A. DYING, PALLIATIVE CARE
Palliative care as a separate discipline is not fully utilized and available in the Czech Republic. Recently, however, there has been development. Now it is more discussed among experts.
The goal of palliative care is a dignified and quality life to its end in spite of incurable illness, and alleviating pain with the participation and support of close people.
At present, in the Czech Republic is specialized palliative care provided:
- in the home environment (mobile home hospice care)
- in bed care facilities exclusively dedicated to palliative care = hospice
- in palliative care sections within hospitals (now only two in the Czech Republic, but the tendency is to create more such sections)
However, basic palliative care is part of routine care in all health and social facilities. Such facilities typically follow the standards of patient care at the terminal stage.
The hospice care in Czech republic
In the Czech Republic there are currently 18 facilities providing specialized hospice care. There is a growing number of agencies providing home hospice care.
A hospice is a facility that guarantees the patient the certainty of being dignified, not lonely and not suffering from pain. It is intended for patients who are at the terminal stage of an incurable disease.
The patients are usually in single rooms where it is possible to accommodate one close person throughout the stay. Other close persons may visit the patient at any time and for an unlimited period. The daily regime is completely subordinate to the wishes and needs of the patient. The patient is allowed to have all their personal belongings, they can wear any of their clothes.
The stay is covered by a health insurance company, the patient is partially involved (about 10%). Any insured is entitled to this care, it depends only on the free capacity of the facility. Among other information, the application must provide a report on the current state of health of the patient, where his doctor also confirms that the patient has unsuccessfully used all available treatment methods, therefore the illness cannot be cured. However, the quality of life can be improved with the support therapy.
Some hospice facilities also offer other services:
- respite stay – relief service that help families with long-term care of an incurable person, the stay can be weeks
- family and close people care even after death of the patient, they can contact hospice staff to provide them friendly, psychological and spiritual help and support
1/ Paliativní medicína. Available from: https://www.paliativnimedicina.cz/paliativni-pece-v-cr-2016-situacni-analyza/ (2018-02-14)
2/Historie a současnost paliativní medicíny. http://www.umirani.cz/clanky/historie-a-soucasnost-paliativni-pece-v-cesku (2018-02-14)
3/Hospice v ČR. Available from: http://asociacehospicu.cz/hospice-v-cr/
4/Umírání. Available from: http://www.umirani.cz/poradna/co-je-a-neni-eutanazie (2018-02-14)
B. EUTHANASIA AND DNR
Euthanasia is not legal in the Czech Republic, now it is not possible to do it under any circumstances. Discussions about its legalization are repeatedly presented in the media, public opinion is not entirely unified. The biggest debate is about the possibilities of abuse and about possible forms of euthanasia.
DNR (Do not resuscitate) is treated as follows: if the patient asks for it during his active life, it should be respected. The wish should be in a written form with verified signatures and should also be recorded in the patient’s documentation. The wish cannot be respected for a person under the age of 18 and for persons with limited legal capacity.
In general, the indication for resuscitation is entirely on the decision and the responsibility of the doctor. His duty is to follow accepted and recommended rules with respect to the individuality of the patient.
C. DEATH AND AUTOPSY
In the Czech Republic, death is a topic that is partly tabooed, many Czechs are having problems talking about death.
Human death, burial, dissection, and related topics are governed by legal standards.
Any person living in the Czech Republic has an obligation to notify authorities about finding a dead body. It is communicated to the emergency call line 112, the dispatcher sends a coroner’s medical service to the place. After the examination, he confirms or disproves death. He has subsequently the obligation to write the Letter of Examination of the Deceased, marks the body, contacts the family or a close person. If it is not possible, the Police of the Czech Republic is called. The coroner also decides whether an autopsy will be done. If an autopsy is not indicated by the coroner, then the deceased person may be handed over to a funeral service that can be freely chosen by the relatives.
The funeral is possible in the Czech Republic in two ways:
- by placing the remains of the body in a coffin and then into a grave or a tomb
- by incinerating the body’s remains
In earlier times, placing the remains of the body into graves and tombs was done almost exclusively. At present, the cremation is used more often and the urn (a vessel with the ashes of the deceased person) is stored within a cemetery.
The bereaved should provide the body of the deceased person within 7 days. The funeral is covered by the family, or it is paid from the estate of the deceased. If there is no one who would set up and pay the funeral, it is the duty of the municipality in which the deceased was found.
If death occurs in a health care facility, the procedure is usually practiced according to the appropriate standard of the facility. Death must always be reported by a doctor and he also fills the Letter of Examination of the Deceased and decides whether an autopsy should be done. Always a doctor informs the family of the deceased (it is not a nurse’s competence). The doctor may also contact the family at a time when the patient’s death is expected, so that the closest people can say good-bye to the dying patient. Upon the request of a patient or family, it is possible to invite a priest.
Obligations of a healthcare professional at the time of death:
- carry out hygienic cleansing of the deceased, take off jewellery and dental prosthesis, remove bandages
- the removal of cannulas and catheters depends on the practice of the department and the doctor’s regulation (also depending on the circumstances of the patient’s death)
- then the nurse flattens the body of the deceased into a horizontal position, pushes his eyes, ties up his chin, adjusts his facial expression
- the body must be marked to avoid confusion; each facility has different methods of marking (most often the body is marked with a sticker on the limbs or by attaching a card to the limbs of the deceased; some facilities mark the body also on the chest)
- after these necessary actions, the body of the deceased is covered and taken to a separate room where it always stays at least 2 hours and then it is handed over to a funeral service or to a pathology department
- nurse has obligation to document all the patient´s belongings, especially valuable personal items
- the documentation of the patient’s belongings is always carried out with participation of two medical workers who confirm its correctness by their signatures
A doctor who confirms the death of the patient decides about the need of an autopsy.
Based on the circumstances, the autopsy can be:
- pathological-anatomical; the purpose is to identify basic and other diseases of the deceased; to identify their complications to verify the diagnosis and the treatment; it is performed when the patient died in a healthcare facility
- a medical autopsy is performed to detect and explain deaths of people who have died outside healthcare facilities by a sudden, unexpected or violent death or when there is a suspicion of a suicide
- judicial autopsy is done if death was apparently caused by a criminal offense
- anatomical autopsy is done for purposes of science, research or teaching in the field of health care; the person must express a written consent in his life, otherwise there is an automatic disagreement with this type of autopsy
1/ Pohřebnictví. Available from: http://www.pracepropravniky.cz/zakony/zakon-o-pohrebnictvi (2018-02-14)
2/ Zákon o pohřebnictví. Available from: http://www.sagit.cz/info/sb17193 (2018-02-14)
3/ Pitva. Available from: https://cs.wikipedia.org/wiki/Pitva (2018-02-14)
4/ Available from: http://www.uslhk.cz/pro-verejnost.htm (2018-02-14)
D. PREGNANCY AND CHILDBIRTH
In Czech Republic a routine screening is done for every pregnant woman, to eliminate health complications regarding both the mother and the children. Care of a pregnant woman is provided by ambulatory gynaecologists.
Up to 36th week of pregnancy the examinations are carried out every 4 to 6 weeks and they include:
- interview, assessment of weight gain of a woman, measurement of blood pressure, urinalysis, vaginal examination of a woman, measurement of the uterus
- between the 24th and 28th week, the OGTT test is carried out
- between the 27th and 28th week, blood group and Rh factor are examined
- between the 27th and 32nd week of pregnancy, haematological examination of blood and serological examination of blood for the presence of infectious diseases (syphilis, HIV, hepatitis B) are carried out
- between the 35th and 38th week, the cervical smear for the presence of streptococci is investigated
- ultrasound screening reveals possible birth defects, determining the size of the foetus, placing of the placenta, determining the date of delivery:
between 11th and 14th week
between 20th and 22nd week
between 30th and 32nd week
- biochemical screening focuses on the possibility of congenital developmental defects:
between 12th to 14th week
between 16th to 17th week
- if any abnormality is found, the pregnant woman is sent for a consultation at the department of genetics, where further examination can be carried out (amniotic fluid sampling, placental test, chorionic villus removal, umbilical cord blood collection…)
- currently, mothers are increasingly using the non-invasive option of examining the foetus from the mother’s blood; this option is paid by the patient, the cost is around CZK 25 000 (980 €), the tests offer recognition of a wide range of developmental defects
From the 37th week until the scheduled delivery date:
- examinations are performed once a week and include interview, vaginal examination, weight control, blood pressure control, urine control, and KTG (cardiotocogram)
From the scheduled delivery date:
- examinations of the pregnant woman are taken over by the chosen hospital, where a doctor plans the care of the pregnant woman
Selection of facility of childbirth
The choice of a maternity hospital is completely free in the Czech Republic, and in addition to standard care, every facility can offer other benefits and alternative birth management options. In some maternity hospitals it is required to register in an early stage of pregnancy. The birth of a child who is expected to have complications or premature birth is usually performed in larger healthcare facilities specializing in neonatal care (so-called neonatal centres).
In the Czech Republic, it is common for a woman to undergo a prenatal course during her pregnancy that prepares a woman for pregnancy, childbirth and puerperium, and prepares her for baby care. Some of the courses also include pregnancy swimming, yoga etc. These courses usually take place at the maternity hospital, where the woman simultaneously learns about the environment.
The woman has the right to prepare a so-called birth plan, which in writing expresses the ideas and wishes of the expectant mothers about the process of childbirth. However, the woman should consider whether these wishes are real and allowable. The most common wishes of women are usually: refusal to perform enema, rejection of drugs that support uterine contractions, rejection of episiotomy, wishes concerning the position in which the woman wants to give birth, the possibility of spinal analgesia etc.
To childbirth, a woman can take a close relative, usually her husband, sister, friend, or sometimes dula (whose task is to help the woman meet the needs during childbirth).
The woman usually comes to the hospital when she has regular contractions or her foetal water has drained. The woman is examined by a doctor who decides whether it really is a childbirth.
Subsequently, the woman is placed in the room where she spends her first period of labour, or if the room is equipped, whole time of the childbirth. The woman can take advantage of activities helping the childbirth, such as showering, bathing in warm water, rehabilitation balls, etc. According to the patient’s wish, epidural anaesthesia can be performed, or pain is alleviated in other ways (non-pharmacological, analgesic…). All the time, the woman is regularly checked by a midwife or a doctor, and the baby’s heart activity is monitored.
The prenatal preparation is performed by a midwife, it involves the application of an enema, it is also possible to shave the genitals and if the woman does not drain the amniotic fluid, the dirrupse is done.
The birth alone, if it is uncomplicated, is attended by a midwife, but the doctor is always within range, or oversees the course, and is ready to give birth in case of complications. Childbirth usually takes place on an examination chair, most often in position on the back. As far as physiological birth is concerned, a woman can choose a position during childbirth according to her wishes and possibilities. Some establishments also offer alternative births (childbirth, obstetric stool, etc.).
If birth does not progress physiologically, the pregnancy is terminated by caesarean section. A close person is usually allowed to be with a woman even in this way of giving birth. Usually, epidural anaesthesia is used so that the mother can be in contact with the new-born immediately after birth.
After delivery, the baby is laid to the mother’s breast and subsequently examined by a paediatrician. It is then returned to the mother. Father, or other accompanying person, is offered the opportunity to cut the umbilical cord. Throughout the period of hospitalization, the baby is already together with her mother, the nurses help the mother with baby care and to successfully start a lactation.
After a physiological birth, a woman with a baby is usually hospitalized in a puerperium department usually for 3 days, if there is no complication during her delivery.
After a caesarean delivery, the woman is hospitalized for one day in the intensive care unit, then she is transferred to the puerperium department for 5 to 7 days. Most health care facilities offer premium rooms for hospitalization, where a partner (or other person) may also stay. The price is around CZK 1 000 (40 E) per day.
If a new-born baby needs to be hospitalized for any reason, mother can be hospitalized with him/her at the neonatology department.
1/ Těhotenství. Available from: http://www.porodnice.cz/tehotenstvi-a-z (2018-02-14)
2/ Porod. Available from: http://www.tehotenstvi.cz/porod (2018-02-14)
3/ Těhotenství a porod. Available from: http://www.aperio.cz/tags/209 (2018-02-14)
4/ Těhotentsví. Available from: https://www.babyonline.cz/tehotenstvi (2018-02-14)
5/ KLÍMA, Jiří. Pediatrie pro nelékařské zdravotnické obory. Praha: Grada Publishing, 2016. Sestra (Grada).
E. CHILD CARE
After birth, the new-born is basically examined by a paediatrician, the APGAR score is also evaluated, the nurse takes care of the umbilical cord, the new-born is drained, dressed and marked in at least two ways – all under the control of the mother – then weighed (the length is measured the next day so the new-born is not traumatized by stretching of its limbs). As a standard, CRD (Septonex gtt.) and preventive vitamin K are given. Umbilical cord blood test is also standardized.
A woman can also decide to donate umbilical cord blood or to store it for her own needs. It is necessary to inform the personnel of the facility before birth, not all the facilities are able to carry out the sampling. Storage is possible for 20 years but can be extended. The cost of collecting and depositing umbilical cord blood is around
CZK 40 000 (1 600 €).
In the next few days, capillary blood from a heel is taken from the new-born for screening developmental defects and blood grouping. During hospitalization, the first hip examination is carried out, also auditory (otoacoustic), ophthalmic examination (congenital cataract screening) and ultrasound examination of the kidneys and urinary tract (screening of birth defects) are performed.
Vitamin D and vitamin K are given in the Czech Republic, and the paediatrician informs the mother of their use.
After admission to home care, examination is performed at a paediatrician (in the home environment or at the office). He performs physical examination and in the following weeks he also evaluates the weight gain of the new-born.
Other preventive examinations take place in the 2nd week, 3rd, 4th, 6th, 8th, 10th, 12th and 18th month, and in 5th, 7th, 9th, 11th, 13th, 15th, 17th, 18th year of the child’s life.
Paediatric examinations include measuring, weighing, birth defect screening, urine testing, blood pressure measurement, eye examination, mental status, speech, voice, and more as needed.
Children are vaccinated according to the vaccination schedule. Vaccinations are obligatory in the Czech Republic, legally prescribed and the mother can decide to vaccinate the child against other diseases.
Among the diseases against which the child is vaccinated are: measles, rubella, diphtheria, tetanus, black cough, hepatitis B, polio, infectious Haemophilus, mumps. These vaccinations are covered by health insurance. Non compliance with the vaccination calendar is subject to criminal prosecution by the child’s legal representative. The child cannot be admitted to pre-school facilities, cannot participate in various children’s events, camps, etc.
Optional vaccinations include vaccination against rotavirus, pneumococcal disease, varicella, tick encephalitis etc.
1/ KLÍMA, Jiří. Pediatrie pro nelékařské zdravotnické obory. Praha: Grada Publishing, 2016. Sestra (Grada).
In the Czech Republic, it is possible to carry out abortion at own request until the 12th week of pregnancy. From the medical indication (mother’s disease) it is possible to terminate pregnancy until the 24th week of pregnancy. The performance can only be done in hospitals (1 to 2 days).
The woman can decide freely about the possible abortion. Most often for the termination of pregnancy, women decide because of their poor financial situation, low age, poor family background. Interruption in these cases is paid by the pregnant woman, the price is between 3 500 and 5 000 CZK (140-200 €). For a girl under the age of 16, the legal representative must also agree. For girls between the ages of 16 and 18, it is the duty of a health worker to inform the legal representative after a successful performance. Abortion is usually done surgically, mini-invasive, during brief hospitalization (some hospitals offer release with accompaniment after 2 hours after the procedure).
Three years ago, the mifepristone drug, which can be used until the 9th week of pregnancy, was also approved for abortion. It is prescribed by a doctor of an inpatient facility. It allows abortion without hospitalization when a woman is given a tablet in two doses (within 3 days), which must always be taken under medical supervision, but then she can go home. The price is about 5 000 CZK (200 €).
The implementation of abortions in the Czech Republic is still under discussion, the Roman Catholic Church is strongly against the interruptions.
1/ Interupce. Available from:http://interupce.info/do-kdy-interupce (2018-02-14)
2/ Miniinterupce. Available from: http://miniinterupce.cz/potratova-pilulka-mifegyne-mifepriston-cena (2018-02-14)
3/ Interrupce. Available from: http://www.gynprenatal.cz/interrupce/ (2018-02-14)
Transfusion of blood or its components is a common practice in the Czech Republic. Transfusions do not require patient consent. Blood and blood derivatives are referred to a thorough examination after receipt from the donor, so the risk of infection from the donor and other complications is very low.
Blood donation in the Czech Republic
In the Czech Republic, most larger hospitals have a blood donation centre (usually part of a haematological department). These centres have a Registry of regular donors who are invited at regular intervals to come to blood donation. In the event of acute need, donors are also used extraordinary. Before each donation, the donor completes a detailed questionnaire where he answers several questions (e.g. whether he has recently spent time in exotic countries, whether he has recent tattoos, whether he feels healthy, is not suffering from a serious illness, a few questions also concern sexual area…), the donor confirms the truth of the information. The donor should fill in the questionnaire responsibly and its answers should exclude risks associated with the subsequent blood transfusion. Then own donation takes place. Each donor is entitled to a free day (on the day of collection) and for snacks. Each donor can also have tax benefits depending on the number of blood donations.
The blood is then thoroughly examined and processed by the specialist, according to the needs of the facility, immediately utilized or stored for further use.
Throughout the Czech Republic, various motivational events are taking place several times a year to obtain new donors. Such events are also usually associated with motivating patients to simultaneously agree to be included in the bone marrow donor registry.
The refusal of a transfusion in the Czech Republic is not very common. These are usually patients who are followers of the Jehovah’s Witnesses Church. Such cases are usually not simple, especially when it comes to paediatric patients. An adult has the right to refuse transfusion. In this case, the doctor must carefully inform the patient of the consequences of his decision as well as of any possible alternative. Then the patient signs an informed consent to the consequences of the decision.
In the case of a child patient or a patient with limited competence, the doctor proceeds according to the urgency of the condition in which the patient is. If the patient is in a serious condition and the transfusion is a part of emergency care for him, then the doctor must follow lege artis, that is to give the transfusion, even if the legal representative refuses to do so. However, if the condition of such a patient is not so serious and the transfusion is not needed in emergency care, the doctor must once again advise the legal representative about the implications of their decision and they must confirm such information in writing. In such a situation, the doctor is obliged to inform the state authority – the Social and Legal Protection Department of the Child. Parents can be accused of neglecting child care.
Despite these rules, there is a danger that the doctor is exposed to legal disputes either because he has filed a transfusion (legal representative disagreement) or because he did not transfuse (he did not follow lege artis). In some cases, both variants may be questionable.
1/ ŘEHÁČEK, Vít a Jiří MASOPUST. Transfuzní lékařství. Praha: Grada, 2013. ISBN 978-80-247-4534-3.
2/ PENKA, Miroslav a Eva. Hematologie a transfuzní lékařství. Praha, 2012. ISBN 978-80-247-3460-6.
3/ Transfuze. Available from: http://www.transfuznispolecnost.cz/index.php?page=dokumenty&identifikator_kategorie=DOPORUCENE_POSTUPY (2018-02-14)
H. TRANSPLANTATION, ORGAN DONATION
Transplantation of organs is organized in the Czech Republic through the Transplantation coordination centre. The whole topic is treated by law. Most Czechs perceive transplantation positively, as hope for patients with no other chances to cure. The kidneys, liver, lungs, heart and pancreas are the most commonly transplanted in the Czech Republic. Bone marrow transplantation is also common. Operations are always carried out in specialized centres – there are seven in the Czech Republic, fully covered by health insurance, including aftercare.
Expectant is a patient who is considered by the physician to be a suitable recipient of a tissue or an organ. Such person is included in the National register of persons waiting for the transplant = waiting list. There are health criteria set for the inclusion on the waiting list and the patient must agree. At present, there are about 700 patients on the waiting list.
An organ or tissue donor may be a deceased person (unless he has expressed his disagreement during life – see below). But also, a living donor who volunteered to donate a paired organ or the tissue that regenerates.
The choice of the recipient and the donor is assessed with respect to defined criteria that are different for each organ or tissue (immunological match, blood group, weight ratio, length of waiting etc.).
In the Czech Republic (as in most European countries) is valid the agreed consent for post-mortem tissue and organ donation. Such a donor can help up to 8 expectants. Disagreement in for this must be expressed during life. Potential donors whose age does not exceed 18 years and those who have limited competence, must be legally authorized by their legal representative.
The national registry of persons disagreeing with post-mortal donation of tissues and organs lists persons who have expressed their disagreement with donation in their life. At present, about one thousand people are registered. This is possible to enlist by filling in the short questionnaire on the website of the registry (http://www.nrod.cz/) and it is necessary to verify the signature. The second option is to express your disagreement directly with a doctor in a health facility. One witness is needed, then signatures no longer need to be verified.
Disagreement can also be expressed in part, i.e. disagreement with the collection of only some tissues or organs. Disagreement can be cancelled at any time.
In situations where the post-mortal collection of tissues and organs is considered, this list is always checked. If a person is not enrolled in the register, the family is always informed about the donation, but they may not agree. The Coordination centre is then informed, which organizes the care.
When post-mortem donation is considered, the patient must meet the criteria of brain death, a clinical examination is done by two doctors who independently examine the patient twice in at least four hours. It is also mandatory to perform a brain blood flow test (CT angiography) that is evaluated by two doctors independently. Consequently, the doctors follow the instructions of the Coordination centre and keep the patient as instructed.
1/Transplantace. Available from: http://www.kst.cz/o-transplantacich/co-se-transplantuje/ (2018-02-14)
2/ Legislativa. Available from: http://www.kst.cz/odborne-informace/legislativa/(2018-02-14)
3/ Transplantace. Available from: https://transplant.cz/intranet/ (2018-02-14)
4/ Transplantace lidských tkání a orgánů. Available from: https://www.epravo.cz/top/clanky/transplantace-lidskych-tkani-a-organu-ii-prokazatelny-nesouhlas-s-odberem-a-narodni-registry-souvisejici-s-transplantacemi-18256.html