Palliative Project Vorarlberg: Report on a Multidisciplinary Development

) Palliative


Introduction
"In view of the demographic development with increasing aging of the population, major challenges for palliative care (PC) arise. The expansion of palliative care to non-oncologic chronic diseases and early integration will significantly increase the demands on palliative geriatrics. It is estimated that 69-82% of patients in higher-income countries need palliative care [1]. This report reflects 30 years of multiprofessional development of PC.
Vorarlberg is an Austrian province with 400,000 inhabitants. Nursing associations for outpatient care at home exist nationwide. Also in the nursing homes (52 for 96 communities) there are staff trained in PC everywhere (about 30%). In addition, there is a palliative care unit and a hospice with 16 beds each, which corresponds to the planning horizon of the Austrian Federal Institute for Health Care.

Education and Training
For 22 years, interdisciplinary palliative courses have been held at the Bildungshaus Batschuns with renowned international speakers, each lasting 15 days, with 773 participants to date, of whom 65% are nurses, 18% physicians and 17% other psychosocial professions. The participants also have to carry out an elaborate project work, which is then most moving on site. This has led to the development of a palliative crisis plan, which has been introduced in most homes for forward planning. In addition, topic-based PC workshops are held here regularly, such as on pain management, symptom control, death and grief [2].

Medical Coordination in the Nursing Home
Medical coordination in the nursing home was a particularly targeted project in 2014 and 2015, led by Frederic Fredersdorf. These projects showed improved resident and staff well-being. Medications were changed or used in a more targeted manner. The potential savings totaled € 40,000. Basic care should remain with the general practitioner, who has known the patients and their relatives for a long time. Nevertheless, a guardian is needed to monitor the availability of pain medication, to view new admissions and to ensure communication within the team. This task can be taken over by the community physician or another general practitioner after appropriate training. Increasingly, this coordination of exchange and a team building is performed by nursing [3]. The latter is closer to the residents and perceives more accordingly.

Places of Death
In Vorarlberg, 33% die at home, 20% in a nursing home, 40% in hospital, the rest in accidents. The wish to die at home or in familiar surroundings (nursing home) is 80%. The trend toward nursing homes will increase as hospitals increasingly outsource dying for cost reasons. On the other hand, with the current singualization, more people will be dependent on a nursing home [4].

Honorary Office
The Hospice Movement Vorarlberg has 8 full-time coordinators and provides about 250 volunteers. The primary goal of the hospice companions is to enable the dying person to live a dignified life to the end (i.e. life support), whether at home, in the hospital, or in a nursing home. To achieve this goal, the hospice movement focuses on the sick and dying person, but also on the relatives, with their wishes and needs, but also with their fear and helplessness -regardless of their social, religious and political status. The volunteers of the Hopsice movement do not provide nursing services.
In addition, there are still nursing associations throughout the country that are increasingly involved in palliative care, especially in palliative geriatrics. An increased focus of outpatient nursing on PC has recently become clearly noticeable.

Migration Background
Next challenge: Around 30% of the population in our state has a migration background. Their socio-cultural backgrounds deserve special attention. In a recent study from Aachen, a discrepancy between the professionals' own and others' perceptions of culturally sensitive interaction with clients stood out. Those who belonged to the group showed themselves to be grateful and satisfied. They placed value on empathy and openness. The professionals are still not very familiar with end-of-life rituals in different religions [5][6][7][8].