The Czech Republic belongs to the relatively developed and rich European countries and has a population of 10.5 million inhabitants.
Approximately 105,000 people die in the country every year: 25% of malignant tumours, 50% of cardiovascular and cerebrovascular disease, and the remaining 25% of pulmonary disease, liver and kidney disease, poisoning and accidents.
Most people thus die following progression or complications of a chronic disease.
The causes of death are similar to those in other developed eastern and western European countries.
Based on current knowledge of the usual course taken by these common diseases, it is possible to estimate that every year, there are between 60,000 and 70,000 people in the Czech Republic who need some aspect of palliative care. As in other European countries, the most frequent place of death is in the hospital (60% of all deaths occur in acute hospitals, 9% in long-term care hospitals, and 3.5% in inpatient hospices).
About 20% of all deaths occur at home, but those deaths consist mainly of sudden unexpected deaths.
Palliative care should be developed, provided and analysed at two levels: general palliative care and specialised palliative care.
General palliative care
General palliative care is the clinical care that healthcare professionals from specialities other then palliative care provide within their routine duties to terminally ill patients.
The main quality indicators for general palliative care are: healthcare professionals’ education in palliative care, accessibility of the drugs needed for symptom control and willingness of doctors to prescribe these drugs, possibility for the patient to choose their place of care, quality of accommodation and food in healthcare facilities, quality of the communication between healthcare professionals and patients, and accessibility of psychological support.
An opinion poll conducted in 2011 among a representative sample of laypeople and professionals showed that citizens of the Czech Republic are worried about their end of life.
The most frequent deficiencies are: poor communication with the family, insufficient treatment of pain and other symptoms, too many beds per room, little attention given to the psychological and spiritual aspects of care. Of course there are exceptions.
Specialised palliative care
Inpatient hospices and palliative care units
Hospice and palliative care – with a specific multiprofessional approach and models of care for the incurably ill – started being developed in the Czech Republic in 1989.
From the beginning, development has focused on the provision of inpatient hospice care.
Inpatient hospices are usually non-governmental establishments that are independent (that is, not part of another health institution such as a hospital).
Their funding comes from multiple sources. Between 40% and 60% of the total cost of care is covered by public health insurance.
Approximately 20% is covered by healthcare subsidies and social care allowances. Hospices thus have to raise 20-40% of their funds from donations and collections. Patients pay a fee of 200-500CZK per day (around 9-20 Euros).
At present, there are 16 inpatient hospices in the country and, in 2011, 3.5% of all deaths occurred in those hospices.
Most of these are affiliated to the Czech Association of Hospice Palliative Care Providers. Apart from these 16 hospices, there are also two palliative care units (which are part of another health institution).
Among the 16 hospices and the two palliative care units, the total capacity is 460 beds (that is 4.5 beds per 100,000 inhabitants of the country). The mean length of stay is 30 days and the mortality rate is 80-95%.
Outpatient palliative care
There are two oncology centres with dedicated oncology clinics led by palliative medicine specialists who provide ambulatory palliative care to cancer patients.
There are also 90 pain clinics in the Czech Republic, led by doctors specialising in palliative medicine and pain management.
These clinics care mostly for non-cancer patients with chronic pain and do not provide comprehensive palliative care.
Home hospice care
Palliative care is now recognised by law as a specific form of care delivered in home settings, but the issue of reimbursement has not been resolved yet. Since 2001, the association Cesta Domu (which means ‘the homecoming’) has been running, in Prague, a mobile hospice service providing multiprofessional, specialist palliative care in patients’ homes.
Besides Cesta Domu in Prague, there are three other hospice organisations of a similar scope in the Czech Republic.
Education and general palliative care
A number of palliative care topics are already parts of undergraduate curricula. Palliative care is also taught as an independent subject by several medical schools in their training programme for nurses.
However, the contents and extent of palliative care training in these different settings differ greatly. End of life care as a separate, independent topic is absent in the curriculum of future doctors. Palliative care topics are only compulsory for those junior doctors who specialise in general medicine and oncology.
Palliative care as a medical sub-specialty
The medical sub-specialty ‘Palliative medicine and pain management’ has existed in the Czech Republic since 2004. Most of those who apply to undergo training in this specialty come from the field of anesthesiology.
Since 2004, 125 doctors have received accreditation in the specialty. Most of them work at pain clinics. Out of the 125 doctors, only 15 work solely in palliative care.
In 2010, the training programme in palliative medicine and pain management was divided into two distinct sub-specialties: one is palliative medicine, the other one is pain management. As of May 2013, 20 doctors had received their accreditation in palliative medicine, while another 10 were in the process of being trained.
The Czech Society for Palliative Medicine
The Czech Society for Palliative Medicine (CSPM) was founded in 2009 by a group of physicians from different professional backgrounds engaged in the care of the incurably ill.
CSPM is a member of the J.E. Purkyne Czech Medical Association (to which almost all other medical societies in the country are affiliated) and currently has 130 members. Most of them are physicians working with the incurably ill. About 20% of members are other healthcare professionals – mainly nurses, psychologists and social workers.
The main goal of the CSPM is to develop and support education and good clinical practice, both in general and specialised palliative care, in order to improve the care of patients at the end of life.
An important step towards this goal has been the publication, at the beginning of 2013, of a document detailing palliative care standards, developed by the CSPM with the support of the Czech Ministry of Health. The CSPM provides training for those who are studying to become specialists in palliative medicine. In cooperation with the Czech Institute of Postgraduate Education, the CSPM organises a number of courses for the specialisation and continuing education of doctors.
A national strategy for palliative care development
In the Czech Republic, those who form health policies do not recognise palliative care as an independent area providing health and social care with a different conceptual approach. However, others have argued in favour of a national strategy for palliative care development. In 2011, the CSPM took part in the production of a draft strategy at the request of the Human Rights Committee of the Czech Council for Human Rights. Since then, there have been ongoing negotiations around the adoption of the National Strategy. The text was submitted to the Czech government in July 2012. Unfortunately, it has not yet been adopted.
Perspectives and objectives
In the near future, the CSPM has the following aims:
- To support the adoption and implementation of the proposed National Strategy for palliative care development
- To support the development of mobile specialised palliative care in its different forms (at the patient’s home or in other settings)
- To further promote the integration of palliative care topics in the undergraduate and postgraduate curricula of all medical professionals who will care for patients at the end of life
- To further support and further develop the palliative medicine specialty training programme
- To create an accredited educational palliative care programme for nurses
- To collaborate with other disciplines and professional medical societies on joint projects.
ehospice would like to thank the Czech Society for Palliative Medicine for writing such an insightful article, and we wish them all the best in achieving their aims.