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Objective: The aim of this research is to compare the current state of hospice and palliative medicine in The Republic of Poland, Romania, and the Slovak Republic. Original Article 94 Clinical Social Work and Health Intervention Clinical Social Work and Health Intervention Vol. 10 No. 2 2019 Development Polish Palliative Care The term “hospice-palliative care” is commonly used in Poland, originating from the necessity for special care of terminally ill cancer patients (Schmidlin, 2012). The beginning of palliative care in Poland is associated with the democratic opposition in the 1980s. Earlier in 1978, Dame Cicely Saunders visited Gdansk, Warsaw, and Krakow, supporting an organization of palliative care in Poland. By 1981 palliative care societies, which had previously been only informal, became formal and officially registered. Both institutional and homebased hospice care existed in all larger cities in Poland in the 1990s (Swietlik & Doboszynska, 2009). In Poland, many of the palliative care organizations are run by religious organizations, considering the Polish palliative care movement began primarily as a religious undertaking. There are also nearly 200 institutions within the national health care service created by civic associations. Though they still have many volunteers, they have evolved from fully volunteer hospices in the beginning (Schmidlin, 2012). In 1991, National Forum of the Hospice Movement was founded, and in 1998, Poland officially offered a specialization in palliative care for both physicians and nurses (Swietlik & Doboszynska, 2009). According to Dr. Stephen Connor (personal communication, April 3, 2017), the Executive Director of the Worldwide Hospice Palliative Care Alliance, today Poland is one of the model nations for palliative care development in Central Eastern Europe. Romanian Palliative Care In Romania, the concept of palliative care arose in the late 1980s from a need to care for HIV/AIDS patients, specifically children (Mosoiu, Andrews, Perolls, 2000). As the result of a heavily regulated system, gaining access to opioids was extremely difficult, and Romania’s annual morphine consumption was among the lowest in Eastern Europe (Institute of Medicine, 2007). Since then, a number of developments have turned Romania into a regional leader in end-of-life care. The palliative care movement gained momentum in the late 1990s, with the support of a philanthropists from the United Kingdom, Graham Perolls. Through that support, the first home-based hospice in Romania, Hospice Casa Sperantei, opened in Brasov in 1992, covering an area with a population of 400,000 (Hospice Casa Sperantei Annual Report, 2015). Design: The paper is a secondary source literature review. Results: Hospice and palliative medicine are well integrated into each national healthcare system, but proper funding is needed in order to continue expanding this form of care and reach all patients in need. Conclusion: Since the 1990s, Poland, Romania, and the Slovak Republic have made significant strides in developing hospice and palliative medicine and integrating this care into their national healthcare systems. Opportunities for future development include creating models for funding through the national healthcare systems and expanding homebased palliative care modalities. 95 Original Articles Clinical Social Work and Health Intervention Vol. 10 No. 2 2019 Today Hospice Casa Sperantei has become a model institution, now replicated in other parts of Eastern Europe, while its funder, the Hospices of Hope, has helped establish partner organizations and hospice care programs across Romania and in the Central Eastern European Region (Hospice Casa Sperantei Annual Report, 2015). According to the Annual Report for 2015, during that year 3,498 children and adults received services free of charge. There were “17,531 home visits, 849 hospice inpatients, and 4,867 received consultation from the outpatient clinic.” Additionally, in Romania individuals can redirect 2% of their income tax to the care of patients with incurable illnesses. In 2015, “18,500 donors chose HOSPICE, redirecting a total of 301,000 euros to the organization. There is no cost to the donor.” Slovak Republic Palliative Care In the Slovak Republic, palliative medicine was developed on the principles of pain management for the terminally ill, developing primarily in the 1990s. The term “hospice” first appeared in legislative documents in 2000, and the first hospice was Matky Terezy Hospice in Bardejovská Nová Ves, established in July 2003. Many other hospices followed after that, and by 2006 palliative care was adopted in multiple care settings such as outpatient departments, hospitals, hospice institutions, in the home setting. In 2014, eight hospice facilities had 154 beds, and 94 beds were in hospital-based palliative departments (Križanová & Škripeková, 2015). Policy Implementation The most important, practical healthcare policy that affects the quality of palliative care in a country is its opioid access laws. Everything done in palliative medicine revolves around pain management. “Pain management opens the gate to bringing in all the rest that we know—the social, spiritual, cultural issues that are there,” says Anne Merriman, founder of Hospice Africa. “With pain control, people can start to think again.” (The Economist, 2010). The World Health Organization (WHO) decreed that adequate pain control is an essential component of caring for cancer patients, and there is no other measure that can improve the quality of life of that population as much as palliative care (The Economist, 2010). In order to achieve quality pain control, the WHO and the International Association for Hospice and Palliative Care (IAHPC) have a published list of recommended opioid formularies, with the WHO recommending four formularies and the IAHPC recommending seven formularies. The chart below outlines the specific recommendations on opioid use. (Cherny N, Baselga J, de Conno, F, Radbruch L, 2010) 96 Clinical Social Work and Health Intervention Clinical Social Work and Health Intervention Vol. 10 No. 2 2019 All three countries provide access to all recommended medications, but this was not always the case. In February 2002, Romania, because of its severe restrictions on access to opioids, was selected as a pilot for follow-up from a workshop run by the University of Wisconsin Pain and Policy Studies Group, which is part of the World Health Organization’s European Office and the Open Society Institute (Mosoiu, D., et al., 2006). During the years of 2003 to 2005, in partnership with University of Wisconsin at Madison, the Ministry of Health and its Palliative Care Commission prepared revisions of Romania’s national narcotics law and regulations. Their recommendations were adopted by the Romanian Parliament in November 2005, and the new law eliminating the regulatory barriers eased access to pain medication for dying patients (Institute of Medicine, 2007). These regulatory changes played a significant role in Romania becoming a regional leader in the provision of palliative care. Another aspect of opioid availability is how easily physicians can provide patients with the necessary medication, and regulations vary by country. Not all physicians are able to prescribe opioid medications to their patients in all three countries. Currently, only Poland allows all physicians to prescribe opioid medications to their patients. In both Romania and the Slovak Republic, only oncologists, surgeons and some pain specialists can prescribe opioid medication. No family medicine physicians can prescribe opioids, and currently in the Slovak Republic, no palliative physicians can prescribe opioids (Cherny N, Baselga J, de Conno, F, Radbruch L, 2010). Additionally, Romania and the Slovak Republic require that most patients who are to receive the opioids register and receive a permit stating that they are indeed eligible to receive the medication. If a patient is an inpatient in a hospital, no permit is needed, but on an outpatient basis, permits are required, though steps have been taken to ensure that permit processes are not burdensome for patients. Poland has no such permitting process and any patient who (Cherny N, Baselga J, de Conno, F, Radbruch L, 2010) 97 Original Articles Clinical Social Work and Health Intervention Vol. 10 No. 2 2019 has a prescription for an opioid may have the prescription filled. Additional regulations exist on the amount of opioid medication that may be prescribed at one time. Poland allows physicians to prescribe an unlimited number of days per opioid prescription. In Romania and Poland, each prescription is limited to a 30-day supply (Cherny N, Baselga J, de Conno, F, Radbruch L, 2010). Level of Integration Another aspect of hospice and palliative medicine policy in each country is how well palliative medicine is integrated into the national health care systems. The Worldwide Hospice and Palliative Care Alliance created a Global Atlas of Palliative Care at the End of Life (2014), and in this atlas the organization developed categories for how well palliative medicine is integrated into the mainstream service provision. Both Romania and Poland are at a 4b (the highest level of integration), and in 2014 the Slovak Republic was re-categorized from a 3b to a 4a (the second highest level of integration). Both Romania and Poland being at a 4b means that palliative medicine is at an advanced state of integration into the mainstream service provision. This is because of the following facts about the country’s palliative services: • comprehensive provision of all types of palliative care by multiple service providers • broad awareness of palliative care on the part of health professionals • unrestricted availability of morphine and all other strong pain-relieving medicines • substantial impact of palliative care upon policy, particularly public health policy • existence of a natio

clinical social work journal

Hospice and Palliative Medicine in the Republic of Poland, Romania &amp; the Slovak Republic: Policy Implementation, Medical Economics, &amp; Clinical Outcomes