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Resolution 1649 (2009)
Palliative care: a model for innovative health and social policies
1. The Parliamentary
Assembly notes that palliative care is a substantial and socially
innovative addition to curative, highly scientific medicine, where
the subjective well-being of the patient comes after the goal of
curing an illness and which involves therapy-related restrictions
and sometimes massive side effects.
2. In this connection, the Assembly builds its position on the
2002 World Heath Organization (WHO) definition: palliative care
is an approach that improves the quality of life of patients and
their families facing the problem associated with life-threatening
illness, through the prevention and relief of suffering by means
of early identification and impeccable assessment and treatment
of pain and other problems, physical, psychosocial and spiritual.
3. The Assembly nevertheless underlines that the innovative potential
of the approach is not given sufficient emphasis in this definition,
which could lead public opinion to believe that palliative care
is a humanitarian luxury which we can no longer afford in the current
difficult economic situation.
4. The Assembly notes that, especially in the final stages of
life and in spite of the high standards and huge costs involved,
contemporary medical care fails to meet the basic needs of many
people (seriously ill, chronically ill, patients requiring high
levels of individual care). Against the background of the increasing domination
of health and social policies by economics, growing numbers of people
do not have a strong enough lobby to defend their basic rights.
5. The Assembly regards palliative care as a model for innovative
health and social policies, as it takes account of the changes in
our perceptions of health and illness and does not assume that curing
diseases is the precondition for self-determination and participation
in society. Autonomy is accordingly the requirement for a subjective
form of “health”, which includes people’s freedom to decide for
themselves how to deal with illness and death.
6. The Assembly notes that palliative care enables people who
have serious illnesses, are suffering pain or are in a state of
great despair, to exercise self-determination. The approach is not,
therefore, just based on need, but contributes directly to human,
civic and participation rights being asserted right up to death.
7. The Assembly believes that there is an urgent need to extend
the scope of this innovative treatment and care method. In addition
to the terminally ill, palliative care should be available to the
seriously ill and chronically ill and all those requiring high levels
of individual care who may benefit from the approach.
8. Palliative care can be seen as an approach to an appropriate
type of care developed on a practical level, which involves patient-oriented
integration of medicine and care, as well as the provision of other
health-related services and social resources. For instance, this
includes the successful involvement of voluntary helpers and the
possibility of including social, psychological and spiritual support
if necessary. This can be more important for individual patients
than medical care in the stricter sense.
9. With the above, the Assembly also draws conclusions from the
debate on the subject of euthanasia, which showed that liberal constitutional
states cannot leave ethical questions concerning the life and death
of individuals unanswered.
10. Sticking to ethical pluralism does not ensure maximum individual
freedom in ethical issues, but, in society it gives precedence to
randomness, relativism and practical nihilism over properly founded
ethical positions. This results in general disorientation and ultimately
in the erosion of the liberal constitutional state.
11. In this connection, the Assembly refers to the relevant recommendations
on dealing with the terminally ill as set out in the European Health
Committee’s report (1980) “Problems related to death: care for the
dying” and in its Recommendation 1418
(1999) on protection of the human rights and dignity of the
terminally ill and the dying.
12. It recognises that the limits of any medical intervention
are determined by the autonomy of the individual patients in so
far as they express their will not to receive curative treatment
or, regardless of any medical assessment of their state of health,
have done so explicitly in a living will, for instance.
13. The Assembly hopes that palliative care also offers individuals
who have given up hope the prospect of dying in dignity if they
are allowed to turn down curative medicine but accept pain relief
and social support.
14. It therefore regards palliative care as an essential component
of appropriate health care based on a humane concept of human dignity,
autonomy, human rights, civic rights, patient rights and a generally acknowledged
perception of solidarity and social cohesion.
15. It underlines that Recommendation Rec(2003)24 of the Committee
of Ministers to member states on the organisation of palliative
care already provides a good basis for strengthening the palliative
care approach.
16. The Assembly endorses the four applications of palliative
care listed in Recommendation Rec(2003)24 following the WHO definition
– namely symptom control; psychological, spiritual and emotional
support; support for the family; and bereavement support – and accordingly,
specifically recommends that member states:
16.1. establish a consistent and comprehensive health-policy
approach to palliative care at national level;
16.2. promote international co-operation between the various
organisations, institutions, research institutes and other players
in the palliative care movement.
17. In view of the great differences in developments in this area
in the various countries in Europe, the Assembly is aware that,
although rapid implementation in existing health-care structures
is desirable with a view to sustainable funding arrangements, the
funding arrangements themselves may involve serious obstacles for
such a flexible care and treatment approach.
18. It therefore believes there is a need for detailed analysis
of structural obstacles and accurate analysis of needs on the basis
of a minimum data set of the kind called for in the appendix to
Recommendation Rec(2003)24 in order to achieve sustainable, effective
changes in existing health systems.
19. It notes that wide-ranging discussion in society on the priorities
of health care based on sensible health objectives is necessary
if fundamental rights are to take precedence over further patient
rights in the health system. As the protection of fundamental rights
is a government task, this must not be left to pressure group politics.
20. The Assembly believes that ethics therefore have a fundamental
role to play as a practical philosophy in shaping the discussion
of health objectives and care priorities in society.
21. Therefore, with regard to general recommendations, the Assembly
recommends that member states:
21.1. focus
on ethics not only in application issues but as a matter of principle,
as only the clarification and typological classification of fundamental
positions will enable a stable consensus to be reached in society
about controversial ethical issues and a fair allocation of resources;
21.2. seek to ensure improved rewards for non-product-related
services both in health and in economic and financial policies so
that social policy can draw on economic policy and fiscal incentives
and to counter more effectively the increasing domination of society
by economics;
21.3. in general, seek to strengthen primary health care so
as to protect patients against inappropriate medical intervention
and place greater emphasis again on the importance of communication
between doctor and patient as the basis for rational, patient-oriented
medicine;
21.4. given governments’ capacity for influence, promote an
approach to medicine in society which highlights palliative care
as a key pillar of care provision to which patients are entitled.
22. Moreover, with regard to practical recommendations, the Assembly
recommends that member states:
22.1. consider
effective symptom control for seriously ill patients as a key requirement
for the doctor-patient relationship and patient self-determination
and promote this view, thereby also bringing the innovative potential
of the palliative care method into the domain of curative medicine;
22.2. within a consistent health-policy approach for the specific
strategy of improving palliative health-care provision, identify
practical indicators that can be used to check what progress has
been made in patient care over a given period;
22.3. draw up annual reports so that shortcomings can be analysed
as quickly as possible and dealt with appropriately;
22.4. react promptly, for instance through special arrangements
for the funding of palliative care, if it becomes apparent that
the appropriate use of painkillers is not taking place as desired
or the standardisation of hospital treatment (through diagnosis-related
groups − DRGs) is having a negative impact on existing structures
and practices;
22.5. with regard to legal regulations on living wills:
22.5.1. avoid creating legal arrangements
which could lead to interpretation problems in practice;
22.5.2. conduct a comprehensive assessment of the legal consequences,
taking account of possible legal side effects such as asset liability
(“care as a financial loss”).