AUSTRIA: HOSPICE AND PALLIATIVE CA RE — DEVELOPMENT AND CURRENT SITUATION Johann Baumgartner Coordination Palliative Care Styria, Medical Directorate, Steiermärkische Krankenanstaltenges.m.b.H., Stiftingtalstr. 4-6, A-8010 Graz Abstract Hospice and palliative care in Austria developed in a continuous progress since the late seventies of last century. After a very active phase of pioneers, hospice and palliative care in Austria went through the phase of building-up from the year 2000 until 2004. Since 2005 hospice and palliative care is in the phase of implementation. The actual situation offers a promising perspective for a comprehensive integration of the different hospice and palliative care services on all levels of care into the health care system. Austria is a rich country of the European Union (EU) spending a lot of money for health care. The population is getting older and the place of death for more than half of all Austrian people is a hospital. The number of deaths in nursing homes is increasing, while the preferred place of death - at home - is decreasing. In 2005 there are 167 different hospice and palliative care services listed in Austria. There is public funding for the existing 17 palliative care units (158 beds), while there are still considerable costs for the patients in the 7 inpatient hospices (46 beds). Furthermore there are 115 volunteer hospice teams working with about 2000 certified volunteers, 12 hospital support teams, 14 home care teams and two day hospices. The aim of the further development is to ensure a high quality and effective provision of hospice and palliative care on all levels of care across Austria. Facts about Austria1'2 In 2001 the population of Austria was 8.1 million. The proportion of the population of elderly people is low by EU standards with 14.6% over 65 and 6% over 75. The average age of the population is expected to rise over the next few decades with the proportion of the population over 75 increasing significantly. Life expectancy at birth was within the EU average, amounting to 80.2 years for females and 73.9 years for males. Standardised mortality amounted to 7.8 per 1,000 populations in 1993. In 2002 Austria spent definite 8 % of the gross domestic product (GDP) for health-care. Around 70 % of health-care spending was financed publicly. Over the last decades the quality of life improved significantly, although this can hardly be measured objectively. 95 Three phases of development of hospice and palliative care Hospice and Palliative care in Austria started 15 years after its beginnings in Great Britain. Three phases of the development in Austria can be described. The first phase, the phase of pioneers started in the late seventies. Essential help came from the famous pioneer, Dr. Elisabeth KUBLER-ROSS, who died last summer. She was giving very inspiring lectures. More and more pioneers offered educational opportunities, influenced the public opinion and founded first hospice services and hospice associations3. It lasted years, until the first palliative care service started in Austria: In 1989, the Hospice and Palliative Home Care Team Caritas Vienna started to work and in 1991 the first palliative care unit in Austria was established in Vienna. Both services are still working. Since then, hospice and palliative care developed in slow but steady progress. Following steps have been important in the development: - A vivid discussion about "death and dying" in our parliament4 has helped to foster public awareness in 1992. - In 1997 the law for the undergraduate education for registered nurses has been changed: 60 hours of palliative care have been made obligatory in the curriculum5. - In 1998 the first public pilot project for hospice and palliative care in Austria initiated the first inpatient palliative care unit in a public hospital (Graz). This project was evaluated rather comprehensively6 and has been very helpful for the further development - not only in Styria. - Also in the same year, the first interdisciplinary palliative care course started in Austria. - Important steps during this first phase of the development of hospice and palliative care in Austria have also been the foundation of the two important organisations: Hospice Austria7 and the Austrian palliative care Association (OPG)8. The next phase of the development, the phase of building-up. started in 2000 with the anchorage of palliative care-units into the national plan for hospitals in Austria9 in combination with criteria for structuring and public funding. - An important step has been the Austrian response to the pro-euthanasia laws in the Netherlands and in Belgium: all political parties voted against euthanasia and for the further development of hospice and palliative care. - More and more provinces in Austria developed federal plans and concepts. In 2002 the family hospice leave was introduced, a possibility for family members to stay at home for the care of a dying person. This helpful leave does not yet reach enough people, who could benefit from it. There are financial reasons and the fear of loss of the working place. - The rather new insight, that hospice and palliative care will be a new and necessary field in health-care was essential for establishing the first palliative care facility in a medical university (2003, Graz). - The first Austrian interdisciplinary palliative care congress in 2004 with about 450 participants was an impressive demonstration of this growing field. 96 - On behalf of the Austrian Ministry of Health a working group defined the structural and organizational requirements for the integration of hospice and palliative care into the health care system. These results10 have been the precondition for the political decision, that hospice and palliative care will be implemented into the health care system step by step. This decision marks the beginning of a new phase of the development of hospice and palliative care in Austria: since 2005 the phase of implementation has started. The ministry of health and the provinces adopted hospice and palliative care into the most important document11 on the organization and funding of health care in Austria. The goal is the structured implementation of specialist hospice and palliative care facilities to ensure fair access for all those who need it. Places of death in Austria The number of deaths in Austria declined from 1950 to 2003 from 84.930 to 77.209. The places of death changed: more and more people die in institutions. In 2003 (see Fig.1) more than half of the people died in hospitals (55.3%), about a quarter (26,8%) at home, 12.5% in nursing homes and 5.4% died in other places. There are considerable differences in the place of death between the 9 provinces. In rural provinces, still more people die at home (Burgenland: 38%) and In Vienna (2.000.000 inhabitants) 70% die in a hospital. There is also an important change of the place of death going on: more and more people die in nursing homes: an increase of 239% between 1988 and 2003. Those who die from cancer die more often in hospitals - again a striking difference between the provinces of Austria (Salzburg: 54.3%, Vienna: 80.5%). About 80% of all Austrians want to die at home. Hospice and palliative care services support the patients to spend their remaining time at home. Places of Death in Austria (2003) n= 77.209 Fig. 1: Places of death in Austria 2003 (Source: Statistik Austria) 97 Levels of Hospice and Palliative Care The aim is to ensure a high quality and effective provision of hospice and palliative care on all levels of care across Austria. For this reason it is necessary to implement adequate structures adapted to the different settings in the different provinces. There are three levels of provision of hospice and palliative care (see Tab.1): Of critical importance for fair access is the provision of hospice and palliative care in the traditional health care settings (hospitals, nursing homes, at home). It is necessary for the professionals to have required knowledge in hospice and palliative care. It is also important that they know where specialists are available for support (second level) and for specialist care in an inpatient setting (third level). Trained volunteers are very helpful on all levels of care for psychosocial support of patients and family members. Additionally, day hospices can enable patients to prolong their time spent at home. Tab. 1: Levels of Care (Austrian Institute of Health Care - ÛBIG, Hospice Austria) Hospice a first level traditional health care setting nd Palliative Care second level specialists for support third level for care hospitals départements, wards, ambulatories hospice teams (volunteers) hospital support teams palliative care units long term care nursing homes, residencies home support teams inpatient hospices family doctor, specialists, hcyc lursing socia' ,A'orker physiotherapists day hospices Hospice and palliative care Services in Austria by numbers In the last decade an increasing number of services started to work. In March 2005 167 different hospice and palliative care services are listed in Austria. Most of them (115) are hospice teams with about 2000 certified volunteers. 17 palliative care units (158 beds) and 7 inpatient hospices (46 beds) are available. Furthermore there are 12 hospital support teams, 14 home care teams and two day hospices available. The second Austrian Hospice and Palliative directory with addresses of all services will be edited in October 2005. Detailed informations can be found on www.hospiz.at (see also Fig.2). 98 175 150 125 100 75 50 25 0 Fig. 2: Development of Hospice and Palliative Care services in Austria from 1989 until 2005 (Hospice Austria, J. Baumgartner) Outlook and Conclusion The successful development of hospice and palliative care in Austria happened in very constructive and 'familiar' circumstances. The actual situation of health care in Austria gives hope that the integration of the different specialist hospice and palliative care services can be reached during the next decade. Now, in the phase of implementation, necessary requirements (laws, public funding) for the systematic integration are being developed. Further education and training are needed: this concerns the professionals in the traditional health care as well for the specialists. Hospice and palliative care is more and more accepted as a part of health care, but it will still take many years for palliative medicine to be recognized as a medical speciality. There are good reasons to hope that the development of hospice and palliative care in Austria goes on with similar success in the oncoming decade. Annotation: I am thankful for their constructive support to A. Halbertschlager, E. Meran, M. Narath, L. Stachi and R. Zweiger. Email for correspondence: ¡ohann.baumgartner@kages.at Sources and literature 1 Health care systems in the EU - a comparative study, Working paper of the European Parliament, Directorate General for Research, Public Health and Consumer Protec- Hospice and Palliative Care Services in Austria (1989 - 2005) CO i □tj U 2 day hospices □ 17 palliative care units B 12 hospital support teams 7i 7 inpatient hospices H114 home support teams □ 115 volunteer teams □qt i 03 i m 1 5 CEE i S B I ra I53 99 tion Series SACO 101 EN, Brussels 1998, Internet: http://www.europarl.eu.int/workingpapers/saco/pdf/101_en.pdf 2 Pharmig, Facts and Figures, Medication and Health Care in Austria, Vienna 2002, Internet: http://www.pharmig.at/pharmig/2001/english/publications/facts-u-figures 2003/pdf/Facts-Figures2002.pdf 3 Höfler A.E., ed. Geschichte der Hospizbewegung in Österreich - Zukunft braucht Vergangenheit, IFF Kursbuch Palliative Care 2/2001, ISSN 1609-3968, Vienna 2000 4 Enquete: Sterben in Österreich, Art, Umstände und Betreuung, Bundesministerium für Gesundheit, Sport und Konsumentenschutz: 1992 Wien 5 Gesundheits- und Krankenpflegegesetz - GuKG, Änderung des Krankenpflegegesetzes sowie des Ausbildungsvorbehaltsgesetzes und des Ärztegesetzes 1984, in 12. Bundesgesetzblatt. Wien 1997 6 Baumgartner J„ Narath M., Schlussbericht Pilotprojekt Stationäre Palliativbetreuung, Stmk. KAGes, Graz, 2000 7 A. l-,^.-* Ur-N^-N»-. -f^. inHA^ ¡r> 1 OOQ onr) io ho i-r\r\f r.rncjni7catir>n nf all Wncniro I nUOtl ICl I ICtO WOi^l l I Iii >_