20 PALIATIVNA OSKRBA V SLOVENIJI Maja Ebert Moltara Glede na podatke Statističnega urada Republike Slovenije in Nacionalnega inštituta za javno zdravje letno v Sloveniji umre okoli 19.000 ljudi, od tega velik del zaradi kroničnih in neozdravljivih bolezni kot so npr. kardiovaskularne bolezni (39%), rak (31%), pljučne bolezni (7%) in druge. Nekaj več kot polovico bolnikov umre v zdra- vstvenih ustanovah, ostali doma ali v domovih za starostnike. Paliativna oskrba (PO) je aktivna celostna oskrba bolnika z neozdravljivo boleznijo in podpora njihovih bližnjih. PO priznava življenje in umiranje kot naraven proces; ne pospešuje smrti, niti je ne zavlačuje; njen glavni cilj je doseganje čim večje kakovosti življenja bolnika. Večina bolnikov, ki umre zaradi kronične neozdravljive bolezni potrebuje PO. Prav je, da osnovno paliativno oskrbo nudijo vsi zdravstveni timi, ki obravnavajo neozdravljivo bolne. Po ocenah EAPC specialistično paliativno oskrbo v zadnjem letu življenja potre - buje le približno 20% bolnikov z napredovalim rakom in okoli 5% ne-onkoloških bolnikov. Mreža in izvajalci PO V slovenskem zdravstvenem prostoru je PO trenutno regijsko različno urejena in razvita. Mreža je marsikje nezadostno strukturirana in pomanjkljivo koordinirana. Slovenija ima od leta 2010 Državni program paliativne oskrbe in Akcijski načrt za izvajanje le tega. V osnovi naj bi šlo za dvostopenjsko organizacijo: • osnovni nivo PO (osebni zdravnik s patronažno sestro, zdravniki z negovalnim osebjem v DSO, zdravniki vseh specialnosti, ki obravnavajo neozdravljivo bolne v bolnišnicah), • specialistični nivo PO (oddelki za (akutno) PO v bolnišnicah, mobilne enote). V Sloveniji posamezni elementi mreže obstajajo in tudi delujejo, ne gre pa za uskla- jeno in povezano delovanje, ki bi zagotavljalo neprekinjeno in celostno PO. V okviru projekta Metulj, www.paliativnaoskrba.si, je objavljen seznam izvajalcev PO stori- tev z nekaterimi dodatnimi znanji s področja PO. Izobraževanje s področja PO Paliativna medicina predstavlja eno izmed bazičnih ved medicine, katere osnove naj bi poznal vsak zdravnik, in bi zato morala biti vključena že v dodiplomski študij me- dicine kot obvezni predmet. Trenutno, in še to le kratko obdobje, se izvaja zgolj kot izbirni predmet v okviru Medicinske Fakultete v Mariboru ter kot posamezna preda- 21 vanja v okviru drugih predmetov (Onkologija, Interna medicina). Tudi izobraževanj preostalega zdravstvenega kadra ni ustrezno urejeno in usklajeno potrebam. Vrzel v potrebah po izobraževanju s področja PO zato trenutno delno zapolnjuje Sloven- sko Združenje Paliativne Medicine (www.szpm.si) z izvajanjem 50-urnih Dodatnih znanj s področja paliativne oskrbe »Korak za korakom«, kjer udeleženci pridobijo osnovna znanja. Specialna znanja s področja PO za zdravnike v tem trenutku ni možno pridobiti znotraj Slovenije, temveč so potrebna izpopolnjevanja v tujini. Z namenom pridobiva- nja specialnih znanj za posamezne strokovne skupine v Sloveniji je bil v letu 2013 v okviru Mariborske Univerze ustanovljen Inštituta za paliativno medicino in oskrbo. Zaključek: Paliativna oskrba je temeljna zdravstvena veda, katere osnove mora poznati vsak, ki oskrbuje neozdravljivo bolne. V Sloveniji mnogi že uporabljajo principe paliativne oskrbe, vendar med trenutnimi potrebami in realnimi možnostmi še vedno zeva prepad. Entuziazem in zagon posameznikov velja ceniti in ga podpirati, vendar se moramo zavedati, da je mreža močna le toliko kot je močan najšibkejši vozel. Tako je tudi mreža paliativne oskrbe Slovenije, ki naj bi zagotavljala celostno in nepreki- njeno oskrbo neozdravljivo bolnih, trdna le toliko kot njen najšibkejši člen. Pred nami je še veliko trdnega dela, a le skupaj nam lahko uspe. PALLIATIVE CARE IN SLOVENIA Maja Ebert Moltara According to Statistical Office of the Republic of Slovenia and the National Institute of Public Health in Slovenia there are about 19,000 deaths annually, of which a large part due to chronic and incurable diseases such as cardiovascular diseases (39%), cancer (31%), lung diseases (7%), and others. Slightly more than half of the patients die in a hospital, the rest at home or in homes for the elderly. Palliative cares (PO) is an active, holistic approach to a patient with an incurable disease and support to their families. It affirms life and regards dying as a normal process. It intends neither to hasten nor postpone death. It enhances quality of life, and may also positively influence the course of illness. Majority of patients who die from chronic incurable diseases needs PO. All medical teams dealing with the incurable patients should provide basic palliative care. Accord- ing to EAPC estimates specialist palliative care in the last year of life requires only about 20% of patients with advanced cancer and about 5% of non-cancer patients. 22 PO network At the moment PO in the Slovenian is regionally differently regulated and devel- oped. The network is inadequately structured and coordinated. Since 2010 Slovenia has the National program of palliative care and the Action plan for its implementa- tion. Basically it has a two-level organization: • a basic level of PO (family physician, district nurse, teams in senior homes, spe- cialists dealing with incurable sick patients in hospitals) • specialized level of PO (departments (acute) PO hospitals, mobile units). In Slovenia, the individual elements of the network exist and function, but it is not well coordinated and continuous and comprehensive PO is difficult to achieve. Within the project, Butterfly, www.paliativnaoskrba.si, has published a list of pallia- tive care providers with some additional educations in PO. Education in the field of PO Palliative medicine should represent one of the elementary issues every physician treating incurable patient should know. For that reason it should be included al- ready in the undergraduate medical studies as a compulsory subject. Currently, and only for a short period, palliative care has been carried out only as an optional sub- ject in the framework of the Medical Faculty in University of Maribor, as well as in- dividual lectures in the context of other subjects (Oncology, Internal medicine). Also the training of health personnel of other health professionals is not adequate- ly regulated and coordinated. The gap between the need for education is currently at least partially filled by the Slovenian Association of Palliative Medicine (www.szpm.si) with the implementation of the 50-hour Basic education on palliative care “Step by Step”. At the time being, specialized education in PO for physician cannot be obtained in Slovenia, but need the training abroad. Due to the gap in acquiring special skills in PO for each professional group in Slovenia in 2013 there was Institute of palliative medicine and care estab- lished in Maribor University that will in future offer specialized educational programs. Conclusion: Palliative care is an elementary chapter of medicine, anyone who serves incurable ill should be familiar with. In Slovenia, many are already using the principles of pal- liative care, but the current needs and services available are far apart. The enthusi- asm of individuals should be appreciated and supported, but we must realize that the network is only as strong as the weakest knot in ne net. This is also the way we can see a palliative care network in Slovenia, which need to provide comprehensive and continuous care of the terminally ill. Ahead of us there is still a long way to go, but only together we can succeed.