Portal de Periódicos da CAPES

Palliative Care: No Longer a Luxury But a Necessity?

2009; Elsevier BV; Volume: 38; Issue: 1 Linguagem: Inglês

10.1016/j.jpainsymman.2009.04.015

1873-6513

Irene J Higginson, Kathleen M. Foley,

Patient Dignity and Privacy

Health spending has increased in most countries in recent decades, both in real terms and as a percentage of Gross National Product (GNP). Indeed, even those countries, such as Ireland, that have seen a fall in the percentage of GNP spent on health care (Table 1), their actual spend on health care has risen—in Ireland from $1081 in 2000 to $3082 in 2006.1Organisation for Economic Co-Operation and Development (OECD). OECD frequently requested data 2008. Total spend per capital in USD, 2008. Available from http://www.oecd.org/document/16/0,3343,en_2649_33929_2085200_1_1_1_1,00.html. Accessed February 3, 2009.Google Scholar In the United States, spending on health is now over 15% of GNP, exceeding that of all other countries (Table 1), estimated in 2006 at $6714 per capita, more than double that in the United Kingdom at $2760 or Australia at $3141, and almost double that of Canada at $3679. Factors driving health care costs higher include the aging of the population and the growing drug bill. Current global economic challenges may mean that GNP will fall in many countries. As a consequence, there will be intensive pressure to slow the burgeoning costs of health care and probably to reduce spending in real terms.Table 1Percentage of GNP Spent on Health Care in Selected Countries, 1960–2006YEARCountries19601965197019751980198519901995200020052006Australia3.86.56.36.66.97.48.38.88.7Austria4.34.65.27.07.56.58.49.79.910.310.1Belgium3.95.66.37.07.28.28.610.610.3Canada5.45.96.97.07.08.18.99.08.89.910.0France3.84.75.46.47.08.08.410.410.111.111.0Germany6.08.48.48.88.310.110.310.710.6Ireland3.74.05.17.38.37.56.16.76.38.27.5Italy7.77.38.18.99.0Japan3.04.44.65.76.56.76.06.97.78.28.1Norway2.93.44.45.97.06.67.67.98.49.18.7Spain1.52.53.54.65.35.46.57.47.28.38.4United Kingdom3.94.14.55.55.65.96.06.97.28.28.4United States5.15.67.07.98.710.011.913.313.215.215.3Note: Data not provided for some countries for some years.Source: OECD Health Data (see Ref.1Organisation for Economic Co-Operation and Development (OECD). OECD frequently requested data 2008. Total spend per capital in USD, 2008. Available from http://www.oecd.org/document/16/0,3343,en_2649_33929_2085200_1_1_1_1,00.html. Accessed February 3, 2009.Google Scholar). Open table in a new tab Note: Data not provided for some countries for some years. Source: OECD Health Data (see Ref.1Organisation for Economic Co-Operation and Development (OECD). OECD frequently requested data 2008. Total spend per capital in USD, 2008. Available from http://www.oecd.org/document/16/0,3343,en_2649_33929_2085200_1_1_1_1,00.html. Accessed February 3, 2009.Google Scholar). In such a crisis, could palliative care, symptom relief, and pain management be seen as dispensable luxuries? Certainly the origin of palliative care, with its roots in the nonprofit and voluntary sector, implies that palliative care is not a necessity but something that the state need not necessarily provide. With its mission to provide care and treatment that "improves the quality of life of patients and their families facing the problems associated with life-threatening illness,"2Davies E. Higginson I.J. Better palliative care for older people. World Health Organization, Denmark2004http://www.euro.who.int/document/E82933.pdfGoogle Scholar palliative care could well be regarded by some as an unnecessary extra. Instead, that priority could be to make working people healthy, to boost the economy. Such thinking could be attractive to some policy makers seeking to cut costs without major outcry, because, as in John Hinton's words, "The dissatisfied dead cannot noise abroad the negligence they have experienced."3Hinton J. Dying. Penguin, London1967Google Scholar Health costs in the last year of life are high. A recent study in Manitoba, Canada, found that 21% of the province's health care costs were consumed by people in the last six months of life, who occupied 24% of hospital beds.4Menec V. Lix L. Steinbach C. et al.Patterns of health care use and cost at the end of life. Manitoba Centre for Health Policy, Winnipeg, Canada2004Google Scholar These figures reflect the costs of hospital care and intensive treatments, without the input of specialist palliative or hospice care. Palliative care should and must be given on the grounds of higher quality care—and the argument that palliative care should be given because it is cheaper is highly dangerous. No care anywhere at all is probably cheapest. But compared with other forms of care, there is evidence now emerging that not only is palliative care effective, producing quantifiable benefits in terms of pain and symptom relief,5Higginson I.J. Finlay I. Goodwin D.M. et al.Do hospital-based palliative teams improve care for patients or families at the end of life?.J Pain Symptom Manage. 2002; 23: 96-106Abstract Full Text Full Text PDF PubMed Scopus (278) Google Scholar it also is cost-effective, providing savings in real terms for the health care system.6Morrison R.S. Penrod J.D. Cassel J.B. et al.Cost savings associated with US hospital palliative care consultation programs.Arch Intern Med. 2008; 168: 1783-1790Crossref PubMed Scopus (615) Google Scholar As some articles in this issue of the JPSM show, these benefits can be found in different health systems, whether in the Medicare system of the United States or in health care systems in Europe, such as that in Spain.7Paz-Ruiz S. Gomez-Batiste X. Espinosa J. Porta-Sales J. Esperalba J. The costs and savings of a regional public palliative care program: the Catalan experience at 18 years.J Pain Symptom Manage. 2009; 38: 87-96Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar However, the evidence of cost-effectiveness, although growing, remains relatively weak. It is vital to strengthen this in several ways. First, there are too few evaluations and cost-effectiveness studies of palliative care treatments and services. These must now be undertaken. But the right tools are crucial. As the international think tank on health economic issues in palliative care reported8Gomes B. Harding R. Foley K.M. Higginson I.J. Optimal approaches to the health economics of palliative care: report of an international think tank.J Pain Symptom Manage. 2009; 38: 4-10Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar—incidentally, a meeting planned long before the current economic crisis was evident—tools to measure both costs and outcomes are needed. The meeting identified some potential ways to do this. If internationally agreed-upon protocols for collecting cost and outcome data could be realized, the knowledge base would advance more quickly because it would be easier to conduct multicenter studies, make comparisons, and conduct meta-analyses. New discovery is important. Is it time to get rid of the quality-adjusted life year in health economic analysis related to palliative care and pain control and move to more appropriate measures taking account of the way that time is viewed in a palliative care context, as outlined by Normand9Normand C. Measuring outcomes in palliative care: limitations of QALYs and the road to PalYs.J Pain Symptom Manage. 2009; 38: 27-31Abstract Full Text Full Text PDF PubMed Scopus (64) Google Scholar and the meeting conclusions?10Harding R. Gomes B. Foley K.M. Higginson I.J. Research priorities in health economics and funding for palliative care: views of an international think tank.J Pain Symptom Manage. 2009; 39: 11-14Abstract Full Text Full Text PDF Scopus (16) Google Scholar A further consideration is the way that hospice and palliative care services are supported in different parts of the globe.11Higginson I.J. End-of-life care: lessons from other nations.J Palliat Med. 2005; 8: S161-S173PubMed Google Scholar In many countries, palliative care is partly or fully supported from charitable donations. Although this may promote innovation and flexibility, funding may fall in times of economic downturn. There is no doubt that in all countries palliative care is playing a major role in providing health care. In some places, funding for palliative care remains as a block grant, but in others, diagnostic-related groups have been developed. And across and within countries, there is variation in the way palliative care is organized and provided in terms of the skill mix, mix of inpatient and home services, and patients cared for. There could be much to learn from international comparisons. At a time of economic challenge, palliative care must look at providing services in the most effective and efficient ways. It may be that some clues as to how to do this arise from comparing palliative care in different contexts. It is a time to press for investment in palliative and hospice care, especially into generating the knowledge that underpins its treatments and care and learning from the different models that operate. The time has come to recognize palliative care as a necessity, and to invest in services and care and in the knowledge to develop them effectively and efficiently.