Palliative
Medicine
http://pmj.sagepub.com/
Barriers to the development of palliative care in Western Europe
T. Lynch, D. Clark, C. Centeno, J. Rocafort, L. de Lima, M. Filbet, K. Hegedus, O. Belle, A. Giordano, F. Guillén and M.
Wright
Palliat Med 2010 24: 812 originally published online 25 May 2010
DOI: 10.1177/0269216310368578
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Original Article
Barriers to the development of palliative
care in Western Europe
Palliative Medicine
24(8) 812–819
! The Author(s) 2010
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0269216310368578
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T Lynch Lancaster University, Lancaster, UK
D Clark University of Glasgow, Glasgow, UK
C Centeno University of Navarra, Pamplona, Spain
J Rocafort Regional Palliative Care Program, Extremadura, Spain
L de Lima International Association for Hospice and Palliative Care, Houston, TX, USA
M Filbet Centre Hospitalo-Universitaire de Lyon, Palliative Care Unit, Lyon, France
K Hegedus Semmelweis University, Budapest, Hungary
O Belle Help the Hospices, London, UK
A Giordano European Association for Palliative Care, Milan, Italy
F Guillén University of Navarra, Pamplona, Spain
M Wright Lancaster University, Lancaster, UK
Abstract
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.
Keywords
Barriers, palliative care, Western Europe
Corresponding author:
Thomas Lynch, Lancaster University, Lancaster LA1 4YT, UK
Email: t.lynch2@lancaster.ac.uk
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Lynch et al.
Introduction
The European Association for Palliative Care (EAPC)
Task Force on the Development of Palliative Care in
Europe was founded in 2003 under the leadership of Dr
Carlos Centeno from the University of Navarra. The
task force combines the expertise of the EAPC with
that of the International Observatory on End of Life
Care (IOELC), Hospice Information (itself a partnership between Help the Hospices and St Christopher’s
Hospice, UK) and the International Association for
Hospice and Palliative Care (IAHPC).1 A progress
report on the work of the task force was published in
2004,2 initial findings were first presented in 2006,3 the
EAPC Atlas of Palliative Care in Europe was published
in 2007,4 and the EAPC Review of Palliative Care in
Europe appeared in 2008.5 Associated articles have
been subsequently published in peer-reviewed journals.6–8 The work of the task force has also been utilized to compile a technical report for the European
Parliament,9 and a set of specific EAPC country reports
are disseminated via the web pages of the EAPC, as
well as via links from the web pages of other organizations participating in the task force.
The aim of the task force is to undertake a reliable
and comprehensive analysis of palliative care developments within each European country, in order to generate and disseminate an evidence base of clear and
accessible research-based information concerning the
current provision of the discipline across both countries
and regions. It is hoped that this overview of palliative
care provision, achievements and challenges will provide governments and policymakers with a new and
improved understanding of the development of programmes to promote palliative care within the
European region and that this will, in turn, assist the
providers of palliative care services in a direct, practical
way through the development of future policy and
practice. The specific aim of this particular study is to
identify barriers to the development of palliative care
within Western Europe.
Methods
From the outset, the task force sought to work collaboratively in a manner that would bring together experience from groups and institutions working to
promote palliative care in their own countries. The
national palliative care association of each country
was therefore requested to nominate someone with
extensive local knowledge to participate in the project
(for example, a chairperson or secretary). The EAPC
Head Office, the IAHPC, Help the Hospices and the
IOELC provided vital information in identifying
national associations, local contacts, and key palliative
care workers in each country and region who had studied the development of hospice and palliative care in
their own setting and who could provide specific data to
assist policy makers and planners; these organizations
also provided valuable assistance in the compilation of
the qualitative Eurobarometer Survey that was disseminated amongst the boards of national associations,
eliciting opinions and views on opportunities for, and
barriers to, palliative care development.
The Eurobarometer Survey was developed to gain
insights into the views of key palliative care leaders
across the 52 countries of the WHO European region
in relation to the current state of palliative care in each
country. This qualitative survey included questions on
the strengths and weaknesses of palliative care at the
country level, and aimed to show the achievements and
breakthroughs that had been made in each jurisdiction.
The survey had five main sections:
(1) background questions (name, contact details, palliative care organization, etc.);
(2) questions on the current state of development of
palliative care in each country (has improved,
remained the same, got worse, etc.);
(3) questions on barriers to, and opportunities for, the
development of palliative care in each country (for
example, availability of opioids, other issues relevant to the development of palliative care);
(4) questions on policy (for example, national health
policies, euthanasia and assisted suicide;
Recommendations on Palliative Care from the
Council of Europe);10
(5) questions on the future of palliative care in each
country.
A caveat was included within the survey to ensure
that the participant was aware that the responses they
provided would be assumed to reflect the vision of the
palliative care organization that they represented; participants were therefore encouraged to discuss details of
the survey and their responses to it with colleagues
prior to submission in order to provide as balanced a
view as possible.
The resulting data were analysed thematically by
geographical region and by the degree of development
of palliative care. A thematic mode of analysis allows
the participant to be centre stage, and as such was considered a suitable choice for this particular study.11
Common themes were revealed in the survey through
qualitative secondary analysis, data synthesis and metaanalysis of data findings. Initially, the survey responses
were carefully reviewed in order to identify relevant
concepts; these concepts were then sorted into potential
themes, data relevant to each theme collated, and theoretical categories developed. Themes were modified
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Palliative Medicine 24(8)
Table 1. Countries of Western Europe (2005)
a
Andorra
Austria
Belgium
Cyprus
Denmark
Finland
France
Germany
Greece
Iceland
Ireland
Israel
Italy
Luxembourg
Malta
a
Monaco
Netherlands
Norway
Portugal
a
San Marino
Spain
Sweden
Switzerland
Turkey
United Kingdom
significance than others, a number of common barriers
to the development of the discipline in Western Europe
do exist: (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.
(i) Lack of palliative care education and training
programmes
a
Did not respond to Eurobarometer Survey.
and developed as survey data were revisited and analysis progressed. The aim of categorizing in this manner
was to satisfy the theoretical requirement of qualitative
research through the development of theoretical categories arising directly from evidence expressing personal meaning.12 The overall aim of the categorizing
process was to give meaning to the voices of respondents within the survey and to represent them as accurately as possible.13
In this paper, we focus on findings concerned with
one part of the Eurobarometer Survey, relating specifically to 22/25 (88%) countries in Western Europe. Each
country makes a contribution to this paper, although in
some cases selected parts of text have been edited to
improve the English language fluency. A list of
Western European countries that did and did not
respond to the Eurobarometer Survey are shown in
Table 1.
Results
Western Europe is a region generally thought to contain countries with well-developed palliative care networks,14 yet significant barriers to the development of
the discipline do exist. Whilst it is acknowledged that
the barriers described within this paper may differ substantially from each other in both their scope and context and some may be considered to be of greater
Lack of palliative care education and training opportunities is the most frequently reported barrier to the
development of palliative care in Western Europe (39
references by 19 different countries). In Finland,
Austria, Belgium, Greece, France, Italy, Norway,
Luxembourg, and Turkey, it is reported that an insufficient focus on palliative care within both undergraduate and postgraduate medical education results in a
lack of university curricula and training programmes
for healthcare professionals and medical students. A
similar situation exists in Malta, where it is reported
that the lack of formal education for undergraduates
combined with a lack of clearly defined career progression for doctors often results in medical graduates
choosing not to enter palliative care. In Germany, it
is reported that palliative care is not integrated into
the obligatory syllabus for medical or nursing students,
and that the majority of medical universities do not
have their own university palliative care unit and are
not obligated to organize tuition in the field of palliative medicine.
Against this backdrop, shortages of a skilled palliative care workforce resulting from a lack of education
and training are reported to be affecting the delivery of
palliative care; for example, in Norway the lack of palliative care personnel is acknowledged, and in Ireland
there is a shortage of certain grades of staff with specialist palliative care training. This is also the case in the
UK, where difficulties are reported in the recruitment of
doctors, nurses and allied healthcare professionals:
‘The UK is currently facing shortages of healthcare
staff and this is affecting palliative care amongst other
specialisms. Even when funding has been made available to support palliative care, services are not always
able to grow as quickly as they would like because of
the time and resources required to train new specialists.
There is also a need for more training for generalist
healthcare staff in palliative care.’ (UK)
Lack of palliative care education and training programmes is reported as resulting in a dearth of research
at the national level within Israel and also Iceland,
where only a very limited number of journal articles
have been published on palliative care and pain control.
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Lynch et al.
In Germany, research activities in the field of palliative
medicine and palliative care are increasing, but still
remain at an insufficient level with improved networking and increased funding and education in research
required.
(ii) Lack of awareness and recognition
of palliative care
Across the Western European region, respondents
report a lack of awareness and recognition about
issues of palliative care (19 references by 14 different
countries). In Turkey and Greece, people are not very
well informed about the discipline, with a similar situation existing in Denmark, where many people, including politicians still think it is about ‘loving tender care’
as opposed to highly qualified professional care. Even
in countries where the public has developed an awareness of the discipline of palliative care, problems of
perception remain:
‘Even though there are information programmes of
hospices and palliative care/medicine representatives,
public awareness of palliative care services is not as
good as it should (be) . . . According to a poll in 2004,
only 3% of the public know what the term palliative
care means.’ (Germany)
A degree of passivity on the part of medical professionals in many areas continues to be a potential barrier
to the development of palliative care, and, as we have
reported elsewhere,7 the discipline lacks recognition in
several Western European countries. Although there is
limited palliative care accreditation provided by universities and other academic organizations, policy makers
and government departments fail to recognize the discipline as a medical or nursing specialty in Austria,
Cyprus, Greece, and Netherlands. In Israel, although
discussions on the certification of palliative medicine as
a sub-specialty are progressing,15 it has yet to be fully
embraced into the traditional healthcare system. A similar situation is reported from Denmark, Iceland and
Sweden, although there is some evidence that a process
of palliative care certification is being developed in
these particular countries. In Finland, it is reported
that despite similar progress in relation to the certification of palliative medicine, Ministry of Health recognition of the discipline remains essential to clarify the
process of definition:7
‘Palliative medicine should have a (sub)speciality to
be able to state what it is. One can not organise something which does not exist. So far anyone or any unit
can call themselves a palliative care unit or specialist if
there is no official recommendations and requirement.
In general opinion, so far, all healthcare professionals
can give palliative care – no need for specialised knowledge and organisation is needed. Therefore we need the
speciality to be able to organise education and a specialised palliative care service.’ (Finland)
Whilst there is information to show that there are
some palliative care postgraduate courses and university diplomas in Italy,7 the difficulty in providing services to a homogenous standard without adequate
professional certification for physicians and nurses
remains a potential barrier to the development of the
discipline; it is suggested that this virtual absence of
professional certification fails to guarantee patients
high quality palliative care services. In Portugal, it is
reported that there is little political will to implement
palliative care, whilst in Spain a lack of political commitment to palliative care from some regional health
ministries is described. The medical model was perceived as dominant according to most respondents in
the survey, and was often seen to take priority over care
for the dying patient; for example, in Turkey, a predominant focus on curative treatment is reported,
whilst in France, the biomedical model is pre-eminent
in medicine and in the plan against cancer. A similar
story emerges from the UK:
‘The main barrier to the development of palliative
care is also the reason it developed as a distinct specialism in the first place. It is the tendency of mainstream
health services to focus on curing disease and saving lives
and for this to mean that care of the dying is not given
priority. Because improvements in quality of life are difficult to measure, palliative care has tended not to feature in national NHS targets . . . The tendency to focus
on curing disease has also meant that many healthcare
professionals perceive death to be a poor outcome and
may not be comfortable discussing palliative care with
patients because it is associated with dying.’ (UK)
(iii) Limited availability of/knowledge about
opioid analgesics
A frequently reported barrier to the development of
palliative care in Western Europe is the limited availability of/knowledge about opioid analgesics (14 references by eight different countries). In Greece, Portugal,
and Turkey, the lack of availability and choice of opioids is identified as a problem; the situation is similar in
Malta where diamorphine is available in state hospitals
but not in privately owned pharmacies because of the
fear of theft. In Portugal, the prohibitive cost and the
lack of available funding streams for the purchase of
expensive opioids is perceived to be a significant barrier, whilst restricted availability of certain opioids in
Greece is often related to issues of cost-effectiveness:
‘The pharmaceutical companies are not interested in
distributing different kinds of opioids (newer agents)
because [the markets] are not [profitable] for them.’
(Greece)
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Palliative Medicine 24(8)
Both the UK and Ireland report a lack of availability
of a range of opioids outside of standard working hours,
whilst problems relating to legislation and government
‘bureaucracy’ concerning opioids come from Cyprus and
Greece. A similar situation exists in Austria, where prescribing strong opioids requires the completion of a
number of different forms and the provision of rigorous
safeguards in relation to storage and distribution.
Lack of professional knowledge about the prescription of strong opioids amongst physicians and other
health professionals is reported to be a problem in
Austria, Cyprus, Finland, France, Germany, Israel,
Italy, Netherlands, Norway, and Spain. In
Luxembourg, despite optimal national availability of
strong opioids, there is a lack of knowledge about
their prescription and use amongst both doctors and
nurses. The lack of knowledge relating to the prescription of opioids results in prejudices and an ‘opioid mentality’ among healthcare professionals in a number of
countries (for example, Austria, Luxembourg, and
Switzerland); this often results in reluctance and fear
on the part of doctors to prescribe the necessary
doses of opioids to patients, such as in Turkey, and
also in the UK, where the high-profile conviction of
Dr Harold Shipman, a general practitioner who had
murdered over 215 of his patients, may have made general practitioners more reluctant to prescribe diamorphine for their patients.
Respondents from nine countries (Austria, Belgium,
France, Luxembourg, Netherlands, Norway, Switzerland,
Turkey, UK) suggest the lack of knowledge about the
use of opioids may result in irrational myths and negative stereotypes about the dangers of abuse; the close
association between the use of opioids in palliative
care and the psychological or physical problems of
drug addiction/dependence has been prevalent for
many years amongst members of the general public in
these countries. The stigmatizing and taboo status of
opioid use is reported as a barrier to the development
of palliative care in Belgium, where there is a long-standing perception that the use of morphine inevitably leads
to the death of the patient:
‘. . . a mental barrier is the taboo on morphine (as
many times emphasised by Twycross); this is a vicious
circle: ‘‘morphine is a killer’’ so we start too late due to
the resistance of the patient, the family or the doctor;
then the patient dies soon after first admission because
death was so near and subsequently the reaction often
is: ‘‘I told you the morphine would kill him.’’’
(Belgium)
(iv) Limited funding
A lack of sufficient funding for the provision of palliative care is perceived as a barrier to the development of
the discipline in Western Europe (11 references by 10
different countries). For example, lack of state funding
is described as a barrier in Belgium, where there is
insufficient financial support by the government for
local and national initiatives and hardly any money
for research in the field of palliative care. In Ireland,
Israel, Netherlands, Switzerland, and Turkey, there is a
reported lack of sufficient public funding for the provision of palliative care, with a similar situation in
Germany where there exists a need to find funding
from private and charitable sources to pay for establishing and maintaining palliative care services. Some
respondents highlighted funding difficulties due to
political bureaucracy; for example, in Austria where
the necessary political motivation to spend more
money on hospice and palliative care services is
reported as being a very slow process. Insufficient funding of palliative care services concomitant with a lack of
clarity and transparency in the way in which funding is
made available is reported from the UK:
‘Palliative care in the UK was pioneered by local hospice charities and was originally funded entirely from
voluntary income. Over time, palliative care services
have developed in both the NHS [National Health
Service] and the voluntary sector and the NHS has
increased the contribution it makes to palliative care services. However, services in both sectors still receive a
significant proportion of income from charitable
sources. The NHS contribution is variable around the
country, and tends to be a contribution towards costs
rather than payment for a specific level of services . . .
more resources will be needed to really mainstream palliative care practice across generalist healthcare.’ (UK)
A number of respondents report that limited funding
often results in education and training initiatives being
abandoned; this may, in turn, result in a deterioration
of service provision. In Greece, slow development and
expansion of palliative care services in primary, secondary and tertiary health care due to limited funding is
perceived to be a barrier to the development of the
discipline; a similar story emerges from Belgium:
‘We try to develop guidelines, standards for (nurse)
education and a national registration system. Owing to
a lack of means most of this is executed by a few enthusiastic people in their spare time. The danger is that
lack of means leads to the development of systems
that are not sufficiently professional based.’ (Belgium)
(v) Lack of coordination amongst services
The lack of effective coordination amongst different
bodies responsible for the delivery of palliative care services is often reported as a barrier to the development
of the discipline in Western Europe (11 references by
nine different countries). For example, in Austria there
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Lynch et al.
are a number of different authorities responsible for
implementation of the required services (federal and
regional authorities, social health insurance and retirement pension insurance companies). In Ireland, the
lack of coordination amongst palliative care providers
may make it difficult to deliver an integrated healthcare
service and homogeneous standards of palliative care in
the future. The lack of a coordinated referral system to
access palliative care services is a potential barrier to
the development of the discipline in Malta, where reluctance on the part of doctors to refer patients to palliative care services is deemed to have an adverse affect on
patient care. Lack of coordination between state and
voluntary services is reported in Greece, Finland, and
Italy:
‘The devolution of many political decisions concerning health care from the central government to the
regional government had made it difficult to propose
homogeneous standards for the provision of palliative
care with the development of very different reimbursement and accreditation models all over the country . . .
In some cases this leads to different attitudes of nonprofit organizations which have been developing
models of care providers in competition with and in
substitution to hospital-based and NHS professionally
driven models.’ (Italy)
There is a lack of a national coordination board in
Luxembourg, whilst in Portugal it is reported that
although there is a pain network and a palliative care
network written into public documents, these are not
adequately implemented in the field. Inadequate
national standards to regulate and determine the quality of palliative care provision are also reported as a
barrier to the development of the discipline in the
Netherlands.
Lack of coordination between different medical specialties and disciplines is a barrier to the development of
palliative care in a number of countries; for example, in
Italy:
‘[There is] strong debate among oncology, anaesthesia and other medical specialties to keep control of palliative care services . . . At the moment depending on
regional differences palliative care services are directed
by oncologists or by anaesthesiologists . . . [there is]
continuous debate with [general practitioners] about
their role in palliative care in integration with specialist
services . . . There is a danger of bureaucratization . . . in
a way that the revolutionary role of palliative care
within modern medicine is lost or is confined in a few
‘‘excellence’’ centres.’ (Italy)
(vi) Uneven palliative care coverage
Uneven palliative care coverage is the least reported
barrier to the development of palliative care in
Western Europe (seven references by seven different
countries). In Germany there are a considerable
number of palliative care services, though not enough
to cover the needs of the population; the distribution of
services is also uneven, and in some areas there exists a
substantial number of ‘blind spots’. The inability to
provide comprehensive coverage is also reported from
Greece, where it is stated that at a national level, much
still needs to be done to achieve the required coverage.
Similar problems in relation to the distribution of palliative care are being experienced in Finland, and also
in Switzerland, where many cantons do not have any
palliative care services. In Turkey, it is reported that a
wider range of palliative care programmes is of paramount importance, whilst in Denmark, palliative care
appears to be occurring spasmodically across the country, rather than according to any specific strategy; this
often results in counties with little coverage:
‘. . . the development (of palliative care) has been
very unevenly spread in the country, in some counties
there is still no specialist palliative care service, in some
the so-called specialist palliative care service is very far
from WHO and international standards . . . It is a good
thing to have hospices, but the government seems to
believe that the palliative care needs are covered by
12 hospice beds in each county.’ (Denmark)
One of the reasons why there is uneven coverage in a
number of countries in Western Europe is an absence of
sufficient public funding. In the UK, this factor is
reported to affect the ability to provide comprehensive
palliative care coverage:
‘The level of investment through personal giving has
enabled palliative care services to develop more rapidly
than they would have done if they had been entirely
reliant on public funding. The disadvantage has been
that these developments have been located where there
was a public will and the means to do so, rather than
following any strategic plan. This may leave some areas
underprovided for compared with others.’ (UK)
Conclusion
Data collected in the Eurobarometer Survey reveal a
number of barriers to the development of palliative
care in the countries of Western Europe (Table 2).
The barriers identified differ considerably in scope
and context, and of course some are more significant
than others. For example, in countries where palliative
care is not integrated into undergraduate and postgraduate education and training programmes for medical
students and other health professionals, lack of awareness and recognition of the discipline may continue
unabated, and the discipline is thereby rendered ‘invisible’ amongst other medical specialties. This lack of
education and training programmes, combined with
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Palliative Medicine 24(8)
Table 2. Most frequently reported barriers to the development of palliative care in Western Europe
Most frequently reported barrier to the development of palliative care
Number of references by number of different countries
Lack of palliative care education and training programmes
Lack of awareness and recognition about palliative care
Limited availability of/knowledge about opioid analgesics
Limited funding
Lack of coordination amongst services
Uneven palliative care coverage
39 references by 19 different countries
19 references by 14 different countries
14 references by 8 different countries
11 references by 10 different countries
11 references by 9 different countries
7 references by 7 different countries
the absence of clearly defined career progression for
doctors within palliative care, often results in medical
graduates choosing not to enter the discipline. In turn,
an inability to deliver homogeneous standards of palliative care in a country due to the lack of suitably qualified staff may result. A lack of palliative care education
and training programmes may also result in limited
knowledge about opioid analgesics amongst health professionals (for example, in the prescription of opioids
for pain control) and in a dearth of research at the
national level.
Similarly, limited funding impacts upon the provision of palliative care in a variety of ways; for example
where a lack of coordination between services leads to
different reimbursement and accreditation models being
developed. Inadequate funding often results in palliative care services occurring spasmodically across the
country, rather than according to any specific strategy
or plan, and this may leave some areas underprovided
for compared with others. Limited funding also circumscribes the availability of opioid analgesics in some
countries, and may lead to the development of education and training systems that are not sufficiently
professional-based or that are abandoned completely.
There are a number of instances where barriers may
intertwine and interconnect with each other. For example, a lack of palliative care education and training concomitant with a lack of knowledge about the use of
opioids may result in the promulgation of irrational
myths and negative stereotypes about the dangers of
opioid abuse amongst health professionals. A lack of
awareness and recognition of palliative care can result
in uneven coverage in countries where services that are
promoted as ‘specialist palliative care services’ are far
removed from established international standards, or
where governments consider that the palliative care
needs of the population are covered by a small
number of hospice beds in each area. Within this context, the restricted focus on resources allocated solely
for hospices may be a potential barrier to the provision
of palliative care for the wider population; for example,
in some Western European countries, palliative care is
still rarely integrated into hospital departments or
nursing and care homes. Lack of government awareness and recognition of palliative care often means
that the political will necessary to generate funding is
absent or that palliative care does not feature in government financial targets.
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.
Acknowledgements
The EAPC Task Force on the Development of Palliative Care
in Europe is partly supported by the University of Navarra
Research Program and an unrestricted grant from
Mundipharma International. The International Observatory
on End of Life Care, the International Association of Hospice
and Palliative Care, Help the Hospices and the EAPC itself
also contribute financially or provide other resources in support of this work. We are especially grateful to the following
respondents from Western Europe who participated in the
EAPC Eurobarometer Survey:
AUSTRIA: Johann Baumgartner, Member of the Board,
Austrian Palliative Care Association
BELGIUM: Trudie van Iersel, Secretary, Working Group
Research Palliative Care Flanders
CYPRUS: Sophia Nestoros Pantekhi, Medical Director,
Cyprus Anti-Cancer Society
DENMARK: Tove Bahn Vejlgaard, Co-chairman Danish
association for Palliative Medicine
FINLAND: Tiina Hannele Saarto, physician, palliative care
unit, Helsinki University Central Hospital
FRANCE: Bernard Devallois, President, Société Française
d’Accompagnement et de Soins Palliatifs
GERMANY: Birgit Jaspers, Scientific assistant to the president, German Association for Palliative Medicine
GREECE: Emmanouela Katsouda, Medical doctor in
Pain Relief and Palliative Care Unit, Department of
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Lynch et al.
Radiology, University of Athens, Medicine School, Areteion
Hospital; Athina Vadalouca, President, Hellenic Society of
Palliative and Symptomatic Care for Cancer and non
Cancer Patients (HSPSCCNCP)
ICELAND: Valgerdur Sigurdardóttir, Chairman, Icelandic
Association of Palliative Care
IRELAND: Geraldine Tracey, Secretary, Irish Association
for Palliative Care; Anna Marie Lynch, Honorary Secretary
and Member, Executive Committee Irish Association for
Palliative Care
ISRAEL: Micheala Bercovitch, Chairperson, Israel Palliative
Medical Society
ITALY: Augusto Caraceni, National board Secretary, Italian
Association of Palliative Care
LUXEMBOURG: Keilen Michel, Omega 90 asbl
MALTA: Theresa Naudi, Chair - The
Management, Malta Hospice Movement
Council
of
NETHERLANDS: André Rhebergen, Director Netwerk
Palliatieve zorg voor Terminale Patienten Nederland (NPTN)
NORWAY: Jon Håvard Loge, Consultant, Centre for
Palliative Medicine, Ullevål University Hospital
PORTUGAL: José António Saraiva Ferraz Gonçalves,
President, Associação Nacional de Cuidados Paliativos
SPAIN: Xavier Gómez-Batiste, President,
Sociedad Española de Cuidados Paliativos
SECPAL,
SWEDEN: Inger Fridegren, Chairman, Swedish Association
of Palliative Medicine
SWITZERLAND: Françoise Porchet, Vice-president of the
National Board and responsible for the Swiss Education
Committee, Swiss Society for Palliative Care
TURKEY: Seref Komurcu, Head of
Supportive Care, Turkish Oncology Group
Subgroup
for
UNITED KINGDOM: Mrs Erica Young, National Policy
Director, National Council for Palliative Care; Lucy Sutton,
Director of Policy Development, National Council for
Palliative Care; Ann Eve, MDS Project Manager, National
Council for Palliative Care; Ms Hannah Lynes, Policy and
Public Affairs Manager, Help the Hospices
The following countries in Western Europe were invited to
participate in the Eurobarometer Survey but returned a nil
response: Andorra, Monaco and San Marino.
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