Entwicklung der Palliativmedizinischen Dienste (PMD) in Bayern 2011–2015: Aufgaben, Akzeptanz, Struktur und Finanzierung

Zusammenfassung

Einleitung Palliativmedizinische Dienste (PMD) bieten stationären Patienten aller Fachabteilungen palliativmedizinische Unterstützung an. Schwerkranke und sterbende Menschen, die in Häusern ohne eigene Palliativstation behandelt werden, können von diesen multiprofessionellen Teams ebenso profitieren wie Patienten, bei denen ein Aufenthalt in einer Palliativstation (noch) nicht notwendig erscheint. Bis Ende 2015 waren in Bayern 53 PMD genehmigt, die den Anforderungen des 2009 vom bayerischen Gesundheitsministerium erstellten Fachprogramms entsprachen.

Methoden Mittels eines postalisch versandten Fragebogens (2011) und einer Online-Umfrage (2015) baten wir alle zu diesen Zeitpunkten genehmigten bayerischen PMD, Fragen zu ihren Aufgaben, der Akzeptanz im eigenen Haus, zur Personalstruktur und Finanzierung zu beantworten. Neben Fragen, deren Zutreffen auf einer Skala von 0–10 zu beantworten war, wurde auch Raum für Freitextkommentare angeboten.

Ergebnisse Der Rücklauf 2011 betrug 77% (17 Bögen), 2015 53% (28). Insgesamt wurde die Organisationsform „PMD“ weitgehend als geeignetes Instrument erachtet, die Palliativversorgung im eigenen Haus zu verbessern (2011: Mittelwert 7,8 (0–10) ±1,9, 2015: 7,2 (0–10) ±2,3; n.s.). Die Akzeptanz durch die Abteilungen der eigenen Einrichtung wurde 2015 signifikant besser eingeschätzt (7,2±2,3) als noch 4 Jahre zuvor (5,7±2,2; p<0,05). Die PMDs nehmen vielfältige Aufgaben wahr, am häufigsten „stützende Gespräche“, „Begleitung in der Sterbephase“, „Schmerztherapie“ und „Entlassmanagement“. Dennoch war in den Teams ein Rückgang der Multiprofessionalität v. a. im Bereich Psychologie/Psychoonkologie und Seelsorge (p<0,05) zu beobachten. Wesentlich für die Finanzierung der Teams war in beiden Umfragen bislang das Zusatzentgelt ZE 60 für die „Palliativmedizinische Komplexbehandlung“. Insgesamt wurde die Finanzierung überwiegend als schwierig betrachtet: nur 29% der Dienste gaben 2015 an, kostendeckend zu arbeiten.

Schlussfolgerung PMD in Bayern nehmen wichtige Aufgaben in der Betreuung von schwerkranken und sterbenden Patienten und ihrer Familien wahr. Nach eigener Einschätzung nimmt deren Akzeptanz innerhalb der Einrichtungen zu. Es bleibt zu hoffen, dass Neuregelungen wie die 2017 eingeführte neue OPS 8–98 h (spezialisierte palliativmedizinische Komplexbehandlung durch einen Palliativdienst), eine solide Finanzierung sicherstellen ohne die notwendige multiprofessionelle Zusammensetzung der PMD zu gefährden.

Abstract

Introduction Palliative care hospital support teams (HPCTs) provide inpatients from all departments palliative medical support. Seriously ill as well as dying patients, who are being treated in facilities that do not have their own palliative care unit, can benefit from these multi-professional teams just as much as patients who do not (yet) need to be admitted to a palliative care unit. At the end of 2015, 53 HPCTs, which were in accordance with the requirements established in the “Program for HPCTs” by the Bavarian Ministry of Health in 2009, had been approved in Bavaria.

Methods Using a questionnaire that was distributed by mail (2011) and an online survey (2015), we asked all Bavarian HPCTs, which had been approved up until then, to answer questions regarding their tasks, the level of acceptance within their hospital, the structure of their staff and funding. In addition to questions, which were rated on an applicability scale from 0 to 10, there was also room for written comments.

Results The return rate in 2011 was 77% (17 questionnaires) and 53% (28) in 2015. In sum, HPCTs were widely regarded as a suitable instrument for improving in-house palliative care (2011: median 7.8 (0–10) ±1.9, 2015: 7.2 (0–10) ±2.3; n.s.). The level of acceptance among the other departments of the hospital was assessed as being significantly higher in 2015 (7.2±2.3) than it was 4 years earlier (5.7±2.2; p<0.05). HPCTs cover various tasks, most commonly including “supportive conversations,” “accompaniment in the dying phase,” “pain therapy” and “discharge management.” However, a decline in multi-professionalism within the teams could be seen, especially in the fields of psychology/psycho-oncology and spiritual care (p<0.05). Both surveys showed that an essential aspect in funding the teams was the supplementary payment ZE 60 for “complex palliative medical treatments.” However, funding in general was predominantly reported as being quite difficult: only 29% of the HPCTs of 2015 indicated that all of their costs were covered.

Conclusion HPCTs in Bavaria take over important tasks in caring for seriously ill and dying patients and their families. According to their own appraisal, the level of acceptance within hospitals is improving. The hope is that new regulations, such as the new OPS 8–98 h (specialized complex palliative treatments provided by a HPCT), which was introduced in 2017, will solidify funding without jeopardizing the multi-professionalism that characterizes HPCTs.

Schlüsselwörter

Palliativdienst - multiprofessionell - Finanzierung - OPS 8–98 h

Key words

palliative care hospital support teams - multi-professional - funding - OPS 8–98 h

• Literatur

• 1 Higginson IJ, Evans CJ. What is the evidence that palliative care teams improve outcomes for cancer patients and their families?. Cancer J. 2010; 16: 423-435
• 2 Higginson IJ, Finlay I, Goodwin DM. et al. Do hospital-based palliative teams improve care for patients or families at the end of life?. J Pain Symptom Manage 2002; 23: 96-106
• 3 Centeno C, Lynch T, Garralda E. et al. Coverage and development of specialist palliative care services across the World Health Organization European Region (2005–2012): Results from a European Association for Palliative Care Task Force survey of 53 Countries. Palliat Med 30: 351-362
• 4 https://www.stmgp.bayern.de/wp-content/uploads/2016/03/krankenhausplan_2016.pdf#page=107
• 5 http//ops-icd-code.de/ops/code/8-98.html
• 6 Woitha K, Garralda E, Martin-Moreno JM. et al. Ranking of palliative care development in the countries of the European Union. J Pain Symptom Manage 2016; pii: S0885-3924(16)30141-5 DOI: 10.1016/j.jpainsymman.2016.03.008. [Epub ahead of print]
• 7 Radbruch L, Payne S. EAPC White Paper on standards and norms for hospice and PC: part 2. Eur J Palliat Care 2010; 17: 22-33
• 8 Hess S, Stiel S, Hofmann S. et al. Trends in specialized palliative care for non-cancer patients in Germany – data from the national hospice and palliative care evaluation (HOPE). Eur J Intern Med 2014; 25 (02) 187-192
• 9 Bausewein C. Finale Betreuung nicht nur für Krebspatienten. Deutsche Ärzteblatt 2007; 104: 2850-2852
• 10 Radbruch L, Andersohn F, Walker J. Faktencheck Gesundheit. Palliativversorgung –Modul 3- Überversorgung kurativ- Unterversorgung palliative? Analyse ausgewählter Behandlungen am Lebensende. Bertelsmann Stiftung 2015
• 11 Maeda I, Tsuneto S, Miyashita M. et al. Progressive development and enhancement of palliative care services in Japan: nationwide surveys of designated cancer care hospitals for three consecutive years. J Pain Symptom Manage 2014; 48: 364-373
• 12 Pantilat SZ, O’Riordan DL, Bruno KA. Two steps forward, one step back: changes in palliative care consultation services in California hospitals from 2007 to 2011. J Palliat Med 2014; 17: 1214-1220
• 13 Balboni T, Balboni M, Paulk ME. et al. Support of cancer patients' spiritual needs and associations with medical care costs at the end of life. Cancer 2011; 117: 5383-5391
• 14 Schneider W, Eichner U, Thoms S. et al. Zur Praxis von SAPV in Bayern: Wirksamkeit, Struktur-/prozesseffekte und ländliche Versorgung. Gesundheitswesen 2015; 77: 219-224
• 15 Strohscheer I, Verebes J, Samonigg H. Implementation of a palliative care team in an Austrian university hospital. Support Care Cancer 2006; 14: 795-801
• 16 Sasahara T, Watakabe A, Aruga E. et al. Assessment of reasons for referral and activities of hospital palliative care teams using a standard format: a multicenter 1000 case description. J Pain Symptom Manage 2014; 47: 579-587
• 17 Frick E, Riedner C, Fegg M. et al. A clinical interview assessing cancer patients’ spiritual needs and preferences. Eur J Cancer Care 2006; 15: 238-243
• 18 Martinuz M, Dürst AV, Faouzi M. et al. Do you want some spiritual care? Different rates of positive response to chaplains’ versus nurses’ offer. J Pastoral Care Counsel 2013; 67: 3
• 19 http://www.who.int/cancer/palliative/definition/en/