Effective integration of hospice palliative care into national oncology and general practice / A hospice-palliatív ellátás hatékony integrálása a hazai onkológiai és családorvosi gyakorlatba

Introduction: Hospice movement began in Hungary in 1991, today home care and impatient care is accessable na-tionwide. However, despite the growing number of patients receving palliative care, according to the survey of the Hungarian Hospice Palliative Association, the average time they have spent receiving home hospice care was only 26,7 days in 2020, when the ideal would be 8,5 months. It has been proven by studies, that involving hospice -palli-ative care early on in the treatment of oncology patients has benefits for both the quality of life and treatment and cost-effectiveness. To make this possible, we have to make certain ways of health care which lead the patients in need to specialised palliative care. Objective and method: In this statement, we introduce two forms of treatment which have proven that the early inte-gration of palliative care is efficiently attainable throughout health care systems in Hungary today.Results: Starting September of 2019, the National Institute of Oncology Palliative Mobil Team has been helping the patients of the Institute receive optimal care through consultation. In the general medicine, general practice partner-ship of Szentendre, two family doctors with palliative licence examination have been organizing trainings for their colleagues in order to show a new approach and help more patients of the region receive palliative care in time. Conclusion: These examples further prove that by accessing the current financial and human resources, through edu-cation and a change of attitude, the improvement of palliative care in Hungary is possible.

Medical Communication during the Transition to Palliative Care in Pediatric Oncology in Hungary-The Parents' Perspective.

The transition to palliative care (PC) is a critical aspect of pediatric oncology, and it requires a high level of communication skills from doctors, which could be best judged by the parents of children who have died from cancer. Our aim was to explore the parents' perspectives regarding the timing of the consultation on the implementation of PC, as well as facets of verbal and nonverbal communication in Hungary. Semistructured interviews were conducted with parents who had lost a child to cancer within the past 1-5 years. Interview transcripts (n = 23) were scrutinized with interpretative phenomenological analysis. The parents frequently associated palliation with end-of-life care and they clearly delimited the transition to PC after curative treatments had been exhausted. The parents were ambivalent with regard to the use of the word "death" during this consultation, and they often did not receive information on what to expect (e.g., regarding symptoms) or on who to turn to for further information or support (e.g., concerning bereavement). Although significant progress could be observed in the organization of pediatric palliative care in Hungary, there is still no widely accepted communication method for the transition to sole PC. There is a need for a culturally sensitive approach to refining the recommendations on the word use and communication protocol in pediatric PC in Hungary.

When and how to integrate oncology and palliative care? / Mikor és hogyan integráljuk az onkológiai és a palliatív ellátást?

Összefoglaló. A palliatív ellátások korai bevonása az onkológiai betegek ellátásába elonnyel jár mind a beteg életminosége, mind a kezelés színvonala, mind a költséghatékonyság szempontjából. Szükség van egy olyan modellre, mely alapján a megfelelo idoben, a megfelelo beteg a megfelelo minoségu palliatív ellátásban részesül. Ebben a közleményben a palliatív ellátás korai integrációjának elonyei, szintjei és a speciális palliatív ellátás fogalmának ismertetése után a leginkább elterjedt beutalási modellek elonyeit és hátrányait mutatjuk be a nemzetközi szakirodalom alapján. A speciális palliatív ellátást igénylo betegek kiszurésére szolgáló, prognózisalapú modellek hátránya, hogy nincs elég kapacitás az ilyen módon beutalt nagyszámú beteg ellátására, ezért széles körben nem terjedtek el. A tüneteken alapuló modellek sokszor bonyolultak és a mindennapi klinikai gyakorlatban nem használatosak. Az új kutatások alapján egyszeru, gyakorlatias kérdéssorokat alkalmaznak, melyekkel könnyen kiemelhetok, akik profitálnak a speciális palliatív intervencióból. Ezek közül a Yale egyetemi és a PALLIA -10 modellt ismertetjük részletesen. Amennyiben az aktív onkológiai ellátást végzok a megfelelo palliatív beutalási kritériumokat ismerik és alkalmazzák, a betegek idoben jutnak a megfelelo komplex kezeléshez anélkül, hogy a palliatív ellátórendszer túlterhelodne. Orv Hetil. 2021; 162(44): 1769-1775. Summary. Early integration of palliative care into the trajectory of cancer care brings advantages into the patients' quality of life, the level of care and cost-efficiency, too. On the basis of a predefined model, the right patient may receive the right level of palliative care at the right time. Having defined the advantages, the levels of early integration of palliative care and the concept of special palliative care, we also aim to describe the advantages and disadvantages of the most common referral models on the basis of international literature in this article. The drawback of prognosis-based models to identify patients needing special palliative care is the lack of capacity to provide care for the large number of patients so recognised; therefore they have not become widespread. Needs-based models tend to be complicated and thus rarely applied in everyday clinical practice. On the basis of new researches, simple, pragmatic questionnaires are utilised through which the patients who could benefit from special palliative care interventions are easy to identify. Here we give a detailed report of the Yale University and PALLIA-10 models. On condition that appropriate palliative referral criteria are known and applied by active oncology care providers, patients may receive adequate complex care without the palliative care system being overloaded. Orv Hetil. 2021; 162(44): 1769-1775.

Two tagging single-nucleotide polymorphisms to capture HLA-DRB1*07:01-DQA1*02:01-DQB1*02:02 haplotype associated with asparaginase hypersensitivity.

AIMS: Asparaginase (ASP) hypersensitivity is a well-known challenge in the treatment of lymphoblastic malignancies. In terms of cost considerations, the cheap native Escherichia coli ASP, the most immunogenic form of this medication, is used in the first line in middle-income countries. Previously, the role of the HLA-DRB1*07:01-DQA1*02:01-DQB1*02:02 haplotype had been established to associate with E. coli ASP hypersensitivity. We investigated a possible cost-effective genetic testing method to identify patients harbouring the risk HLA haplotype in order to pave the way for safer ASP treatment. METHODS: In 241 patients with previously determined HLA-DRB1*07:01-DQA1*02:01-DQB1*02:02 haplotype and known ASP hypersensitivity status, 4 candidate HLA-tagging single-nucleotide polymorphisms (SNP)s were measured, and the performance of the different sets of these tag SNPs was evaluated. RESULTS: We identified a combination of 2 SNPs - rs28383172 and rs7775228 - as a tag for HLA-DRB1*07:01-DQA1*02:01-DQB1*02:02 haplotype with sensitivity and specificity values >95%. In line with previous findings, we found complete concordance between HLA-DRB1*07:01 and rs28383172. With bioinformatics methods, the results were also confirmed in the 1000 Genomes dataset in different ethnic groups. CONCLUSION: Rs28383172 and rs7775228 are suitable for identifying HLA-DRB1*07:01-DQA1*02:01-DQB1*02:02 carriers. Compared to the rest of the population, patients with hypersensitivity-prone genotype would benefit more from the administration of less immunogenic PEGylated ASP before the hypersensitivity evolves, incurring minimal extra cost.

Differences in well-being and fear of death among female hospice employees and volunteers in Hungary.

BACKGROUND: Voluntary work plays a significant role in hospice care, but international research has mainly been conducted on the mental health and fear of death of paid hospice staff. The aim of the present study was to compare the Hungarian hospice volunteers with paid employees with regard to attitudes and fear of death, as well as mental health in order to see their role in hospice work and their psychological well-being more clearly. METHODS: The target population of the cross-sectional questionnaire study was hospice care providers in Hungary (N = 1255). The response rate was 15.5% (N = 195); 91.8% (N = 179) of them were women. The mean age of female hospice workers was 45.8 years (SD = 10.46 years, range: 23-73 years). One-quarter (27.9%, N = 50) of the female respondents were volunteers. The instruments were: the Multidimensional Fear of Death Scale, the Perceived Stress Scale, the WHO-5 Well-Being Index, and a shortened versions of the Beck Depression Inventory and the Maastricht Vital Exhaustion Questionnaire. RESULTS: Volunteers scored significantly lower on 5 dimensions of fear of death than paid employees, and showed significantly lower levels of vital exhaustion and significantly higher levels of psychological well-being than paid employees. Fear of the dying process was associated with an increased perceived stress, depressive symptoms, and vital exhaustion in both groups. Psychological well-being showed a significant negative, moderate correlation with four aspects of fear of death among paid staff; this pattern did not appear in the volunteer group. In addition, the association between fear of premature death and perceived stress, vital exhaustion, and depressive symptoms was more pronounced is case of paid workers. CONCLUSION: Higher levels of psychological well-being and lower levels of fear of death among hospice volunteers suggest that they are less exhausted than paid employees. Increasing the recruitment of volunteers in hospices may help reduce the overload and exhaustion of paid employees.

Influential factors of well-being among Hungarian female hospice workers examined through structural equation modelling.

According to national hospice data in Hungary, approximately 1,600 healthcare employees and volunteers work in hospice care (country population of 9.9 million). The aim of the study was to identify and examine influential relationships among several variables that may affect well-being among female hospice workers. Structural equation modeling analysis was conducted utilising survey responses of 179 female hospice workers, including 79 nurses. Path analysis revealed that work over-commitment (being employed in more than one job) contributed to decreased psychological well-being through increased perceived stress, sleep difficulties and vital exhaustion. A greater sense of coherence was associated with lower levels of subjective stress, depressive symptoms and vital exhaustion and negatively correlated with over-commitment. Overall, even though the physical and mental burden of the workers is increasing because of increased use of hospice, according to these results, most still engaged in hospice work. Deeper analysis of the sense of coherence may point to development of effective interventions that can help maintain well-being of hospice workers and reduce attrition.

[Possibilities and challenges of perinatal hospice-palliative care]. / A perinatalis hospice-palliatív gondozás lehetoségei és kihívásai.

Perinatal hospice care is a special form of paediatric palliative care, with a focus on prenatally diagnosed malformation, providing physical, psychological and mental support with a holistic approach for the families. Our aim was to analyse how perinatal hospice-palliative care can be implemented and what opportunities it may provide on the basis of available professional guidelines. We introduce study and analysis of the professional guidelines and protocols, mainly from Anglo-Saxon countries, and describe some examples of best practices. Perinatal hospice is a specially demanding care regarding professional and personal challenges. Standardised guidelines based on consensus can serve as starting points, describing proper care and its conditions. Moreover, they can facilitate communication and coordinative processes between the collaborating specialists. Challenging conditions and possible solutions to them can be identified during supportive formative courses. Continuous formation means competency development in palliative care as well as in adequate communication. Orv Hetil. 2020; 161(12): 452-457.

[Special aspects of medical communication in the field of pediatric oncology focusing on palliative care]. / Az orvosi kommunikáció sajátosságai a gyermekonkológia területén, különös tekintettel a palliatív ellátásra.

Relation between the treating physician, the child with cancer and his/her parents is decisive in the field of pediatric oncology. Medical communication plays a crucial role in this relation. The quality of communication is particularly emphasized during the phase of palliative care in the case of children with incurable malignant disease. The proper medical communication during pediatric palliative care is subject of intensive research which is hindered by the sensitivity of the topic and the difficulties with inclusion of parents whose child has been lost or receiving palliative treatment and of health-care providers, respectively. In the present work, we review the publications focusing on palliative care in the field of pediatric oncology. Despite extensive research, only few investigations focus on the practical aspects of medical communication. Reports on the effectiveness of practical implementation of the existing theories are lacking. Drawing general conclusions is highly hindered by socio-cultural differences, including the diverse parental expectations towards doctors in different cultural and religious settings. However, there is a general agreement that early, simultaneous integration of palliative care at the time of diagnosis sharing is crucial. With the current knowledge, it is essential to conduct further research in this field considering the different socio-cultural backgrounds as well. Orv Hetil. 2020; 161(9): 323-329.

Neuropsychological characteristics of benign multiple sclerosis patients: A two-year matched cohort study.

BACKGROUND: The definition of benign multiple sclerosis (BMS) is still debated. It is mainly based on physical status, however, there is an attempt to involve cognitive functioning or paraclinical factors in order to avoid unnecessary long-term treatment with disease-modifying therapies and to identify these subjects in the early stages of the disease. Therefore the aim of our two-year follow-up study was to investigate the pattern of cognitive functioning and depression in patients with BMS compared to treated relapsing-remitting MS (RRMS) patients and healthy controls. METHODS: A group of 22 BMS patients was tested against matched RRMS patients and healthy controls. All individuals underwent neuropsychological evaluation exploring mood and the cognitive domains most frequently impaired in MS. MS patients were retested at two-year follow-up. RESULTS: In terms of cognitive functions there were no differences between BMS and RRMS patients either at baseline or at two-year follow-up. Compared to healthy controls BMS patients showed poorer performance in long-term visuo-spatial memory and information processing speed, whereas, complex attention, working memory, long-term verbal memory - despite slower verbal learning - and executive function were found to be intact. RRMS patients showed significant difference in complex attention, long-term visual memory and information processing speed. Cognitive impairment differed in the patient groups in terms of severity. Both patient groups were depressed compared to controls, but significant differences were found only between BMS and healthy individuals. CONCLUSION: The results of our study confirm that cognitive functions and mood can be affected in MS independent of disease course and disease modifying treatment. The "benign" label should be treated as only a reference to physical status and non-motor symptoms should be routinely monitored. Without receiving therapy it is an existing entity with longstanding minimal disability.

[Validation of the Hungarian version of the Professional Quality of Life Scale]. / A szakmai élet minoségét méro kérdoív (Professional Quality of Life Scale) magyar változatának validálása.

INTRODUCTION: The Professional Quality of Life Scale, measuring the quality of professional life, has been developed to examine the positive and negative changes in the work of those who have undergone extremely stressful experiences. The quality of life of the personnel of palliative-hospice teams may be influenced physically as well as emotionally by their every-day experiences of suffering, death, dying and the patients' traumas. AIM: The aim of the study was the examination of the psychometric features and factor structure of the Hungarian version of the Professional Quality of Life Scale questionnaire, which can measure compassion fatigue and satisfaction, secondary traumatisation and burnout. Our long-term objective is the development of formative and intervention strategies for hospice workers in order to increase their satisfaction, physical and mental well-being and their willingness to work in hospice. METHOD: The cross-sectional, questionnaire study was made with hospice workers. The questionnaires were available in an anonym, printed form. We used the Hungarian versions of the Shortened Maastricht Vital Exhaustion Questionnaire and of the Shortened Beck Depression Scale, of the CES-D Depression Scale and of the Shortened WHO General Well-Being Scale to validate. STATISTICAL ANALYSIS: IBM SPSS 23.0© software was used for the analysis. To explore the factor structure of the measurement scale, explorative factor analysis was made (analysis of the main component, Varimax rotation); subsequently, 4 scales were prepared the Cronbach-alpha values of which were suitable for further examination. RESULTS: 188 questionnaires were sent back (female 86.2%, male 13.8%); the majority work as nurses and in home hospice care (94 people). The inner consistency of the created 4 scales is acceptable according to the Cronbach-alpha values. The inner consistency of the questions regarding burnout is low. The correlation of our measurement scales with the standardised scales for outer validity has sufficient strength and direction. CONCLUSIONS: Our questionnaire can measure the phenomena under examination according to the expected values, with suitable consistency on the basis of the inner and outer indicators. Orv Hetil. 2018; 159(35): 1441-1449.

The timing and circumstances of the implementation of pediatric palliative care in Hungarian pediatric oncology.

Despite the continuous improvement of pediatric palliative care, medical professionals still face various barriers regarding its implementation; our aim was to investigate this question in Hungarian pediatric oncology practice. Structured interviews were carried out in person with physicians from the Hungarian Pediatric Oncology Group (n = 22). Codes were generated inductively with the aid of Atlas.ti 6.0 software. Most physicians placed the palliative care discussion at the end of curative treatment (n = 21) and preferred to conduct it in a team setting (n = 18), mainly in the presence of a psychologist. Preparing parents for the child's death can occur during the palliative care discussion (n = 3), in the child's final days/h (n = 6), gradually (n = 10), or never (n = 3). There are words consciously utilized and avoided during this discussion, with the word "death" proving to be the most ambivalent (utilized n = 5, avoided n = 6). CONCLUSIONS: There is no widely accepted unified practice among pediatric oncologists concerning the implementation of palliative care in Hungary. Despite the international recommendation, the common practice of timing is still at the end of curative treatment. Physicians rely on multidisciplinary teamwork, where the psychologist's role is the most prominent in this discussion. What is Known: • There is an international consensus that palliative care should commence at the diagnosis of a pediatric malignant disease regardless of illness outcome. • Barriers to the early implementation of palliative care in pediatric oncology involve resource-based and attitudinal factors. What is New: • In Hungary, where pediatric oncologists are sole decision-makers, early implementation of palliative care is rare. • There is a strong preference among physicians for working within a team, while also asserting that presence of team members may decrease the level of intimacy.

European Association for Palliative Care: Forging a Vision of Excellence in Palliative Care in Central and Eastern European and Former Soviet Union Countries.

The European Association for Palliative Care (EAPC) represents many thousands of health care workers and volunteers working in or with an interest in palliative care. In 2016, the EAPC has individual members from 48 nations across the world, and collective members from 57 national palliative care associations in 32 European countries. Throughout its history, the EAPC has produced guidance on a range of palliative care issues. The biennial congresses and research congresses and the comprehensive Web site (www.eapcnet.eu) are renowned and well utilized platforms for dissemination and exchange of palliative care information. The EAPC has also published a newsletter specifically for Eastern European and Central Asian countries that has been available in both English and Russian from 2005 to 2012. In addition, for a period of time, a Russian Web site (www.eapcspeaksrussian.eu) was also available. A survey of palliative care in Central and Eastern European nations sponsored by Open Society Foundation's International Palliative Care Initiative found that in most countries, the national language is preferred rather than using English or Russian for the provision of information. Accordingly, the EAPC Web site provides translations of white papers, position papers, and blog posts in a number of languages.

[Difficulties in communication with parents of pediatric cancer patients during the transition to palliative care]. / A kommunikáció nehézségei daganatos gyermekek szüleivel a palliatív ellátásra történo áttérés során.

INTRODUCTION: Adequate communication by medical personnel is especially important at certain points during the treatment of childhood cancer patients. AIM: To investigate the timing and manner of communication with parents concerning the introduction of palliative care in pediatric oncology. METHOD: Structured interviews, containing 14 questions, were carried out with physicians working in pediatric oncology (n = 22). Codes were generated inductively with the aid of Atlas.ti 6.0 software. RESULTS: Interviews show a tendency of a one-step transition to palliative care following curative therapy. Another expert is usually involved in communication, most likely a psychologist. Regarding communication, there are expressions utilized or avoided, such as expressing clarity, self-defense and empathy. The communication of death and dying was the most contradictory. CONCLUSION: This was the first investigation regarding communication in pediatric palliative care in Hungary. Our results show that a modern perspective of palliative communication is present, but necessitates more time to become entrenched. Orv Hetil. 2017; 158(30): 1175-1181.

[Experience with natalizumab-treatment at Semmelweis University]. / Natalizumabkezeléssel szerzett tapasztalataink a Semmelweis Egyetem Neurológiai Klinikáján.

Multiple sclerosis is an autoimmune demyelinating disorder of the central nervous system. During the last two decades, numerous disease modifying drugs have been introduced for the treatment of the relapsing-remitting form of the disease. Since 2010, natalizumab (NTZ) treatment has been used as a second-line therapy for patients with breakthrough disease. In comparison to conventional immunomodulant drugs, NTZ has a more specific effect in that it prevents the entry of immune cells into the central nervous system without interfering with systemic immune response. The efficacy and the safety of NTZ have been confirmed by several studies. The most severe side-effect of NTZ is progressive multifocal leukoencephalopathy, which has been associated with an increased incidence in patients with anti-JCV antibody positivity, and in those who have been undergoing NTZ treatment for over two years and who have received prior immunosuppressive therapy. In the present study, our experience with natalizumab treatment of 37 patients at the Department of Neurology of Semmelweis University during the last 6 years is presented. We have observed a significant decrease of disease activity in our patients; in many cases the disease has become inactive both clinically (36/37) and radiologically (34/37). The patients' quality of life has improved significantly during the treatment. In accordance with the literature, we confirm that NTZ is a highly effective treatment in a carefully selected patient group, and can be administered without significant inconvenience to the patient.

[The everyday life of survivors. The quality of life of hospice workers]. / A túlélok mindennapjai. A hospice-ellátásban dolgozók életminosége.

INTRODUCTION: Each year, the number of hospice services and terminally ill patients increase while the number of hospice workers is falling. The intensification of the physical and mental burdens of the latter can lead to burnout and the fluctuation of the workers. AIM: The aim of the authors was to survey the physical and mental state of hospice workers, as well as the risk of burnout and coping strategies. METHOD: A questionnaire survey in hospice experts and volunteers (n ≈ 1500) based on the Hungarostudy survey was performed. RESULTS: Those who filled in the questionnaire (n = 195) had on average 1.86 workplaces and 45.8% of them reported working 12 or more hours a day. Most often, they suffered from lack of energy (65.1%), disturbing physical pain (46.9%), sleeping (56.9%) and digestion (35%), they considered themselves overweight (56.9%) and they were occupied with work problems even at bedtime (72.8%). CONCLUSIONS: Hospice workers are overloaded, they have physical and mental symptoms and they are characterized by compassion fatigue. At the same time, they are also characterized by compassion satisfaction as an ability to accept appreciation for the caretaking.

Palliative Care Information Needs in Central and Eastern Europe and the Commonwealth of Independent States.

In a cross-national survey, we examined the information needs and barriers to accessing palliative care information in Central and Eastern Europe (CEE) and the Commonwealth of Independent States (CIS). In total, 584 healthcare professionals from 22 countries completed the questionnaire. Information on legislation and official papers (67 percent) and information on education courses in palliative care (65 percent) were the most frequently reported information needs. Major barriers to accessing palliative care information were language and a lack of easily accessible and affordable, clinically relevant information. An informative Web site, an electronic newsletter, and regular meetings or conferences were rated as the most important information channels. We concluded that access to reliable and well-structured information should be facilitated for healthcare professionals in CEE and CIS countries to assist them in their clinical decision making. Most importantly, more in-depth qualitative research and dialogue with stakeholders in the different countries are needed to develop context-specific, tailor-made strategies.

[Perinatal and intrauterine infant death: professional practices and their effects on healthcare personnel]. / A perinatalis veszteségek és intrauterin magzati halálozások aktuális szakmai gyakorlatának, valamint a szakemberekre gyakorolt hatásainak vizsgálata.

INTRODUCTION: The sorrow caused by perinatal loss is a phenomenon of pathological mourning, a burden for the parents, their environment and the medical personnel, yet, it is a less studied field. AIM: (1) To present the applied practice in healthcare institutions, to compare the valid protocol with the effective help provided and to study how these events affect the helping personnel professionally and psychologically. METHOD: In-depth interviews with the involved personnel (n = 8). The authors studied the practice of the given institution; existing and wanted theoretical and practical competencies; personal attitude and the experienced difficulties. RESULTS: Acting well professionally is a specially demanding task, with few tools to use when communicating, when helping the parents cope with sorrow, or when coping with their own feelings, all these involving a risk for burn-out. CONCLUSIONS: The results can serve to create trainings aimed at helping the patients with adequate support and improving coping strategies.

[Association between depression and cognitive decline in sclerosis multiplex patients]. / Depresszió és kognitív hanyatlás kapcsolata sclerosis multiplexes betegeknél.

BACKGROUND: Multiple sclerosis (MS) is the most common neuroimmunological disease. In addition to its somatic symptoms, fatigue, mood disorder (depression) and cognitive impairment can be detected. Cognitive impairment significantly affects social relationships, work capacity, quality of life independently of disability. AIM: The aim of our research is to analyse the complex relationship between depression, manifestation of which occurs more often in MS compared to normal population, and cognitive functioning in multiple sclerosis. METHODS: Forty participants (sixteen men, twenty-four women) are MS patients of the Department of Neurology, Semmelweis University. Control group included forty-two age-, gender-, and education-matched subjects (sixteen men, twenty-six women). Patients were screened using MMSE; and verbal learning, visual information processing, attention, short-term and long-term memory were tested. Depression was also assessed. RESULTS: In multiple sclerosis learning, long-term verbal memory and short-term visuospatial memory were impaired compared to control group. Working memory, information processing and attention were found to be intact. Depression scores of MS patients were significantly higher than those of the normal population. Regarding the relationship between depression and cognitive impairment, negative correlation was found between mood and short-term visuospatial memory. CONCLUSION: Results of our research reflect the findings of clinical studies whereas short-term and long-term memory excluding working memory can be impaired in multiple sclerosis. Because of incidence of depression and fatigue and the important role of psychological factors in quality of life, more detailed analysis of the relationship between mood, fatigue and cognitive impairment would be required which is planned in the future.

[The message from heroin overdoses]. / A herointúladagolások üzenete.

Drug use can be defined as a kind of self destruction, and it is directly linked to attitudes toward death and suicide occurring in a significant number of users of different narcotics. The aim of the authors was to look for the background of this relationship between drug and death and examine the origin, development, and motives behind heroin overdose based on an analysis of previous studies. It seems clear that pure heroin overdose increased gradually over the years. The fear of the police is the inhibitory factor of the overdose prevention and notification of emergency health care service. Signs of suicide could be the own home as the chosen location for heroin overdose and the presence of partners ("moment of death companion"). Interventions should include simple techniques such as first aid, naloxone administration, resuscitation, prevention of relapse of prisoners and social network extension involving maintenance programs.

[The current state, the possibilities and difficulties of palliative and hospice care in Hungary]. / A hazai hospice- és palliatív ellátás helyzete, lehetoségei, nehézségei.

Hospice-palliative care has existed in Hungary for more than 20 years but physicians know very little about it. The objective of the study is to give detailed practical information about the possibilities and the reasonability of hospice care and the process of how to have access to it. The authors review and analyze the database of the national Hospice-Palliative Association database to provide most recent national data on hospice-palliative care. In addition, legal, financial and educational issues are also discussed. At present there are 90 active hospice providers in Hungary, which provide service for more than 8000 terminally ill cancer patients. According to WHO recommendations there would be a need for much more service providers, institutional supply and more beds. There are also problems concerning the attitude and, therefore, patients are admitted into hospice care too late. Hospice care is often confused with chronic or nursing care due to lack of information. The situation may be improved with proper forms of education such as palliative licence and compulsory, 40-hour palliative training for residents. The authors conclude that a broad dissemination of data may help to overcome misbeliefs concerning hospice and raise awareness concerning death and dying.