Palliative Care Public Health Programs with a WHO perspective Public Health Planning: Needs assessment, foundation measures, elements of Programs

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Palliative Care Public Health Programs with a WHO
perspective Public Health Planning Needs
assessment, foundation measures, elements of
Programs
OSI/WHOCC Introductory
lecture 3

• Xavier Gómez-Batiste MD, PhD
• Director, WHO Collaborating Center for Public
  Health Palliative Care Programs

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PUBLIC POLICY in PC
Training
Drugs
Services
Stjernsward, Ferris, Foley 2007
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From the rising tides to tsunamis

• Cancer, geriatrics, aids, chronic evolutive
  diseases

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Background 80s

• Eric Wilkes (Sheffield)
• Vittorio Ventafridda (Milano)
• Jan Stjernsward (WHO)
• Kathy Foley (OSI, NY)
• Palliative Care as a Public Health topic

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PCPHP objectives
- Coverage - Equity
- Accesibility
- Quality -
Satisfaction
-(Reference WHO)
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List of elements PC PH Programs Topics

• Foundation measures
• Context analysis and Needs assessment
• Target population
• Clear aims coverage, equity, quality
• Clear leadership and consensus with stakeholders
• Capacity building
• Defined model of care and intervention
• Measures Implementation of specialist services,
  and improvement of conventional services, models
  of organization in demographic scenarios,
  standards of services
• Opioids
• Legislation
• Standards
• Financing systems, budget
• Education, training, and research
• Advocacy
• Quality evaluation and improvement
• Combine in an action plan short, mid, long term,
  implementaion, reallocation, catalytic
• Systematic evaluation of results
• Indicators

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Does the written Palliative Care Plan include? 0 1 2 3
Aims, principles, mission, and vision
Assessment of needs cancer and no cancer
Goals and measurable short, medium and long-term objectives
Plan of action to meet the objectives based on evidence, affordability, coverage, and equity
Integration of activities to existing chronic disease and other related programmes (Cancer, Geriatrics, Chronic, Health Plan)
Opioid availability and accessibility (Decree, Order, or Law)
Standards of specialist services
Directory of palliative care services
Definition of the model of care and intervention
Definition of the model(s) of organisation (in settings or districts)
Standards of general services (primary care, other)
Financing model
Specific budget
Law, Decree, or Order
Education and training Plan
Priority research areas to support the implementation of the plan
Development of an information system for monitoring and evaluating the priorities
Clear process and outcome indicators for monitoring an evaluation
Budget / Costing of the action plan and resources needed for its implementation
Elements for self-assessment
ICO DiR. Centre Collaborador de lOMS per
Programes Públics de Cures Palliatives
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Components of PCPHPs

• Clear leadership and aims
• Needs and Context Assessment
• Clear model of care and intervention and
  definition of the target patients
• General measures in conventional services
  (Specially Primary Care)
• Specialist services in settings
• Sectorised networks with coordination,
  continuing and emergency care
• Education and training at all levels
• Research Planning
• Availability and accessibility of opioids and
  essential drugs
• Legislation, standards, budget and models of
  funding and purchasing
• Evaluation and improvement of quality
• Evaluation of results, indicators
• Action plans at short, mid and long term
• Advocacy
• Social implication volunteers, social
  involvement in the cultural, social and ethical
  debates around the end of life

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Principles of a PHPCP

• Good care as a human right
• Model of care and inervention based on patients
  and families needs
• Model of organisation based on a competent
  interdisciplinary team, with clinical ethics,
  case management, and advance care planning
• Based on population needs and adapted to
  demography and settings in the Health Care System
• Community oriented
• Coverage, equity, access and quality to every
  patient in need of it
• Quality effectiveness, efficiency,
  satisfaction, continuity, sustainability
• Systematic evaluation of results,
  accountability, evidence
• Social interaction
• Added values Compassion, interdisciplinarity

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Foundation measures

• Previous measures consensus, decission-makers,
  advocacy, identifying leaders
• Context analisys, Needs assessment , and Basal
  studies
• Formal plan designed and approved
• Clear Legislation and standards
• Opioid availability and accesibility
• Leadership at the DoH
• Capacity building
• Building reference teams
• Training oriented to capacity building and
  references of key services
• Identifying alliances, barriers and difficulties

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Initial key processes

• Clear ideas
• Clear definition of clients and services
• Leadership
• Catalythic implementation or investment
• Training oriented to build references
• References / experiences
• Institutional support

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Types of processes (always combined)

• Catalythic implementation or investment
• Implementation of new specific resources
• Adaptation of conventional resources (general
  measures)
• Reallocation of resources (reconversion)

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Needs assessment

• Context analysis
• Quantitative
• Qualitative

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Context analysis of Public Health Palliative
Care Programs

• Global country profile (Population, ageing, life
  expectancy, GBP, development)
• Characteristics of the Health care system and
  care settings
• Quantitative needs assessment Demographic and
  general characteristics mortality and prevalence
  of chronic evolutive diseases,
• Basal surveys / studies
• Background previous initiatives
• Mapping the existing services and resources
• Qualitative analysis
• Identification of resistances, barriers, and
  possible alliances

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Context analysis

• Populational data
• Demographic Population, life expectancy, ageing,
  
• Social awareness, family rol, careers
• Economical GDP
• Cultural, religious,
• Political
• The Health Care System resources, funding,
  managerial, academic, research
• Leaders professional, social,
• NGOs
• Quantitative
• Qualitative

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Basal studies

• Select easy basal surveys or studies
• Relevant
• Easy to measure
• Easy to change
• Easy to retrieve and monitorise
• Examples
• Pain prevalence and control
• Use of essential opioids
• Use of resources by termnal patients last month
  of life emergencies, hospitals,
• Focus group of professionals

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The populational perspective- Mortality-
Prevalence (population)- Prevalence by settings
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McNamara, 2006 Mortality
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Mortality, Prevalence, and Estimation of direct
coverage per milion habitants in Spain () ()
Global mortality 8950 persons / milion () 30
direct coverage and 30 flexible interventions



Source Modifified from SECPAL, Informe Mº
Sanidad, 2007
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Every year, in a district of 200.000 h in Spain

• 1.800 persons will die
• 1.450 (75) of them by chronic evolutive diseases
  (25 by cancer, 35-45 by other chronic diseases)
• There will be around 450 prevalent terminal
  patients living
• There will be 340 elderly with pluripathology and
  dependency
• There will be 300 elderly with dementia
• 1.500 elderly will live in Nursing homes or homes
  for the elderly

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Catalonia Mortality / prevalence

• Mortality
• Global 60.000
• Cancer 16.000
• Noncancer chronic 29.000
• Total chronic conditions 45.000
• Prevalence terminal patients
• Cancer 4.000 (mean survl 3 months)
• Other conditions 18.000 (mean sl 9 months)
• Total 22.000

Estimation based in McNamara, 2006
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• 60-75
  of population will die by a chronic evolutive
  disease

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The clinical / individual perspective
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NHS GPs Gold standards prognostic indicators
guidance
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The model of care any PC Program
and/or Service must be based in an impecable
model of care for patients and families
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Pal Care organisational concepts

• Model of needs (individual and populations)
• Model of care and intervention
• Model of micro-organisation
• Model of organisation of services
• Comprehensive district networks
• National/regional perspectives

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Conceptual Transitions

• From Terminal disease to Advanced progressive
  illnesses
• From Prognosis of days weeks, lt 6 months to
  Limited life prognosis
• From Progressive evolution to Evolutive Crisis
• From Curative/paliative dychotomy to Shared
  synchronic care
• Specific and palliative treatment can coexist
• From rigid to flexible intervention
• From prognosis to complexity as criteria of
  intervention
• From response to crisis to advance care
  planning
• From palliative care services to palliative
  measures in all settings

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Implementing Palliative Care Specialist Services
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Specific Resources / settings
Hospices
Acute Hospitals
Mid term and long term, RHB, (Sociohealth
Centers)
Nursing homes
Units Support teams Outps / Day care
Community / home
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Types of services and Levels of complexity
Reference complexity training research
Complete teams Units
Basic suport teams (home, hospitals,
comprehensive)
Transitional measures individual Specialist
nurses or consultants
General measures in conventional Services
(Hospitals, Primary care, Nursing homes,
Emergencies, etc)
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Standards of specific resources

• 1 support team at home / 100.000 h
• 80-100 beds / milion habitants
• (10-20 acute, 40-60 mid term, 20-30
  nursing homes)
• 20-25 full time doctors / milion habitants
• 1 team available in every hospital (units in
  teaching)
• Models of organisation adapted to demographic
  scenarios metropolitans, intermediate, or small
  sectors lt 100.000
• Models in specific resources (cancer institutes,
  nursing homes, etc)

XGB 2005, WHOCC, 2008
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Implementation strategies of servicesinitial
phases

• To create a nucleus of solid experiences
• Combine different types home, hospital, cancer,
  geriatric,.
• Based in feasibility active leaders,
  institutional comittment, .
• Cathalitic measures support teams, transitional,
  
• Define services before starting implementation

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Improving the quality of palliative care in all
settings
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Boundaries other services
Hospices
Acute Hospitals
Mid term and long term, RHB, Centers
Nursing homes
Conventional services Primary care Nursing Homes
Primary care
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General measures in conventional services

• Targets Hospitals (oncology, internal medicine,
  geriatrics, emergencies), mid-term and long-term
  resources (nursing homes), primary care teams
• Training policies, sessions, formal training,
  local references
• Change of organisation teamwork, presence and
  support of the family
• Liaison of resources

General measures cannot substitute the need of
specialist palliative care services
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AIM PRIMARY CARE HOSPITAL CARE
Improving the capacity of professionals Basic and intermediate training in Palliative Care Basic and intermediate training in Palliative Care
Identification of patients in need (PIG from the Gold Standards Framework) Registries Identification of patients in need Use of GSF Clinical charts with registries (symptoms checklist, etc), Assessment Tools, etc Identification of patients in need Use of GSF Clinical charts with registries (symptoms checklist, etc), Assessment Tools, etc
Internal and external reference professionals Specific reference professionals (Doctors, nurses, others) with advanced training and dedication to palliative care Specific reference professionals (Doctors, nurses, others) with advanced training and dedication to palliative care
Improving accesibility of patients and families Promotion home care Phone support programs Access to rapid consultation Direct access to palliative care beds Information Free access of families to Hospital Promotion home care Phone support programs Access to rapid consultation Direct access to palliative care beds Information Free access of families to Hospital
Improving continuing care and emergency care Advance care planning, continuing care, 24h phone access, Actitud preventiva, Teléfonos 24h, tailored emergency care, Direct access to PC beds Advance care planning, continuing care, 24h phone access, Actitud preventiva, Teléfonos 24h, tailored emergency care, Direct access to PC beds
Specific times and places for patients and families Specific times for advanced patients and families Specific outpatients times for advanced patients and families Advanced terminal patients agrupated in units
Improving family care Education and support for careers Prevention and treatment of complicated bereavement Education and support for careers Prevention and treatment of complicated bereavement
Promotion of Team work Team meetings Team support and prevention burnout Team meetings Team support and prevention burnout
Promotion of privacy and dignity Individual bedrooms
Assessing and Improving the quality of care Policies pain, last days, etc EoL inserted in the quality assessment Policies pain, last days, etc EoL inserted in the quality assessment
Coordination and integrated care with Specialist Palliative Care Services Criteria of intervention and shared care with PCSs Nurses able to demand Criteria of intervention and shared care with PCSs Nurses able to demand
Other
Palliative Care Measures in General Services
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Models of organisation in demographic and
geographic scenarios
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Demographic and setting scenarios

• Settings

• Demographic

• Primary/community care
• Nursing homes
• Longterm / intermediate
• Hospitals district general, university
• Cancer Institutes

• Rural
• Urban
• Rural-urban
• Metropolitan

Adapt the organisation to needs and contexts
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District models
Demographic area Demography (citizens N) Examples Main conventional resources Proposed model of PC services
Metropolitan 500,000 Areas of Metropolitan Barcelona (4 Central, North, South University reference General Hospitals SHCs Reference PCS (PCU, OPC, HST and training and research) at the University Hospitals 2-3 SHCs with Units
Urban 200,000 3 urban areas Girona, Tarragona, Lleida University General Hospital 1-3 SHCs HST OPC in Hospital PCU in Hospital and/or SHC
Rural-Urban 80 150,000 16 Districts Osona, Bages, Empordà District General Hospital SHC 1 HST, 1 HCST 1 PCU in Hospital or SHC Preferably as comprehensive system
Rural lt 50,000 High Pyrenees Community Hospital SHC Comprehensive system with a HST/HCST mixed acting in all levelsNo PCU needed
Common in all districts Primary Care Centers every 20,000 habitants Nursing homes Primary Care Centers every 20,000 habitants Nursing homes Primary Care Centers every 20,000 habitants Nursing homes 1 HCST/district / 100,000 hab 1 HST in every hospital
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Training strategies

• Aims
• Short / mid / long term
• Targets
• Levels
• Methods
• Faculty
• Short term oriented to create a nucleus of
  reference leaders and services

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1-2 years Long term gt 5 years
Aim Build up core nucleus of reference services Training coverage for all professionals
Targets Clinical and organisational leaders of reference services All professionals at the appropiate level
Methods Stages, visits, mentorship, tutorship, modelling Pregraduate, Intermediate Specialty
Faculty National international Local leaders from reference services
Different aims, methods, and targets for training
at short or long term
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Research strategies

• Aims
• Short / mid / long term
• Levels
• Methods
• Faculty

Short-term
oriented to show results (to different
targets), describe experience, generate evidence,
and promote development
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The legislation of palliative care includes

• The insertion of palliative care in the existing
  policies and financing models (Global or specific
  Health plans for Cancer, Geriatric, Aids, and
  other chronic conditions)
• The formal approval and recognition of the
  National Plan
• Basic legislation (Law, decree, or ministerial
  order) that could be generic
• Specific changes to assure opioid availability
• Other related legislations advance directives
  and autonomy, rights of patients, ethical
  committees, support (funding or changes in labour
  legislation) for careers

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Legislation and standards

• National Plan
• General or definition law or decret (generic)
• Financing systems (specific for services)
• Opioid and essential medicines availability (the
  simplest, the best)
• Standards of services (description)
• The simplest, the best

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Financing models

• Insert in the common financing model
• Combine structure, activity, results, and
  quality
• Concept of cathalitic investment
• Reallocation
• Estimate expected savings
• The simplest, the best

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Costs and savings
Type of service Calculation Subtotal / type Estimated savings Euros
HCST 229,000 x 72 services 16,488,000 (31) TOTAL SAVINGS 3,000 / patient x 23,100 69,300,000
HST 279,000 x 49 services 13,671,000 (26) TOTAL SAVINGS 3,000 / patient x 23,100 69,300,000
PCU 96 x 209,000 stays 20,064,000 (38) TOTAL SAVINGS 3,000 / patient x 23,100 69,300,000
OUTPAT 155 x 9,000 processes 1,395,000 (3) TOTAL SAVINGS 3,000 / patient x 23,100 69,300,000
PST 190,000 x 5 services 950,000 (2) TOTAL SAVINGS 3,000 / patient x 23,100 69,300,000
TOTAL TOTAL COSTS 52,568,000/ year NET SAVINGS 16,732,000 / year
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Basic Quantitative indicators for PCPHP

• Structure
• Formal program at the DoH (with all of the
  elements)
• Clear leadership
• Specialist resources services, units, teams,
  beds
• Nº Professionals
• Legislation, opioids, standards, financing
  model, specific budget, indicators
• Process
• Care Activity, care processes
• Nº patients (cancer / noncancer) reaching
  specialist services
• Activities training / research / quality
  improvement
• Measures in conventional services
• Outcomes / Results
• Direct coverage cancer and non cancer ( of
  total patients attended by specialist teams)
• Quantitative indicators of services Beds /
  milion, Services / population, geographical
  coverage, etc
• Opioid Consumption (in morphine DDD)
• Outputs length stay, length intervention,
  place of death, etc
• Clinical outcomes of pc services Efectiveness,
  Satisfaction
• Organizational outcomes Efficiency / use /
  cost individual or global
• Economical outcomes global cost, global
  savings

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Does the written Palliative Care Plan include? 0 1 2 3
Aims, principles, mission, and vision
Assessment of needs cancer and no cancer
Goals and measurable short, medium and long-term objectives
Plan of action to meet the objectives based on evidence, affordability, coverage, and equity
Integration of activities to existing chronic disease and other related programmes (Cancer, Geriatrics, Chronic, Health Plan)
Opioid availability and accessibility (Decree, Order, or Law)
Standards of specialist services
Directory of palliative care services
Definition of the model of care and intervention
Definition of the model(s) of organisation (in settings or districts)
Standards of general services (primary care, other)
Financing model
Specific budget
Law, Decree, or Order
Education and training Plan
Priority research areas to support the implementation of the plan
Development of an information system for monitoring and evaluating the priorities
Clear process and outcome indicators for monitoring an evaluation
Budget / Costing of the action plan and resources needed for its implementation
Elements for self-assessment
ICO DiR. Centre Collaborador de lOMS per
Programes Públics de Cures Palliatives
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Advocacy

• Select targets politicians, policymakers,
  managers, funders, academics, NGOs, public
  awareness, media, ..
• Select messages (adapted to targets)
  effectiveness, efficiency, satisfaction, ethical
  issues, values, innovation, stories, ..
• Select key results at short / mid / long times
• Prevent and treat conflicts, threats,
  misunderstandings

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The Catalonia WHO Demonstration Project on
Palliative Care implementation results at 20
yearsCatalan Department of Health WHO Cancer
Unit(1990-2010)
Gómez-Batiste X et al, In press
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- External evaluation of indicators (Suñol et al,
2008) - SWOT nominal group of health-care
professionals (Gomez-Batiste et al, Med Pal,
2007) - Focal group of relatives (Brugulat et al,
2008) - Benchmark process (2008) (Gomez-Batiste
et al, JPM, 2010) - Efficiency (Serra-Prat et al
Pall Med 2002 Gomez-Batiste et al J Pain
Symptom Manage 2006) - Effectiveness
(Gomez-Batiste et al, J Pain Symptom Manage
2010) - Satisfaction of patients and their
relatives (Survey CatSalut, 2008)
Evaluations of the Catalonia WHO Demonstration
Project Methods
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Quantitative analisys JPSM, 2007
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Care Resources 2009 (Total 237)
HSTs 49
PCUs 60
Outps 50
PADES 74
Other 10
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Specialist services Specialist services Specialist services Additional processes / year Other relevant outputs
CARE SERVICES Home Care Support Teams 72 1 / 110,000 citizens Processes 13,000 Cancer / non-cancer 49 / 51 Mean age 76 Death at home 68 Duration of intervention 80 days
CARE SERVICES PCUs in Socio-Health Centers PCUs 28 Beds 383 Processes 6,300 Total PCUs 60 Total beds 742 (110 beds / million) Processes 10,450 Mean age 74 Length of stay 20.3 days Mortality 72.9
CARE SERVICES PCUs in Nursing Homes PCUs 27 Beds 319 Processes 3,150 Total PCUs 60 Total beds 742 (110 beds / million) Processes 10,450 Mean age 82 Length of stay 35 days Mortality 85
CARE SERVICES PCUs in Acute Bed Hospitals PCUs 5 Processes 1,000 Total PCUs 60 Total beds 742 (110 beds / million) Processes 10,450 Cancer 80 Mean age 61 Length of stay 11d Mortality 55
CARE SERVICES Hospital Support Teams 49 Processes 10,700 Cancer / non-cancer 60 / 40 Mean Age 73 Length of stay 10 days
CARE SERVICES Psychosocial Support Teams 6 Processes 1,500 Cancer 80
CARE SERVICES Outpatient Clinics 50 Processes 9,000 Cancer / non-cancer 60 / 40
TOTAL CARE SERVICES 237 TOTAL CARE SERVICES 237 TOTAL CARE PROCESSES 46,200 (2 / patient) TOTAL CARE PROCESSES 46,200 (2 / patient) TOTAL CARE PROCESSES 46,200 (2 / patient)
Other Services (4) Other Services (4) Team at the Department of Health Education and Training Unit (ICO) The Qualy EoL Observatory / WHOCC (ICO) Clinical Research Team (ICO) Team at the Department of Health Education and Training Unit (ICO) The Qualy EoL Observatory / WHOCC (ICO) Clinical Research Team (ICO) Team at the Department of Health Education and Training Unit (ICO) The Qualy EoL Observatory / WHOCC (ICO) Clinical Research Team (ICO)
Specialist Services 241 Full time Doctors 240 (32.8 / million) Total Patients 23,100 Cancer 12,100 (52) Non-cancer 11,000 (48) Coverage Cancer 73.3 Non-cancer 31 -58 Geographic area cover 100 Specialist Services 241 Full time Doctors 240 (32.8 / million) Total Patients 23,100 Cancer 12,100 (52) Non-cancer 11,000 (48) Coverage Cancer 73.3 Non-cancer 31 -58 Geographic area cover 100 Specialist Services 241 Full time Doctors 240 (32.8 / million) Total Patients 23,100 Cancer 12,100 (52) Non-cancer 11,000 (48) Coverage Cancer 73.3 Non-cancer 31 -58 Geographic area cover 100 Specialist Services 241 Full time Doctors 240 (32.8 / million) Total Patients 23,100 Cancer 12,100 (52) Non-cancer 11,000 (48) Coverage Cancer 73.3 Non-cancer 31 -58 Geographic area cover 100 Specialist Services 241 Full time Doctors 240 (32.8 / million) Total Patients 23,100 Cancer 12,100 (52) Non-cancer 11,000 (48) Coverage Cancer 73.3 Non-cancer 31 -58 Geographic area cover 100
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Structure Process Outcomes
Multidisciplinary team Advanced training and competencies Office Documentation Protocols/ policies Criteria for intervention Multidimensional evaluation of patients needs Multidimensional Therapeutic Plans for patients Identifying and supporting primary career Advance care planning Register and Monitorising needs, demands, expectations Evaluation of results Case management and Continuing care Coordination Bereavement Effectiveness Cost Efficiency Satisfaction patients, families, services
Basic Indicators of PCS
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Catalonia 2010

• Coverage (geographic) 100
• Coverage cancer 73
• Coverage non cancer 40-56 ()
• Proportion cancer/noncancer 50
• Nº Dispositives 231
• Beds/milion 101.6
• Full time doctors 220 (30 / milion)

() McNamara, 2006
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Populational impact 1990-2005

• More than 250.000 patients attended
• More than 900.000 persons (14 of population) in
  direct contact with palliative care services

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Efficiency of PCSs

• Multicenter longitudinal study on the use of
  resources by cancer patients attended by PCSs
• Comparison with previous use without PCSs
• 171 teams / 395 patients

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Qualitative analisys results

• Weak Points
• Low coverage noncancer, inequity variability,
  sectors and services (specific and conventional)
• Difficulties in access and continuing care
  (weekends)
• Late intervention
• Evaluation, emotional support, bereavement,
• Professionals low income, support, and academic
  recognition
• Financing model and complexity
• Research and evidence

• Strong Points
• Region of 7.3 milion habs
• High coverage cancer, relative noncancer, and
  geographical
• High coverage home care cancer and non cancer
• Professionals committment
• Public Health Planning
• Insertion in the HCS, diversity, models
• Effectiveness, efficiency, satisfaction

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Types of processes (always combined)

• Catalythic implementation or investment
• Implementation of new specific resources
• Adaptation of conventional resources (general
  measures)
• Reallocation of resources (reconversion)

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Common Resistances

• We are already doing so...
• There is no need of specific services, we will do
  a lot of training....
• Palliative care services will be seen as places
  to die....
• This is good for England, USA, or Catalonia, but
  it will not work in....

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Evolutive tendencies

• From hospice to palliative care to end of life
  care
• From services vision to populational vision
• From cancer to other patients, early and flexible
  interventions
• From opinion into experience and into evidence
• From problems to opportunities of improvement

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Expected results

• Enormous improvement of the quality of care
• Effectiveness
• Efficiency saving more than the structural cost
• Satisfaction patients, families, professionals

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Conceptual Transitions

• From Terminal disease to Advanced progressive
  illnesses
• From Prognosis of days weeks, lt 6 months to
  Limited life prognosis
• From Progressive evolution to Evolutive Crisis
• From Curative/paliative dychotomy to Shared
  synchronic care
• Specific and palliative treatment can coexist
• From rigid to flexible intervention
• From prognosis to complexity as criteria of
  intervention
• From response to crisis to advance care
  planning
• From palliative care services to palliative
  measures in all settings

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Conclusions 15 years

• PC must be inserted in the National Health Care
  System and adapted to settings and districts
• PC development is effective, efficient, and
  generates high satisfaction
• There are evolutive tendencies (noncancer, early
  intervention)
• The governamental committment accelerates the
  process

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• Start low,
• and go slow,
• but do so!!!

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The Parliament of Catalonia

• Organic Law 6/2006 of the 19th July, on the
  Reform of the Statute of Autonomy of Catalonia
• ARTICLE 20. THE RIGHT TO UNDERGO THE PROCESS OF
  DEATH WITH DIGNITY
• 1. Each individual has the right to receive
  appropriate treatment of pain and complete
  palliative attention and to undergo the process
  of death with dignity.
• 2. Each individual has the right to express his
  or her will in advance in order to record
  instructions regarding any medical treatment or
  intervention that he or she may undergo. These
  instructions must be respected especially by
  medical staff, in accordance with the terms
  established by the law, if the individual is not
  able to express his or her wishes personally.

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Access to Pain relief and Palliative Care as a
Human Right, Human Rights Wacht
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Picasso Science and Charity, Barcelona, 1917