Official certification of doctors working in palliative medicine in Europe: data from an EAPC study in 52 European countries

Instruments to measure skills and knowledge of physicians and medical students in palliative care: A systematic review of psychometric properties

PURPOSE

Palliative care is constantly increasing around the world. The knowledge and skills of future physicians in this area are crucial. This study evaluates the psychometric properties of knowledge and skills questionnaires used in palliative care, validated by physicians or medical students based on the COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology.

METHODS

A systematic review was carried out in Cosmin Databases, Cochrane Library, PsycINFO, SciELO, Cinahl, and Medline up to September 2020 (updated June 2021), based on the COSMIN methodology and PRISMA recommendations. The psychometric properties of each included questionnaire were identified. Methodological quality, quality of results, and quality of evidence were evaluated.

RESULTS

The search strategy yielded 12 questionnaires assessing the knowledge and skills of physicians or medical students. The Palliative Care Knowledge Questionnaire for PEACE (PEACE-Q) and Palliative Care Knowledge Test (PCKT) were the instruments with the highest scores for methodological quality, quality of results, and quality of evidence-based on the COSMIN methodology.

CONCLUSIONS

PEACE-Q and PCKT should be the preferred choice to assess palliative care knowledge and skills in physicians. In-depth studies following COSMIN validation criteria are recommended to improve the psychometric properties and cross-cultural validation of the questionnaires.

Twelve Years of Postgraduate Palliative Medicine Training in Finland: How International Guidelines Are Implemented

Background and Objective: The European Association for Palliative Care (EAPC) published recommendations for postgraduate education in palliative medicine in 2009. However, it is currently unknown how the EAPC remommendations are implemented in national programs, as audits of them are lacking. In Finland, the national society of palliative medicine has been organizing postgraduate palliative medicine training for experienced physicians since 2008, but the program has not been audited. The aim of this study was to perform a comprehensive analysis of the program. Design: In 2018-2019, a questionnaire on the Finnish Training Program for Palliative Medicine Competence was sent to past participants and delivered in person to current trainees. Learning outcomes were assessed with validated instruments for received skills and attitudes. All available educational archives were examined as well. Results: Forty-five (32 %) out of 155 specialists and 13 (38 %) out of 34 trainees responded. According to their assessments, the training provided them well with most skills required to work as palliative care specialists, but poorly with research capabilities. However, the Finnish program covers the EAPC guidelines well. Problem-based education, group work, and clinical excursions have been added to the latest curriculum. Maturation through work is needed for administrative and consultant competences. Conclusion: The EAPC guidelines can be included in a national course. The course had an important positive influence on the attitudes and learning of physicians in palliative medicine. The development of the education would benefit from pedagogical consultation. Uniform standards for auditing national programs should be developed.

Attitudes, Aptitudes, Barriers and Knowledge of Pain Physicians towards Palliative Care Practice - A National Survey, India

Objectives:

The bio-psycho-socio-spiritual model is a common management approach in palliative care (PC) and chronic pain medicine (CPM), adopted by PC Physicians and Pain Physicians (PPs), respectively. There is a dearth of services and personnel of PC in India. As PPs are familiar with pain management and the bio-psycho-socio-spiritual model, we hypothesised that they would be willing to incorporate PC in their practice and therefore, sought to understand their attitudes/aptitudes/barriers/knowledge towards it.

Materials and Methods:

We did a cross-sectional cohort study through a national survey of Indian PPs. The ten- item validated, survey questionnaire was mailed to 1300 PPs having E mail and registered with Indian Society for Study of Pain.

Results:

We received responses from 6.6% of the PPs. About 10.39% did not want to practice PC; the rest were either practicing or wanted to, or were unable to. 81.8% had <10 years CPM experience while the rest had 10–15 years. About 53.3% PPs had <10 years’ experience in PC; 10.4% had > 10 years and the rest had not practiced. About 70% were motivated by human suffering or had “personal reasons.” About 40.26% had no barriers; the rest cited stress or lack of infrastructure/knowledge/skills/time/financial compensation. The majority chose institutional courses for training and the popular choice of duration of the course was 3 months. The opinion on financial viability/non-viability of PC was equally divided among the respondents. About 62.3% had “knowledge” but half of them lacked “skills;” 27.6% lacked both; the rest had no inclination towards PC. About a third felt multi-disciplinary care was feasible while half felt that it was partially feasible.

Conclusion:

Policy-makers, at regional to global levels are strategizing options for popularizing PC since it supports the dualistic model of cure and care, most essential for both, chronic-debilitating or life-limiting illnesses. The poor response to our survey was a major limiting factor. However, among the respondents, the majority showed both aptitude and a favourable attitude for PC practice. The inability to identify major barriers for not choosing PC did not support our hypothesis. However, we feel that PPs are a cohort who can be motivated/ encouraged to take up some form of brief, comprehensive courses in PC so that they can be conversant with the specific knowledge and skills needed to practice the multi-dimensional aspects of PC in their own settings.

Retrospective analysis of the prevalence of specialised palliative care services for patients with metastatic breast cancer

Background

Patients with metastatic breast cancer (MBC) have a considerable symptom burden and may require extensive care for a long period of time. Palliative care (PC) has the potential to improve their quality of care and reduce their use of medical services. However, the role of specialised PC (SPC) in patients with MBC remains unclear.

Patients and methods

We performed a retrospective analysis of the medical records of patients diagnosed with breast cancer (BC) from 2008 to 2018 at an university-based referral centre to examine the extent of early and late integration of SPC services for patients with MBC. A descriptive analysis of the patients was also established.

Results

In all, 932 patients were diagnosed with BC from 2008 to 2018; 225 of these patients had or developed metastases related to their BC. In addition, 132 patients received SPC (58.7%) and 93 patients did not receive SPC (41.3%). The median probability of overall survival (OS) for patients who did not receive SPC services was 3.6 years (95% CI 2.0 to 5.1) and 1.8 years (95% CI 1.3 to 2.3) (p<0.0001) for patients who did receive SPC. In multivariate analysis, referral to SPC services was independently associated with OS (HR 1.60, 95% CI 1.16 to 2.22, p=0.004).

Conclusion

Patients who received SPC lived significantly shorter amounts of time than patients not referred for SPC services at our hospital. We concluded that the referral to SPC services was often too late and should be implemented earlier in the course of the disease. We suggest that patients with MBC should participate in a consultation by a SPC team ≤60 days after the start of systemic palliative anticancer therapy in addition to endocrine treatment. Larger prospective studies are needed to evaluate the benefit of the early integration of SPC services for patients with MBC.

Palliative care teaching shapes medical undergraduate students' professional development: a scoping review

PURPOSE OF REVIEW

The aim of this review is to understand how palliative care teaching (PCT) as a patient-centered learning model, influences medical undergraduate students' professional development.

RECENT FINDINGS

To study PCT medical undergraduate students' learning experiences, we have employed the medical teaching concept, 'hidden curriculum,' as a way of describing attitudes and behavior conveyed implicitly by palliative care educators. Fifteen studies were selected: ten of those studies used a qualitative approach; two are theoretical explanations of the topic explored, one guideline, one review and just one quantitative study, made up the review. Medical undergraduate students reported that after PCT, they felt they had acquired better attitudes for effective integration with the patient, such as empathy or holistic care; ethical principles, such as respect or humanization of their clinical practice; and commitment to an improvement in competences, such as self-awareness or self-esteem. They also reported improved behavior in effective integration with patients, such as communication, caring for patients' families, and when addressing psychosocial, cultural and spiritual aspects; their commitment to improvement in competences, such as dealing with emotions and uncertainty; they learned team work as an effective way to interact within the health system; and to become more reliable, making themselves more available and dedicating enough time to each patient.

SUMMARY

PCT seems to be an effective way of fostering medical undergraduate students' patient-centered professional development.

Development of Evaluation Indicators for Hospice and Palliative Care Professionals Training Programs in Korea

INTRODUCTION

The importance of training for Hospice and Palliative Care (HPC) professionals has been increasing with the systemization of HPC in Korea. Hence, the need and importance of training quality for HPC professionals are growing. This study evaluated the construct validity and reliability of the Evaluation Indicators for standard Hospice and Palliative Care Training (EIHPCT) program.

METHODS

As a framework to develop evaluation indicators, an invented theoretical model combining Stufflebeam's CIPP (Context-Input-Process-Product) evaluation model with PRECEDE-PROCEED model was used. To verify the construct validity of the EIHPCT program, a structured survey was performed with 169 professionals who were the HPC training program administrators, trainers, and trainees. To examine the validity of the areas of the EIHPCT program, exploratory factor analysis and confirmatory factor analysis were conducted.

RESULTS

First, in the exploratory factor analysis, the indicators with factor loadings above 0.4 were chosen as desirable items, and some cross-loaded items that loaded at 0.4 or higher on two or more factors were adjusted as the higher factor. Second, the model fit of the modified EIHPCT program was quite good in the confirmatory factor analysis (Goodness-of-Fit Index > 0.70, Comparative Fit Index > 0.80, Normed Fit Index > 0.80, Root Mean square of Residuals < 0.05). The modified model of the EIHPCT comprised 4 areas, 13 subdomains, and 61 indicators.

DISCUSSION

The evaluation indicators of the modified model will be valuable references for improving the HPC professional training program.

Position paper of the Italian Association of Medical Oncology on early palliative care in oncology practice (Simultaneous Care)

One of the priorities of personalized medicine regards the role of early integration of palliative care with cancer-directed treatments, called simultaneous care. This article, written by the Italian Association of Medical Oncology (AIOM) Simultaneous and Continuous Care Task Force, represents the position of Italian medical oncologists about simultaneous care, and is the result of a 2-step project: a Web-based survey among medical oncologists and a consensus conference. We present the opinion of more than 600 oncologists who helped formulate these recommendations. This document covers 4 main aspects of simultaneous care: 1) ethical, cultural, and relational aspects of cancer and implications for patient communication; 2) training of medical oncologists in palliative medicine; 3) research on the integration between cancer treatments and palliative care; and 4) organizational and management models for the realization of simultaneous care. The resulting recommendations highlight the role of skills and competence in palliative care along with implementation of adequate organizational models to accomplish simultaneous care, which is considered a high priority of AIOM in order to grant the best quality of life for cancer patients and their families.

End-of-Life Cancer Care: Temporal Association between Homecare Nursing and Hospitalizations

OBJECTIVES

Most cancer patients want to die at home, but scaleable models to achieve this are not well researched. Our objective was to investigate the temporal association of homecare nursing, especially by generalist nurses, with reduced end-of-life hospitalizations.

METHODS

We conducted a retrospective Canadian cohort study of end-of-life cancer decedents during 2004-2009 in Ontario (ON), Nova Scotia (NS), and British Columbia (BC), which have homecare systems that use generalist nurses to provide end-of-life care. Each province linked administrative databases to examine the association during the last six months of life between the homecare nursing rate and the hospitalization rate in the subsequent week, using standardized definitions and controlling for other covariates. We dichotomized nursing into standard and end-of-life care intent.

RESULTS

Our cohort included 83,827 cancer decedents. Approximately 55% of decedents were older than 70 and the most common cancer was lung. Nearly 85% of the cohort had at least one hospital admission. Receiving end-of-life compared to standard homecare nursing significantly reduced a patient's hospitalization rate by 34%, 33%, and 17% in ON, BC, and NS. In the last month of life patients having a standard nursing rate of greater than five hours compared to one hour per week had a significantly lower hospitalization rate (relative reduction of 15%-23%) across the three provinces.

CONCLUSIONS

Our study showed a protective effect of nursing with an end-of-life intent on hospitalization across the last six months of life and of standard nursing in the last month. This finding's generalizability is strengthened, since the trends were similar across three different homecare systems.

Palliative care development in the Asia-Pacific region: an international survey from the Asia Pacific Hospice Palliative Care Network (APHN)

BACKGROUND

Although palliative care is an important public healthcare issue worldwide, the current situation in the Asia-Pacific region has not been systematically evaluated.

OBJECTIVES

This survey aimed to clarify the current status of palliative care in the Asia-Pacific region.

METHODS

Questionnaires were sent to a representative physician of each member country/region of the Asia Pacific Hospice Palliative Care Network (APHN). The questionnaire examined palliative care service provision, information regarding physician certification in palliative care, the availability of essential drugs for palliative care listed by the International Association for Hospice and Palliative Care (IAHPC) and the regulation of opioid-prescribing practice.

RESULTS

Of the 14 member countries/regions of the APHN, 12 (86%) responded. Some form of specialist palliative care services had developed in all the responding countries/regions. Eight member countries/regions had physician certifications for palliative care. Most essential drugs for palliative care listed by the IAHPC were available, whereas hydromorphone, oxycodone and transmucosal fentanyl were unavailable in most countries/regions. Six member countries/regions required permission to prescribe and receive opioids.

CONCLUSIONS

The development of palliative care is in different stages across the surveyed countries/regions in the Asia-Pacific region. Data from this survey can be used as baseline data for monitoring the development of palliative care in this region.

End-of-life communication: a retrospective survey of representative general practitioner networks in four countries

CONTEXT

Effective communication is central to high-quality end-of-life care.

OBJECTIVES

This study examined the prevalence of general practitioner (GP)-patient discussion of end-of-life topics (according to the GP) in Italy, Spain, Belgium, and The Netherlands and associated patient and care characteristics.

METHODS

This cross-sectional, retrospective survey was conducted with representative GP networks. Using a standardized form, GPs recorded the health and care characteristics in the last three months of life, and the discussion of 10 end-of-life topics, of all patients who died under their care. The mean number of topics discussed, the prevalence of discussion of each topic, and patient and care characteristics associated with discussions were estimated per country.

RESULTS

In total, 4396 nonsudden deaths were included. On average, more topics were discussed in The Netherlands (mean=6.37), followed by Belgium (4.45), Spain (3.32), and Italy (3.19). The topics most frequently discussed in all countries were "physical complaints" and the "primary diagnosis," whereas "spiritual and existential issues" were the least frequently discussed. Discussions were most prevalent in The Netherlands, followed by Belgium. The GPs from all countries tended to discuss fewer topics with older patients, noncancer patients, patients with dementia, patients for whom palliative care was not an important treatment aim, and patients for whom their GP had not provided palliative care.

CONCLUSION

The prevalence of end-of-life discussions varied across the four countries. In all countries, training priorities should include the identification and discussion of spiritual and social problems and early end-of-life discussions with older patients, those with cognitive decline if possible, and those with non-malignant diseases.

Palliative care research on the island of Ireland over the last decade: a systematic review and thematic analysis of peer reviewed publications

Background

As palliative care research continues to expand across Europe, and the world, questions exist about the nature and type of research undertaken in addition to the research priorities for the future. This systematic review, which is the first stage of a larger scale study to identify the research priorities for palliative care on the island of Ireland, examined palliative care research conducted on the island over the last decade.

Methods

A comprehensive search strategy was implemented and strict eligibility criteria were applied in order to identify relevant peer-reviewed journal articles. Inclusion criteria were all of the palliative care studies undertaken on the island of Ireland and published between January 2002 and May 2012. These were assessed in relation to year, setting, sample size, research methodology, and relevant findings.

Results

412 publications were identified for screening and their abstracts obtained. After eliminating articles that did not meet the inclusion criteria, 151 remained for further analysis. A thematic analysis of 128 studies published between 2006 and 2012 revealed eight core themes: (1) specific groups/populations; (2) services and settings; (3) management of symptoms (physical, psychological, social); (4) bereavement; (5) communication and education; (6) death and dying; (7) spirituality; and (8) complementary and alternative medicine/intervention (CAM). There was an upward trend in the number of publications in palliative care research over the last ten years with over 72% of studies being published within the previous four years. A slightly higher number of studies were quantitative in nature (surveys, questionnaires, standardised assessments) followed by qualitative (individual and focus group interviews, case studies, documentary analysis and retrospective case note reviews), mixed methods, and systematic reviews.

Conclusions

Whilst there has been a welcome growth in palliative care research across Ireland, this has largely been needs-based and small scale studies. In contrast, international researchers and decision makers recommend the need for more outcomes focused multidisciplinary research. An examination of palliative care research is an essential first step in seeking to develop future priority areas for further research, highlighting opportunities for future collaboration both nationally and internationally.

Palliative care training and research: the development in europe and the bologna experience

Development of palliative care (PC) culture spur the need of proper and formal training. Palliative medicine is not fully recognized as an academic medical discipline due to its humanistic influences, and studies show that physicians declare to be not prepared to provide care and pain management to dying patients. Nowadays, despite leading countries in PC being considered more innovative than other countries,such as Italy, facts show that the achievement of acknowledged discipline went through a long process. In Italy,professionals from about 450 PC units and organizations need to receive a proper and homogeneous training. In Italy, palliative medicine official certification is an undergoing process advocated by a few organizations and in Bologna the Academy of the Sciences of Palliative Medicine operates since 2007 with the defined mission of developing PC culture, also within the University. In order to be as much effective in pursuing its mission, the Academy has strengthened several international cooperation programs and today is leader in PC professional training and research in Italy. The recent law and its feasibility is fastening the process of development of Palliative Care Culture in Italy even if training is not properly regulated and official certification for physician is under evaluation. In Europe, the European Association of Palliative Care is stressing the need for training programs in palliative medicine and the outcomes of the dedicated task force on official certification and specialty in Palliative Medicine will remarkably force policy makers and national councils to officially recognize the discipline.

The landscape of postgraduate education in palliative care for general practitioners: results of a nationwide survey in Flanders, Belgium

OBJECTIVE

To describe the offer of continuing medical education (CME) in palliative care in Flanders, Belgium and to explore the way providers of CME address the preferences of general practitioners (GP's) towards CME.

METHODS

Questionnaire-survey among official providers of formal CME.

RESULTS

The response rate was 43%, equally distributed over all 5 provinces of Flanders. Data show large content gaps, an under usage of appropriate educational techniques and an absence of evaluation of the impact of CME on clinical practice. Providers of CME explain how they take the preferences of GP's concerning education in palliative care into account.

CONCLUSIONS

The present offer of CME is insufficient to educate GP's in palliative care. The absence of quality criteria and the lack of coordination between different providers results in an unattractive labyrinth of courses leaving GP's and their patients in the cold.

PRACTICE IMPLICATIONS

A comprehensive offer of CME sessions should be installed in a coordination between all providers. This could render the use of means (logistics and speakers) more efficient. Further research could look into other ways of acquiring palliative care competences such as evaluating the learning effect of GP's working together with specialized palliative home care teams.

Experience with palliative care in patients with advanced cancer at a tertiary care hospital in a developing country

The importance of palliative care in patients with advanced cancer is established. Reports on the experience with palliative care in the Middle East region are limited. A prospective study was performed to characterize the palliative care experience at a tertiary care center in Lebanon and to identify the profile of patients requiring palliative care. This communication highlights the results of the study. Authors conclude that the profile of needs for individuals requiring palliative care in Lebanon is similar to westernized countries. Revisiting the continuum of cancer care is called for to better identify the optimal timing of intervention and avoid end of life distress.

Barriers to the development of palliative care in Western Europe

The Eurobarometer Survey of the EAPC Task Force on the Development of Palliative Care in Europe is part of a programme of work to produce comprehensive information on the provision of palliative care across Europe.

AIM

To identify barriers to the development of palliative care in Western Europe.

METHOD

A qualitative survey was undertaken amongst boards of national associations, eliciting opinions on opportunities for, and barriers to, palliative care development. By July 2006, 44/52 (85%) European countries had responded to the survey; we report here on the results from 22/25 (88%) countries in Western Europe.

ANALYSIS

Data from the Eurobarometer Survey were analysed thematically by geographical region and by the degree of development of palliative care in each country.

RESULTS

From the data contained within the Eurobarometer, we identified six significant barriers to the development of palliative care in Western Europe: (i) lack of palliative care education and training programmes; (ii) lack of awareness and recognition of palliative care; (iii) limited availability of/knowledge about opioid analgesics; (iv) limited funding; (v) lack of coordination amongst services; and (vi) uneven palliative care coverage.

CONCLUSION

Findings from the EAPC Eurobarometer Survey suggest that barriers to the development of palliative care in Western Europe may differ substantially from each other in both their scope and context and that some may be considered to be of greater significance than others. A number of common barriers to the development of the discipline do exist and much work still remains to be done in the identified areas. This paper provides a road map of which barriers need to be addressed.

Silver paper: the future of health promotion and preventive actions, basic research, and clinical aspects of age-related disease--a report of the European Summit on Age-Related Disease

BACKGROUND. In September 2008, under the French Presidency of the European Union and with the support of the Polish Minister of Health, a European Summit on Age-Related Disease was organised inWroclaw (Poland). At this meeting, European politicians, gerontologists and geriatricians gathered to discuss a common approach to future challenges related to age-related disease. Politicians and decision-makers from the European Union and Ministers of Health and their deputies from many European countries raised the problems and difficulties to be tackled in a growing population with a high burden of disease, and asked scientists to write a consensus document with recommendations for future actions and decisions. Scientists and clinicians worked in parallel in three different groups, on health promotion and preventive actions, basic research in age-related disease, and clinical aspects of disease in older people. Beforehand, the format of the paper with recommendations was discussed, and it was finally agreed that, for a better understanding by decision- makers, it would be divided in two different columns: one with facts that were considered settled and agreed by most experts (under the heading We know), and a second with recommendations related to each fact (We recommend). No limit on the number of topics to be discussed was settled. After careful and detailed discussion in each group, which in most cases included the exact wording of each statement, chairpersons presented the results in a plenary session, and new input from all participants was received, until each of the statements and recommendations were accepted by a large majority. Areas with no consensus were excluded from the document. Immediately after the Summit, the chairpersons sent the document both to the main authors and to a list of experts (see footnote) who had made presentations at the summit and agreed to review and critically comment on the final document, which is presented below. As regards the scientific aspects of the planning of the Summit, several organisations, under the leadership of the EUGMS, were asked both to review the program and to suggest names of speakers and participants. After the Summit, the Boards of these organizations (European Union Geriatric Medicine Society (EUGMS), International Association of Gerontology and Geriatrics-European Region (IAGGER), European Association of Geriatric Psychiatry (EAGP), International Society of Gerontechnology (ISG) and International Society for the Study of the Aging Male (ISSAM) agreed to consider the document as an official paper, and help with its dissemination. The name Silver Paper was used, recalling the grey or silvery hair of our older citizens, as an easy reference. It has been sent officially to several bodies of the European Union and to Health Ministers of most European countries; and will be published in other languages in local journals. Its declared intention is to foster changes in policies which may, in the future, reduce the burden of disease in old age.

Teaching dying patient care in three universities in Argentina, Spain, and Italy

We performed a multicenter comparative survey on undergraduate medical education regarding the care of dying patients at medical schools in three countries. We enrolled 380 first- and sixth-year medical students from Universidad Austral (Argentina), Universidad de Navarra (Spain), and Università Campus Biomedico di Roma (Italy). Answers to the questions were similar among the three universities. Students acknowledged interacting directly with dying patients in all cases. Attitudes toward dying patients were highly positive. Students spontaneously requested more training in end-of-life care. Some attitudes and wishes varied significantly from course to course. Students perceived that this issue received more attention in humanistic rather than in clinical subjects. Ninety-eight percent of students considered that death and helping patients to have a good death should be included in their training. Students' attitudes revealed high interest and poor training in end-of-life issues. Medical curricula should be improved to adequately address these issues.

[Palliative medicine. Fifth pillar of anaesthesia departments]

Palliative medicine has progressed during recent years to an independent medical faculty within the German health system. Despite this development palliative care systems for out-of-hospital and in-hospital palliative care are still insufficient in Germany so that the development of necessary resources must be considered as not yet completed. To support the further national development palliative medicine can be temporarily or permanently coupled to existing departments, which can be advantageous for all concerned and last but not least be profitable to patients and their relatives. Possibilities for participation of anaesthesiologists in this area of medical care are discussed in the study reported here. Anaesthesiologists have always historically been represented in palliative medical departments, e.g. as pain specialists. In the following investigation the special possibilities of anaesthesia departments for supporting the education and development of in-hospital and out-of hospital palliative medical care departments are reported. Previous experience of co-operation between these two departments is well established. Departments of palliative medicine depend on a well working interdisciplinary co-operation between different medical disciplines (e.g. anaesthesiology, radiotherapy, surgery and oncology) and several medical professions (e.g. physicians, nurses, psychologists). The aim of palliative care therapy is to be responsible for the best possible therapy for cancer patients and to give support to their care-giving relatives. Due to the increasing establishment of palliative care procedures in Germany, departments of anaesthesiology should actively take part in the further development. Part of the responsibility of most anaesthesia departments is to practice pain management and critical care medicine, which are reasons why anaesthesiologists are predestined to be part of the system for palliative care patients and their relatives. Anaesthesia departments can be responsible for the organization of in-hospital and out-of-hospital palliative medicine and palliative care. The integration of anaesthesiological expertise into palliative medicine departments and vice versa can be a great opportunity for both medical departments and therefore represents a worthwhile engagement.

Facts and indicators on palliative care development in 52 countries of the WHO European region: results of an EAPC Task Force

The European Association for Palliative Care Task (EAPC) Force on the Development of Palliative Care in Europe was created in 2003 and the results of its work are now being reported in full, both here and in several other publications. The objective of the Task Force is to assess the degree of palliative care development in the European Region as defined by the World Health Organization (WHO). The Task Force is a collaboration between EAPC, the International Observatory on End of Life Care, Help the Hospices and the International Association for Hospice and Palliative Care. The University of Navarra have collaborated in the dissemination of results and is involved in further developments of this group. Four studies, each with different working methods, made up the study protocol: a literature review, a review of all the existing palliative care directories in Europe, a qualitative ;Eurobarometer' survey and a quantitative ;Facts Questionnaire' survey. The work of the Task Force covers the entire WHO European Region of 52 countries. In this article we present a comparative study on the development of palliative care in Europe, drawing on all four elements of the study. Different models of service delivery have been developed and implemented throughout the countries of Europe. For example, in addition to the UK, the countries of Germany, Austria, Poland and Italy have a well-developed and extensive network of hospices. The model for mobile teams or hospital support teams has been adopted in a number of countries, most notably in France. Day Centres are a development that is characteristic of the UK with hundreds of these services currently in operation. The number of beds per million inhabitants ranges between 45-75 beds in the most advanced European countries, to only a few beds in others. Estimates on the number of physicians working full time in palliative care are shown. The countries with the highest development of palliative care in their respective subregions as measured in terms of ratio of services per one million inhabitants are: Western Europe - UK (15); Central and Eastern Europe - Poland (9); Commonwealth of Independent States - Armenia (8). This paper also presents indicators on the development of palliative care based on the bibliometric analysis of scientific journals and on the vitality of the palliative care movement in each country.