1. Xavier Gómez-Batiste MD, PhD
OSI/WHOCC Introductory lecture
Palliative Care Public Health Programs with a WHO perspective Public Health Planning: Needs assessment, foundation measures, elements of Programs
Xavier Gómez-Batiste MD, PhD
Director, WHO Collaborating Center for Public Health Palliative Care Programs
WHO Meeting

2. Training Drugs Services PUBLIC POLICY in PC
Stjernsward, Ferris, Foley 2007

3. From the rising tides to tsunamis
Cancer, geriatrics, aids, chronic evolutive diseases

4. Palliative Care as a Public Health topic
Background 80’s
Eric Wilkes (Sheffield)
Vittorio Ventafridda (Milano)
Jan Stjernsward (WHO)
Kathy Foley (OSI, NY)
Palliative Care as a Public Health topic

5. PCPHP: objectives
- Coverage Equity Accesibility Quality Satisfaction (Reference WHO)

6. List of elements PC PH Programs: Topics
Foundation measures
Context analysis and Needs assessment
Target population
Clear aims: coverage, equity, quality
Clear leadership and consensus with stakeholders
Capacity building
Defined model of care and intervention
Measures: Implementation of specialist services, and improvement of conventional services, models of organization in demographic scenarios, standards of services
Opioids
Legislation
Standards
Financing systems, budget
Education, training, and research
Advocacy
Quality evaluation and improvement
Combine in an action plan: short, mid, long term, implementaion, reallocation, catalytic
Systematic evaluation of results
Indicators

7. Elements for self-assessment
Does the written Palliative Care Plan include? 1 2 3
Aims, principles, mission, and vision
Assessment of needs: cancer and no cancer
Goals and measurable short, medium and long-term objectives
Plan of action to meet the objectives based on evidence, affordability, coverage, and equity
Integration of activities to existing chronic disease and other related programmes (Cancer, Geriatrics, Chronic, Health Plan)
Opioid availability and accessibility (Decree, Order, or Law)
Standards of specialist services
Directory of palliative care services
Definition of the model of care and intervention
Definition of the model(s) of organisation (in settings or districts)
Standards of general services (primary care, other)
Financing model
Specific budget
Law, Decree, or Order
Education and training Plan
Priority research areas to support the implementation of the plan
Development of an information system for monitoring and evaluating the priorities
Clear process and outcome indicators for monitoring an evaluation
Budget / Costing of the action plan and resources needed for its implementation
Elements for self-assessment
ICO DiR. Centre Col·laborador de l’OMS per Programes Públics de Cures Pal·liatives

8. Components of PCPHPs Clear leadership and aims
Needs and Context Assessment
Clear model of care and intervention and definition of the target patients
General measures in conventional services (Specially Primary Care)
Specialist services in settings
Sectorised networks with coordination, continuing and emergency care
Education and training at all levels
Research Planning
Availability and accessibility of opioids and essential drugs
Legislation, standards, budget and models of funding and purchasing
Evaluation and improvement of quality
Evaluation of results, indicators
Action plans at short, mid and long term
Advocacy
Social implication: volunteers, social involvement in the cultural, social and ethical debates around the end of life

9. Principles of a PHPCP Good care as a human right
Model of care and inervention: based on patients and families’ needs
Model of organisation: based on a competent interdisciplinary team, with clinical ethics, case management, and advance care planning
Based on population needs and adapted to demography and settings in the Health Care System
Community oriented
Coverage, equity, access and quality to every patient in need of it
Quality: effectiveness, efficiency, satisfaction, continuity, sustainability
Systematic evaluation of results, accountability, evidence
Social interaction
Added values: Compassion, interdisciplinarity

10. Foundation measures
Previous measures: consensus, decission-makers, advocacy, identifying leaders
Context analisys, Needs assessment , and Basal studies
Formal plan designed and approved
Clear Legislation and standards
Opioid availability and accesibility
Leadership at the DoH
Capacity building
Building reference teams
Training oriented to capacity building and references of key services
Identifying alliances, barriers and difficulties

11. Initial key processes Clear ideas
Clear definition of clients and services
Leadership
“Catalythic” implementation or investment
Training oriented to build references
References / experiences
Institutional support 11

12. Types of processes (always combined)
“Catalythic” implementation or investment
Implementation of new specific resources
Adaptation of conventional resources (general measures)
Reallocation of resources (reconversion) 12

13. Needs assessment
Context analysis
Quantitative
Qualitative

14. Context analysis of Public Health Palliative Care Programs
Global country profile (Population, ageing, life expectancy, GBP, development)
Characteristics of the Health care system and care settings
Quantitative needs assessment: Demographic and general characteristics: mortality and prevalence of chronic evolutive diseases,
Basal surveys / studies
Background: previous initiatives
Mapping the existing services and resources
Qualitative analysis
Identification of resistances, barriers, and possible alliances

15. Context analysis Populational data
Demographic: Population, life expectancy, ageing,
Social: awareness, family rol, careers
Economical: GDP
Cultural, religious,
Political
The Health Care System: resources, funding, managerial, academic, research
Leaders: professional, social,
NGOs
Quantitative
Qualitative

16. Basal studies Select easy basal surveys or studies:
Relevant to quality
Easy to measure
Easy to change
Easy data to retrieve and monitorise
Examples:
Pain and symptoms prevalence and control
Use of essential opioids
Use of resources by terminal patients last month of life: emergencies, hospitals,
Focus group of professionals
ICO DiR. Centre Col·laborador de l’OMS per Programes Públics de Cures Pal·liatives

17. The populational perspective: - Mortality - Prevalence (population) - Prevalence by settings

18. McNamara, 2006: Mortality

19. Mortalidad
Prevalencia
Estimación Cobertura óptima at directa cp
Nº pacientes tributarios
Cáncer
1800 – 2250 (20-25% total mortalidad)
60%
No cáncer
2700 – 3600
(30-40% total mortalidad)
30- 60%(*)
De 810 – a 1620 – 2160
 Cáncer / no cáncer
1 /
1/6 -1/8
---
Total
4500 – 5850
(50-65% del total)  
Directa:
1890 – 2655
Directa + Puntual:
Mortality, Prevalence, and Estimation of direct coverage per milion habitants in Spain (*)
(*) Global mortality: 8950 persons / milion
(**) 30% direct coverage and + 30% flexible interventions
Source: Modifified from SECPAL, Informe Mº Sanidad, 2007 19

20. Every year, in a district of 200.000 h in Spain
1.800 persons will die
1.450 (75%) of them by chronic evolutive diseases (25% by cancer, 35-45% by other chronic diseases)
There will be around 450 prevalent terminal patients living
There will be 340 elderly with pluripathology and dependency
There will be 300 elderly with dementia
1.500 elderly will live in Nursing homes or homes for the elderly

21. Catalonia: Mortality / prevalence
Global :
Cancer :
Noncancer chronic:
Total chronic conditions:
Prevalence terminal patients:
Cancer: (mean survl 3 months)
Other conditions: (mean sl 9 months)
Total:
En éstos 15 años, la situación ha cambiado mucho en Catalunya, debido a la inmigración, y ahora hay más de 7 millones de targetas sanitarias
Las cifras actuales más relevantes son éstas:
Estimation based in McNamara, 2006 21

22. 60-75% of population will die by a chronic evolutive disease

23. The clinical / individual perspective

24. NHS GPs Gold standards: prognostic indicators guidance

25. The model of care: any PC Program and/or Service must be based in an impecable model of care for patients and families

26. Pal Care organisational concepts
Model of needs (individual and populations)
Model of care and intervention
Model of micro-organisation
Model of organisation of services
Comprehensive district networks
National/regional perspectives 26

27. Conceptual Transitions
From “Terminal disease” to “Advanced progressive illnesses”
From “Prognosis of days weeks, < 6 months” to “Limited life prognosis”
From “Progressive evolution” to Evolutive Crisis”
From “Curative/paliative dychotomy” to “Shared synchronic care”
Specific and palliative treatment can coexist
From “rigid” to “flexible” intervention
From “prognosis” to “complexity” as criteria of intervention
From “response to crisis” to “advance care planning”
From “palliative care services” to “palliative measures in all settings”

28. Implementing Palliative Care Specialist Services

29. Specific Resources / settings
Hospices
Acute Hospitals
Mid term and long term, RHB, (Sociohealth Centers)
Nursing homes
Units
Support teams
Outp’s / Day care
Community / home 29

30. Types of services and Levels of complexity
Reference:
complexity+ training+ research
Complete teams Units
Basic suport teams (home, hospitals, comprehensive)
Transitional measures: individual Specialist nurses or consultants
General measures in conventional Services (Hospitals, Primary care, Nursing homes, Emergencies, etc) 30

31. Standards of specific resources
1 support team at home / h
beds / milion habitants
(10-20% acute, 40-60% mid term, 20-30% nursing homes)
20-25 full time doctors / milion habitants
1 team available in every hospital (units in teaching)
Models of organisation adapted to demographic scenarios: metropolitans, intermediate, or small sectors <
Models in specific resources (cancer institutes, nursing homes, etc)
XGB 2005, WHOCC, 2008

32. Implementation strategies of services: initial phases
To create a nucleus of solid experiences
Combine different types: home, hospital, cancer, geriatric,….
Based in feasibility: active leaders, institutional comittment, ….
Cathalitic measures: support teams, transitional, …
Define services before starting implementation

33. Improving the quality of palliative care in all settings

34. Boundaries: other services
Hospices
Acute Hospitals
Mid term and long term, RHB, Centers
Nursing homes
Conventional services
Primary care
Nursing Homes
Primary care 34

35. General measures in conventional services
Targets: Hospitals (oncology, internal medicine, geriatrics, emergencies), mid-term and long-term resources (nursing homes), primary care teams
Training: policies, sessions, formal training, local references
Change of organisation: teamwork, presence and support of the family
Liaison of resources
General measures cannot substitute the need of specialist palliative care services

36. Palliative Care Measures in General Services
AIM
PRIMARY CARE
HOSPITAL CARE
Improving the capacity of professionals
Basic and intermediate training in Palliative Care
Identification of patients in need (PIG from the Gold Standards Framework)
Registries
Identification of patients in need
Use of GSF
Clinical charts with registries (symptom’s checklist, etc), Assessment Tools, etc
Internal and external reference professionals
Specific reference professionals (Doctors, nurses, others) with advanced training and dedication to palliative care
Improving accesibility of patients and families
Promotion home care Phone support programs
Access to rapid consultation
Direct access to palliative care beds Information
Free access of families to Hospital
Improving continuing care and emergency care
Advance care planning, continuing care, 24h phone access, Actitud preventiva, Teléfonos 24h, tailored emergency care, Direct access to PC beds
Specific times and places for patients and families
Specific times for advanced patients and families
Specific outpatients times for advanced patients and families
Advanced terminal patients agrupated in units
Improving family care
Education and support for careers
Prevention and treatment of complicated bereavement
Promotion of Team work
Team meetings
Team support and prevention burnout
Promotion of privacy and dignity
Individual bedrooms
Assessing and Improving the quality of care
Policies: pain, last days, etc
EoL inserted in the quality assessment
Coordination and integrated care with Specialist Palliative Care Services
Criteria of intervention and shared care with PCSs
Nurses able to demand
Other
Palliative Care Measures in General Services

37. Models of organisation in demographic and geographic scenarios

39. Demographic and setting scenarios
Primary/community care
Nursing homes
Longterm / intermediate
Hospitals: district general, university
Cancer Institutes
Rural
Urban
Rural-urban
Metropolitan
Adapt the organisation to needs and contexts
ICO DiR. Centre Col·laborador de l’OMS per Programes Públics de Cures Pal·liatives

40. District models Demographic area Demography (citizens; N) Examples
Main conventional resources
Proposed model of PC services
Metropolitan
500,000
Areas of Metropolitan Barcelona (4 Central, North, South
University reference + General Hospitals + SHCs
Reference PCS (PCU, OPC, HST and training and research) at the University Hospitals
2-3 SHCs with Units
Urban
200,000
3 urban areas: Girona, Tarragona, Lleida
University General Hospital SHCs
HST + OPC in Hospital + PCU in Hospital and/or SHC
Rural-Urban
80 – 150,000
16 Districts: Osona, Bages, Empordà
District General Hospital + SHC
1 HST, 1 HCST
1 PCU in Hospital or SHC
Preferably as comprehensive system
Rural
< 50,000
High Pyrenees
Community Hospital + SHC
Comprehensive system with a HST/HCST mixed acting in all levelsNo PCU needed
Common in all districts
Primary Care Centers every 20,000 habitants + Nursing homes
1 HCST/district / 100,000 hab + 1 HST in every hospital

41. Training strategies Aims Short / mid / long term Targets Levels
Methods
Faculty
Short term: oriented to create a nucleus of reference leaders and services

42. 1-2 years
Long term > 5 years
Aim
Build up core nucleus of reference services
Training coverage for all professionals
Targets
Clinical and organisational leaders of reference services
All professionals at the appropiate level
Methods
Stages, visits, mentorship, tutorship, modelling
Pregraduate, Intermediate
Specialty
Faculty
National & international
Local leaders from reference services
Different aims, methods, and targets for training at short or long term

43. Research strategies Aims Short / mid / long term Levels Methods
Faculty
Short-term: oriented to show results (to different targets), describe experience, generate evidence, and promote development

44. The legislation of palliative care includes
The insertion of palliative care in the existing policies and financing models (Global or specific Health plans for Cancer, Geriatric, Aids, and other chronic conditions)
The formal approval and recognition of the National Plan
Basic legislation (Law, decree, or ministerial order) that could be generic
Specific changes to assure opioid availability
Other related legislations: advance directives and autonomy, rights of patients, ethical committees, support (funding or changes in labour legislation) for careers

45. Legislation and standards
National Plan
General or definition: law or decret (generic)
Financing systems (specific for services)
Opioid and essential medicines availability (the simplest, the best)
Standards of services (description)
“The simplest, the best”

46. Financing models Insert in the common financing model
Combine: structure, activity, results, and quality
Concept of “cathalitic” investment
Reallocation
Estimate expected savings
“The simplest, the best”

47. Costs and savings Type of service Calculation Subtotal / type
Estimated savings; Euros
HCST
229,000 x 72 services
16,488,000 (31%)
TOTAL SAVINGS: 3,000 / patient x 23,100 = 69,300,000
HST
279,000 x 49 services
13,671,000 (26%)
PCU
96 x 209,000 stays
20,064,000 (38%)
OUTPAT
155 x 9,000 processes
1,395,000 (3%)
PST
190,000 x 5 services
950,000 (2%)
TOTAL
TOTAL COSTS: 52,568,000/ year
NET SAVINGS: 16,732,000 / year

48. Basic Quantitative indicators for PCPHP
Structure:
• Formal program at the DoH (with all of the elements)
• Clear leadership
• Specialist resources: services, units, teams, beds
• Nº Professionals
• Legislation, opioids, standards, financing model, specific budget, indicators
Process:
• Care Activity, care processes
• Nº patients (cancer / noncancer) reaching specialist services
• Activities training / research / quality improvement
• Measures in conventional services
Outcomes / Results:
• Direct coverage cancer and non cancer (% of total patients attended by specialist teams)
• Quantitative indicators of services: Beds / milion, Services / population, geographical coverage, etc
• Opioid Consumption (in morphine DDD)
• Outputs: length stay, length intervention, place of death, etc
• Clinical outcomes of pc services: Efectiveness, Satisfaction
• Organizational outcomes : Efficiency / use / cost individual or global
• Economical outcomes: global cost, global savings
• Educational outcomes: Professionals trained, coverage of training levels
• Research: clinical, organizational, evaluation of services
• Publications: Number and impact factor

49. Elements for self-assessment
Does the written Palliative Care Plan include? 1 2 3
Aims, principles, mission, and vision
Assessment of needs: cancer and no cancer
Goals and measurable short, medium and long-term objectives
Plan of action to meet the objectives based on evidence, affordability, coverage, and equity
Integration of activities to existing chronic disease and other related programmes (Cancer, Geriatrics, Chronic, Health Plan)
Opioid availability and accessibility (Decree, Order, or Law)
Standards of specialist services
Directory of palliative care services
Definition of the model of care and intervention
Definition of the model(s) of organisation (in settings or districts)
Standards of general services (primary care, other)
Financing model
Specific budget
Law, Decree, or Order
Education and training Plan
Priority research areas to support the implementation of the plan
Development of an information system for monitoring and evaluating the priorities
Clear process and outcome indicators for monitoring an evaluation
Budget / Costing of the action plan and resources needed for its implementation
Elements for self-assessment
ICO DiR. Centre Col·laborador de l’OMS per Programes Públics de Cures Pal·liatives

50. Advocacy
Select targets: politicians, policymakers, managers, funders, academics, NGOs, public awareness, media, …..
Select messages (adapted to targets): effectiveness, efficiency, satisfaction, ethical issues, values, innovation, stories, …..
Select key results at short / mid / long times
Prevent and treat: conflicts, threats, misunderstandings

51. The Catalonia WHO Demonstration Project on Palliative Care implementation: results at 20 years Catalan Department of Health + WHO Cancer Unit ( )
El programa se diseñó conjuntamente entre la Unidad de Cáncer de OMS y el Departament de Salut, y ahora podemos mostrar resultados a 15 años de su inicio
Gómez-Batiste X et al, In press 51

52. - External evaluation of indicators (Suñol et al, 2008)
- SWOT nominal group of health-care professionals (Gomez-Batiste et al, Med Pal, 2007)
- Focal group of relatives (Brugulat et al, 2008)
- Benchmark process (2008) (Gomez-Batiste et al, JPM, 2010)
- Efficiency (Serra-Prat et al Pall Med 2002 & Gomez-Batiste et al J Pain Symptom Manage 2006)
- Effectiveness (Gomez-Batiste et al, J Pain Symptom Manage 2010)
- Satisfaction of patients and their relatives (Survey CatSalut, 2008)
Evaluations of the Catalonia WHO Demonstration Project: Methods

53. Quantitative analisys: JPSM, 2007

54. Care Resources 2009 (Total: 237)
HSTs: 49
PCUs: 60
Outps: 50
PADES: 74
Figura en la que están representados los distintos dispositivos y su localización en el sistema sanitario.
Rectángulos verdes: Hospitales + ICO
Triángulos azules: centros sociosanitarios
Círculos amarillos: EAPs, círculos rojos: PADES
Other: 10
Care Resources 2009 (Total: 237) 54

55. Additional processes / year Other relevant outputs CARE SERVICES
Specialist services
Additional processes / year
Other relevant outputs
CARE SERVICES
Home Care Support Teams 72
1 / 110,000 citizens
Processes: 13,000
% Cancer / non-cancer: 49 / 51
Mean age: 76
Death at home: 68%
Duration of intervention: 80 days
PCUs in Socio-Health Centers
PCUs: 28
Beds: 383
Processes: 6,300
Total PCUs: 60
Total beds: 742
(110 beds / million)
Processes: 10,450
Mean age: 74
Length of stay: 20.3 days
Mortality: 72.9%
PCUs in Nursing Homes
PCUs: 27
Beds: 319
Processes: 3,150
Mean age: 82
Length of stay: 35 days
Mortality: 85%
PCUs in Acute Bed Hospitals
PCUs: 5
Processes: 1,000
Cancer 80%
Mean age: 61
Length of stay: 11d
Mortality: 55%
Hospital Support Teams 49
Processes: 10,700
Cancer / non-cancer: 60 / 40
Mean Age: 73
Length of stay: 10 days
Psychosocial Support Teams 6
Processes: 1,500
Outpatient Clinics 50
Processes: 9,000
TOTAL CARE SERVICES: 237
TOTAL CARE PROCESSES: 46,200 (2 / patient)
Other Services (4)
Team at the Department of Health
Education and Training Unit (ICO)
The ‘Qualy’ EoL Observatory / WHOCC (ICO)
Clinical Research Team (ICO)
Specialist Services: 241
Full time Doctors: 240 (32.8 / million)
Total Patients: 23,100; Cancer: 12,100 (52%); Non-cancer: 11,000 (48%)
Coverage: Cancer: 73.3%; Non-cancer: 31% -58%; Geographic area cover: 100%

56. Basic Indicators of PCS
Structure
Process
Outcomes
Multidisciplinary team
Advanced training and competencies
Office
Documentation
Protocols/ policies
Criteria for intervention
Multidimensional evaluation of patients needs
Multidimensional Therapeutic Plans for patients
Identifying and supporting primary career
Advance care planning
Register and Monitorising needs, demands, expectations
Evaluation of results
Case management and Continuing care
Coordination
Bereavement
Effectiveness
Cost
Efficiency
Satisfaction: patients, families, services
Basic Indicators of PCS

57. Catalonia 2010 Coverage (geographic): 100% Coverage cancer: 73%
Coverage non cancer: 40-56% (*)
Proportion cancer/noncancer : 50%
Nº Dispositives: 231
Beds/milion: 101.6
Full time doctors: 220 (30 / milion)
Los datos Globales son:
Cobertura geográfica: % de población y localizaciones que tiene algún recurso accesible de cp (o pades y/o ufiss y/o unidad)
Cobertura cáncer: estimación % de enfermos de cáncer que son atendidos por equipos de cp 72%
Cobertura no cáncer: estimación de cobertura de atención para enfermos terminales de otras patologías no cáncer: 31% (fundamentalmente, enfermos geriátricos atendidos por PADES o en Unidades de centros Sociosanitarios)
Dispositivos: es el nº total de dispositivos (PADES + UFISS + UNIDADES + CONSULTA EXTERNA + HOSPITALES DE DIA evaluadores ) que tienen alguna actividad formal de cp. En una comarca como Bages, por ejemplo, hay 1 PADES + 1 UFISS + 1 UNIDAD.
Camas: 552 (SUMA DE LAS 387 ESPECÍFICAS DE CP (STA CREU DE VIC)+ LAS 165 DE MEDIA ESTANCIA POLIVALENTE QUE TIENEN ACTIVIDAD FORMAL CP(CSS Hosp PALAMOS))
Camas/ millón: 78.85: una cifra globalmente alta
(*) McNamara, 2006 57

58. More than 250.000 patients attended
Populational impact
More than patients attended
More than persons (14% of population) in direct contact with palliative care services

59. Efficiency of PCSs
Multicenter longitudinal study on the use of resources by cancer patients attended by PCSs
Comparison with previous use without PCSs
171 teams / 395 patients

61. Qualitative analisys: results
Weak Points
Low coverage noncancer, inequity variability, sectors and services (specific and conventional)
Difficulties in access and continuing care (weekends)
Late intervention
Evaluation, emotional support, bereavement,
Professionals: low income, support, and academic recognition
Financing model and complexity
Research and evidence
Strong Points
Region of 7.3 milion habs
High coverage cancer, relative noncancer, and geographical
High coverage home care cancer and non cancer
Professional’s committment
Public Health Planning
Insertion in the HCS, diversity, models
Effectiveness, efficiency, satisfaction
El grupo ha identificado los PF y A mejora, entre los que destacamos:
P Fuertes: alta cobertura para cáncer, relativa alta proporción de no cáncer, dedicación (EXCELENTE) de los profesionales, planificación pública, y resultados medibles.
Areas de mejora:
1. Cobertura de no cáncer y algunos puntos específicos geográficos (Viladecans, etc)
2. Cáncer: accesibilidad y atención continuada de enfermos avanzados y intervención tardía de equipos de cp.
3. Extender la práctica de la evaluación de resultados clínicos y de satisfacción, y mejorar la atención de aspectos subjetivos
4. Reconocimiento, retribución, y reconocimiento académico y formal de la formación
AQUÍ CONVENDRIA MMOSTRAR SUPORT A QUE LES CURES PAL.LIATIVES SUGUIN UN AREA DE CAPACITACION ESPECÍFICA, en tràmit al Ministerio.
5. Mejorar la financiación casse mix de las UCP de centros sociosanitarios
6. Promover la investigación 61

62. Types of processes (always combined)
“Catalythic” implementation or investment
Implementation of new specific resources
Adaptation of conventional resources (general measures)
Reallocation of resources (reconversion) 62

63. Common Resistances We are already doing so...
There is no need of specific services, we will do a lot of training....
Palliative care services will be seen as places to die....
This is good for England, USA, or Catalonia, but it will not work in....

64. Evolutive tendencies
From hospice to palliative care to end of life care
From service’s vision to populational vision
From cancer to other patients, early and flexible interventions
From opinion into experience and into evidence
From “problems” to “opportunities of improvement”

65. Expected results Enormous improvement of the quality of care:
Effectiveness
Efficiency: saving more than the structural cost
Satisfaction: patients, families, professionals

66. Conceptual Transitions
From “Terminal disease” to “Advanced progressive illnesses”
From “Prognosis of days weeks, < 6 months” to “Limited life prognosis”
From “Progressive evolution” to Evolutive Crisis”
From “Curative/paliative dychotomy” to “Shared synchronic care”
Specific and palliative treatment can coexist
From “rigid” to “flexible” intervention
From “prognosis” to “complexity” as criteria of intervention
From “response to crisis” to “advance care planning”
From “palliative care services” to “palliative measures in all settings”

67. Conclusions: 15 years
PC must be inserted in the National Health Care System and adapted to settings and districts
PC development is effective, efficient, and generates high satisfaction
There are evolutive tendencies (noncancer, early intervention)
The governamental committment accelerates the process
Las conclusiones a 15 años de experiencia son que el desarrollo de los cp en el sistema de salud de catalunya es efectivo, eficiente, y genera satisfacción, de acuerdo con datos de la literatura.
Constatamos tendencias evolutivas (atención no cáncer, intervención precoz, modelos flexibles, )
A la experiencia hemos ido añadiendo evidencia
Los resultados son la consecuencia de combinar medidas de estructura (muchas de ellas de reordenación) con otras de proceso

68. Start low,
and go slow,
but do so!!!

70. 70

74. The Parliament of Catalonia
Organic Law 6/2006 of the 19th July, on the Reform of the Statute of Autonomy of Catalonia
ARTICLE 20. THE RIGHT TO UNDERGO THE PROCESS OF DEATH WITH DIGNITY
1. Each individual has the right to receive appropriate treatment of pain and complete palliative attention and to undergo the process of death with dignity.
2. Each individual has the right to express his or her will in advance in order to record instructions regarding any medical treatment or intervention that he or she may undergo. These instructions must be respected especially by medical staff, in accordance with the terms established by the law, if the individual is not able to express his or her wishes personally.

75. Access to Pain relief and Palliative Care as a Human Right, Human Rights Wacht

76. Picasso: “Science and Charity”, Barcelona, 1917