Abstract
Health care system in an urban community is complicated due to a variety of health care settings. This descriptive research aimed to analyze and synthesize policy recommendation regarding input, process, output, outcome and impact of palliative care system in Chiang Mai city of Chiang Mai province, Thailand. Subjects were patients with terminal illness and their family caregivers, health care team from university hospital, provincial hospital, a hospital of municipality, private hospitals and health promoting hospitals of Chiang Mai city, staff from Chiang Mai municipality and local administrative offices of Chiang Mai city, village health volunteers and key persons in the community of Chiang Mai city, Thailand. Methods of data collection compose of literature review, focus group discussion, in-depth interview, and group meeting. Guided questions for focus group discussion and in-depth interview were developed and tested for validity by experts. Data were summarized and categorized according to the objective the study. Results from analysis showed that: 1. Health workforce was insufficient for palliative care at the community, private, and local unit levels. Health workforce was limited in terms of capability of palliative care management. There was a lack of teamwork among health care personnel and other related personnel. There was no committee overseeing palliative care in private hospitals, sub-district health promoting hospitals, hospitals under local administrative organizations, and community hospitals. 2. There was a system for palliative care service in provincial and university hospitals. Nevertheless, there was no system or model of palliative care in hospitals under local administrative organizations and private hospitals, nor model for palliative care service at a community level. 3. COC link system was used for end-of-life patient referral from provincial hospitals to community hospitals and sub-district health promoting hospitals. However, university hospitals and private hospitals were not connected to such system. 4. Medical equipment and supplies, as well as health care technology were not sufficient for supporting end-of-life patients when living at home. 5. There were limitations in the allocation of budget for the management of end-of-life care after discharge due to the lack of personnel in private hospitals and hospitals under local administrative organizations, as well as the lack of budget for capacity development of palliative care team. 6. The university hospital had palliative care centers and wards operated under the committee. There were three nurses directly responsible for operation. The provincial hospital had committee, but palliative care nurses were also responsible for other routine tasks. There were no palliative care wards but there were beds set aside especially for end-of-life patients referred from other network hospitals. For private hospitals and the hospital under local administrative organizations, there were no systems for palliative care. As regards sub-district health promoting hospitals, there was no committee overseeing palliative care independent from long-term care committee. Moreover, the practice in community care was similar to other types of patient care, including chronic and bed-bound elderly care. 7. End-of-life patients under health care coverage for government employees could access palliative care at university and provincial hospitals. Palliative care patients under social security and universal health coverage could access palliative care at their registered university and provincial hospital. However, after discharge to urban community, the access to care and preparedness for palliative care were limited, particularly home care to allow end-of-life patients to spend the last moments of their lives as they wished. The lack of out-patient unit especially for end-of-life care caused these patients to receive care at the hospital based on their health coverage like other general patients, despite emergency. 8. End-of-life patients receiving services at university and provincial hospitals had relatively comprehensive and efficient services in terms of setting, equipment, personnel, and continuity of care from hospital to home. This was in contrast to those receiving care at private hospitals or hospitals under local administrative organizations where there was no policy for palliative care. Thus, these patients could not access such service, leading to inability to achieve end-of-life quality of life. The findings from analysis and literature review of palliative care in other countries have contributed to recommendations both in regard to the policies and service management, including the development of palliative care by establishing structure, health workforce planning, budget planning, pharmaceutical, equipment and supply support, building care capacity of personnel and networks, as well as improving service system for palliative care to respond to the needs of end-of-life patients and their caregivers in a concrete and a standardized manner.
