Abstract
Introduction: Most patients with incurable diseases prefer to spend their treasured time in home settings. As pain is the most frequent symptom, often requiring opioid analgesics, it is essential that outpatient medical services are supported by policies that allow managing patients’ conditions at home. This paper aims to show how over-restrictive regulations/policies can impact patients’ ability to access pain management and hamper the development of home-based palliative care services.
Methods: To evaluate the influence of strict regulations on pain management and their impact on home-based palliative care services, on one hand the opioid legislation and policy documents were reviewed and on the other opioid consumption reports, data on mortality and provided palliative care services, and data from the patient survey were analyzed.
Results: The palliative care program states that only incurable patients who are at the end of their lives and need home-based support can benefit from the program. Additionally, the physician must be convinced that the diagnosis is correct and that the estimated life expectancy is no more than 3-6 months (duration of benefiting from the program). Consequently, fearing the penalties, physicians mostly include patients in the program, when apparent signs of death are present. Therefore, patients have to be hospitalized, to receive care. As a result, the number of provided home based services has decreased more than half and its’ ratio to inpatient services is 1:4.
Simultaneously, the legislation allows prescribing opioids only to terminally ill patients, for whom no other treatment options are available. Before being prescribed morphine, about 94% of the terminal patients experienced moderate to severe pain. 75% experienced severe pain for 1 month and more. Yet, opioids were prescribed with substantial delay in most cases (61-70%). In 45%, morphine was first prescribed by palliative care physicians available only at inpatient units.
Conclusion: Strict opioid policies negatively impact pain management in palliative care patients. Even been incurable, most patients cannot receive appropriate pain treatment, until they reach the “end-of-life” stage, or receive such treatment in inpatient settings. Such an approach ignores the possibility of improving the quality of life for patients in their home setting.