 1 Seamless transition between specialist and generalistpalliative care services according to intensity of need. [23]Figure 2 Organisation of health system to facilitate needs-based palliative care. [23]Schneider et al. BMC Family Practice 2010, 11:66http://www.biomedcentral.com/1471-2296/11/66Page 3 of 5system. The same holds for the numerous home visitsthat are often required, or for the willingness of manyprimary care doctors to be, for the sake of their patients,available outside of, and in addition to, their officialpractice times and emergency duties. This is not just aquestion of adequate financial compensation, but also ofthe recognition of requirements in health care delivery,and patients’ needs, and of the fundamental value of thisintense form of holistic family medicine.Transition between primary and specialist palliative careAn ideal health system for managing palliative carewould see a seamless transition between primary andspecialist palliative care, and provision of support in theform of access to evidence based guidelines, supportedby specialist involvement ranging from one-off consulta-tions to full referral. In effect, the care of the patient isshared between the two, with the primary care teamusually determining when and how much support isrequired.In Australia, for example, much work has been done tofacilitate needs-based palliative care delivery to ensure thatpatients receive the right level of care at the right time[21,22]. A schematic representation of this model devel-oped by Australian policy makers is shown in Figures 1and 2 [23].In Britain, which has long-established and well devel-oped specialist palliative care services, a general prac-tice-based system of routinely identifying patients whocould die, and developing care plans for these people onan individual basis is encouraged by formal financialsupport by the National Health Service [24,25].In Germany, specialist palliative care in the commu-nity (SAPV) as established with the 2007 health carereforms provides the appropriate legal and systemrequirements for smooth transition between primaryand specialist palliative care [10]. It is much to be hopedthat further refinement of the implementation into prac-tice will facilitate and support appropriate primary pal-liative care.SummaryIt is imperative that in Germany as well as in otherdeveloped nations primary palliative care is better recog-nised by health professionals, health insurers, govern-ment and the scientific community as a central part ofthe delivery of health care for people in the last phase oflife. This needs to include academic and conceptualdevelopment of the field with appropriate research activ-ities, in order to better determine requirements of edu-cation of professionals, and provision of patient andcarer-centred care in the community. Primary palliativecare needs a parallel research and development withspecialist palliative care to permit universal access toend of life care.Author details1End-of-life Care Research Group, Institute of Epidemiology, Social Medicineand Health System Research, Hannover Medical School, Hannover, Germany.2Discipline of General Practice, University of Queensland School of Medicine,Queensland, Australia. 3Primary Palliative Care Research Group, Centre forPopulations Health Sciences, The University of Edinburgh, Edinburgh, UK.Authors’ contributionsNS conceived the idea for the paper and drafted the manuscript. GM andSM made substantial contributions to conception and equally helped todraft the manuscript. All authors read and approved the final manuscript.Competing interestsThe authors are all general practitioners and belong to the InternationalPrimary Palliative Care Research Group http://www.uq.edu.au/primarypallcare.Received: 14 July 2010 Accepted: 15 September 2010Published: 15 September 2010References1. World Health Organization Regional Office for Europe: Palliative Care, thesolid facts. Copenhagen 2004.2. Deutscher Bundestag : Zwischenbericht der Enquete-Kommission Ethikund Recht der modernen Medizin. Verbesserung der VersorgungSchwerstkranker und Sterbender in Deutschland durch Palliativmedizinund Hospizarbeit. [http://dipbt.bundestag.de/doc/btd/15/058/1505858.pdf].3. Schindler T: Palliative Care in Germany. Bundesgesundheitsblatt 2006,49:1077-1086.4. Higginson IJ, Sen-Gupta GJ: Place of care in advanced cancer: aqualitative systematic literature review of patient preferences. J Pall Med2000, 3:287-300.5. 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Schneider N, Buser K, Amelung VE: Ansichten von Hausärzten zurVersorgung von unheilbar kranken Patienten am Lebensende -Ergebnisse einer Befragung in Niedersachsen. Z Allg Med 2006,82:298-304.12. Schumacher M, Schneider N: Older people at the end of life: Delivery ofcare and needs for improvement from the perspective of bereavedrelatives. Z Palliativ Med 2010, 11:123-129.13. Kruse A: Das letzte Lebensjahr. Zur körperlichen, psychischen undsozialen Situation des alten Menschen am Ende seines Lebens. Stuttgart:Kohlhammer Verlag 2007.14. Gesundheitsberichterstattung des Bundes: Gesundheit in Deutschland.[http://www.gbe-bund.de/gbe10/owards.prc_show_pdf?p_id=9965&p_sprache=D].15. Murray SA, Sheikh A: Palliative Care Beyond Cancer: Care for all at theend of life. BMJ 2008, 336:958-9.16. Lindena G, Woskanjan S: Hospiz- und Palliativerfassung HOPE.[http://www.hope-clara.de/download/GesamtberichtHOPE2008.pdf].17. Murray SA, Kendall M, Boyd K, Sheikh A: Illness trajectories and palliativecare. 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BMCPalliative Care 2010, 9:2.22. Waller A, Girgis A, Lecathelinais C, Scott W, Foot L, Sibbritt D, Currow D,Palliative Care Research Program team: Validity, reliability and clinicalfeasibility of a Needs Assessment tool for people with progressivecancer. Psychooncology 2010, 19:726-33.23. Palliative Care Australia: Palliative care service development. A populationbased approached. Canberra: PCA 2005.24. National Gold Standards Framework Centre: The Gold StandardsFramework.[http://www.goldstandardsframework.nhs.uk].25. Thomas K: Caring for the dying at home: companions on the journey.Abingdon: Radcliffe 2003.Pre-publication historyThe pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2296/11/66/prepubdoi:10.1186/1471-2296-11-66Cite this article as: Schneider et al.: Palliative care in urgent need ofrecognition and development in general practice: the example ofGermany. BMC Family Practice 2010 11:66.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitSchneider et al. BMC Family Practice 2010, 11:66http://www.biomedcentral.com/1471-2296/11/66Page 5 of 5

A: Illness trajectories and palliative care. Clinical Review. BMJ

A: Palliative Care Beyond Cancer: Care for all at the end of life. BMJ

Amelung VE: Ansichten von Hausärzten zur Versorgung von unheilbar kranken Patienten am Lebensende -Ergebnisse einer Befragung in Niedersachsen. Z Allg Med

Arbeitsgemeinschaft Spezialisierte Ambulante Palliativversorgung: Verzeichnis der SAPV-Einrichtungen.

Australia: Palliative care service development. A population based approached.

Currow D: Facilitating needs based cancer care for people with a chronic disease: Evaluation of an intervention using a multi-centre interrupted time series design. BMC Palliative Care

Das letzte Lebensjahr. Zur körperlichen, psychischen und sozialen Situation des alten Menschen am Ende seines Lebens.

Eine Disziplin für den “ganzen Menschen”. Dtsch Arztebl

Gesundheitsberichterstattung des Bundes: Gesundheit in Deutschland.

IJ: Developing primary palliative care. BMJ

IJ: What is the best way to help caregivers in cancer and palliative care? A systematic literature review of interventions and their effectiveness. Pall Med

Older people at the end of life: Delivery of care and needs for improvement from the perspective of bereaved relatives. Z Palliativ Med

Organization Regional Office for Europe: Palliative Care, the solid facts.

Organization: Better palliative care for older people.[http:// www.euro.who.int/__data/assets/pdf_file/0009/98235/E82933.pdf].

Palliative care for older people -exploring the views of doctors and nurses from different fields in Germany. BMC Palliative Care

Palliative Care in Germany. Bundesgesundheitsblatt

Palliative Care Research Program team: Validity, reliability and clinical feasibility of a Needs Assessment tool for people with progressive cancer. Psychooncology

Primary palliative care.Edited by: Charlton R.

Sen-Gupta GJ: Place of care in advanced cancer: a qualitative systematic literature review of patient preferences.

Standards Framework Centre: The Gold Standards Framework.[http://www.goldstandardsframework.nhs.uk].

Wernstedt T: Wie wünschen sich Hausärzte die Zusammenarbeit mit Strukturen der spezialisierten Palliativversorgung?

Woskanjan S: Hospiz- und Palliativerfassung HOPE.[http://www.

Zwischenbericht der Enquete-Kommission Ethik und Recht der modernen Medizin.

https://bmcfampract.biomedcentral.com/track/pdf/10.1186/1471-2296-11-66?site=bmcfampract.biomedcentral.com

Palliative care in urgent need of recognition and development in general practice: the example of Germany

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