Integral ecology

Why Spain has a deficit in palliative care

Continues the report on palliative care in our country. Today we address the situation of this specialty in our country and especially the reasons for its lack of development, which are centered on the lack of a regulated medical specialty in this field.  

Rafael Miner-February 5, 2021-Reading time: 4 minutes
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Photo: Enre Kuzu/Unsplash

Palliative services, medications

Let us now look at the challenges posed by the development of palliative care in the different countries. Miguel Sánchez Cárdenas, researcher of the Atlantes Research Group (ICS), points to Omnes that in the context of a person's needs at the end of life, is needed: "1) a culture in the country in which it is considered that at the end of life there are problems to be addressed. This is solved with public policies, awareness campaigns, etc.; 2) professionals trained to solve end-of-life problems. Here education is very important, and also the services where to do it; and 3) essential drugs are required to control the problems that may arise at the end of life".

These are the main parameters, and Sánchez Cárdenas reviews them in the Spanish case, according to the Atlas of Palliative Care in Europe 2019. In his opinion, "there are two very important indicators: how many services there are, and how many opioids are consumed. For the year 2019, the Atlas found 260 services. [in Spain] and an average number of services of 0.6 per 100,000 inhabitants. The European Association for Palliative Care (EAPC) says that this indicator should be at least 2. 0.6 is far from the 2010 standard of the European association. This places Spain in the third quarter".

Unlike most European countries, Spain does not have a specialty in palliative care medicine. That is perhaps the most critical point for developing palliative medicine."

Miguel Sánchez Cárdenas

However, a more global average can be sought. The researcher mentions that also in 2019, a global study was published that puts Spain "very well. In the World Atlas, this position is called Advanced Palliative Care Integration. It does this by computing indicators. It does not take just one, but it takes ten indicators and analyzes them, so that they allow it to define where the country is. In that process, it shows that Spain has a good level of advanced integration of palliative care. It is a much more general look at the countries (198)", contained in the Mapping Levels Glasgow cited at the beginning of this report.

Spain is far from the average proposed by the European Association for Palliative Carethe Atlantes researcher underlines, but "It has already come a long way and must continue to increase the number of services. And a very important indicator is that of education. Unlike most European countries, Spain does not have a specialty in palliative care medicine. That is perhaps the most critical point for developing palliative medicine.".

The hitherto president for the past few years of the Spanish Society of Palliative Care (Secpal), Rafael Mota, synthesized a year and a half ago "five key measures to be implemented as soon as possible".. They are as follows:

  • 1) approval of a National Palliative Care Law, with a budget allocation.
  • 2) Reactivate the 2007 National Palliative Care Strategy, which was then a significant advance in regulation and resourcing, but paralyzed since 2014.
  • 3) To recognize the professionals who develop their work in Palliative Care through the accreditation of the specialty or subspecialty, and that this is a prerequisite for working in specific Palliative Care resources.
  • 4) That the central government urge the Autonomous Regions to develop the professional category.
  • 5) Include Palliative Care as a compulsory subject in the University.

Good opioid use

The use of opioids or strong painkillers, such as morphine, for example, is another indicator that WHO has recognized on countless occasions, but which is sometimes the subject of debate. Miguel Sánchez Cárdenas comments: "There is high resistance to opioid use in the world because they are seen as potentially addictive, which is true if misused. But if professionals are well trained and understand that pain and other symptoms at the end of life are a source of suffering, the consumption of these drugs is a good thermometer of how much states are concerned with alleviating people's suffering and addressing their needs.". In his opinion, it is necessary to put in the balance the fact of having well-trained professionals, but also having the medicines that can essentially help to manage people's suffering.

Therefore, "the WHO itself has considered that the most relevant indicator to assess the development of palliative care is how many opioid drugs are consumed". And it has been established what would be the ideal standard, the appropriate measure. For example, in rich countries, the average consumption is 103 milligrams per capita.

It is necessary to put in the balance the fact of having well-trained professionals, but also having the medicines that can essentially help to manage people's suffering.

Miguel Sánchez Cárdenas

"There are many countries, such as Austria (524) or Germany (403) that have much higher consumption. What we would consider adequate consumption is more than 103 milligrams. Spain has it, Spain has 249 milligrams per capita, which is a good consumption. There are those who worry about that and point out that high consumption could be dangerous in terms of the use of these drugs for addictive purposes. But if you have a clear idea, and a very well-trained staff, this is positive, because it says that the countries have the structure to deal with pain and other end-of-life problems. The ranking eliminates methadone, which is used to eliminate dependencies and other types of problems, and only includes drugs that are useful for relieving pain and other end-of-life problems.

Final balance

The analysis shows that palliative care in Spain is not too bad, but it must be improved, especially in terms of education and training.. "In my opinion, we should not convey a pessimistic message, but recognize that it has some aspects gained in the development of palliative care services, the use of medicines, but it does have opportunities in the short term to consolidate education programs, to integrate palliative care into other areas of medicine."Sánchez Cárdenas adds.

"Today, for example, many oncology patients, people with cancer, receive palliative care, but it is not clear that people with other diseases, such as heart disease, chronic lung disease, liver disease, neurological diseases, etc., receive this type of care."

"Spain has many opportunities for improvement. Every time it moves a little further towards the best position, more opportunities open up; but there are some aspects that deserve attention. Spain being a country that has achieved a relatively adequate level of services, and with adequate levels of consumption of essential medicines, it is very surprising that it does not have a specialty." [in Palliative Medicine]..

And also "it is very striking that Spain is a country with such a well-established primary care system that palliative care services are not integrated into primary care.", concludes.

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