Proposition 54K1051

Projet de loi modifiant la loi du 14 juin 2002 relative aux soins palliatifs en vue d'élargir la définition des soins palliatifs.

General information ¶

Authors

CD&V Sonja Becq, Nathalie Muylle, Els Van Hoof
Ecolo Muriel Gerkens
Groen Anne Dedry
LE Catherine Fonck
MR Damien Thiéry
N-VA Jan Vercammen
Open Vld Ine Somers
PS | SP Daniel Senesael
Vooruit Karin Jiroflée

Submission date

April 29, 2015

Official page

Visit

Status

Adopted

Requirement

Simple

Subjects

health care patient's rights

Voting ¶

Voted to adopt

Groen CD&V Vooruit Ecolo LE PS | SP DéFI ∉ Open Vld N-VA LDD MR PVDA | PTB PP VB

Contact form ¶

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Discussion ¶

June 23, 2016 | Plenary session (Chamber of representatives)

Full source

The rapporteurs are Mr. Frederick and Mr. and Thiery.

I am referring to the written report.

Dear colleagues, if it is a delicate and sensitive area, it is the end of life. Decisions to be made are always difficult, for the patient, for his or her loved ones, but also for the healthcare professionals they meet. In 2002, the legislator provided a fundamental answer to this question of the end of life, by allowing every patient, when the pain becomes unbearable, when the hope of healing disappears and the dignity of the person is no longer guaranteed, to be able to dignifiedly ask questions concerning his end of life, and to be able to be supported by competent professionals who, when the time comes, will meet his expectations.

This legislative balance is now based on three key laws: the one on palliative care, the one on euthanasia and the one on patient rights. My group has always been fiercely present to preserve this indispensable balance. Today, the text that is submitted to our assembly, and which we have co-signed, aims to expand the current definition of palliative care. In our view, however, this text should be seen as a first step in the right direction. Indeed, determining the different types of palliative patients and their needs is an essential step that we will have to go through. Unfortunately, today, we still do not know whether the government is willing to issue a specific budget in this framework, but we will obviously support this text.

I will also say a word about the proposal for a resolution on the legality of the transport and storage of medicinal products for palliative use. While acknowledging the need to find a solution to this problem, it was indispensable for my group that the established framework enables all parties to find an adequate and non-binding response, in order to take into account specific needs and regional disparities, and this in respect of the accountability of all stakeholders in the care chain.

The resolution presented to us today seems to start from a pre-defined framework by referring directly to a pilot project in progress in the Westhoek-Ostende palliative care network. As we have already said in the committee, we regret that the text of consensus proposed by the Federatie Palliatieve Zorg Vlaanderen, the Brussels Pluralist Federation of Palliative and Continuous Care, the Wallon Federation of Palliative Care, the Vlaams Apothekers Netwerk, the Association of Pharmaceutical Unions, the Algemene Pharmaceutisch Bond and the Belgian Pharmaceutical Association, i.e. all the directly involved Franco-speaking and Dutch-speaking actors, has not been fully taken into account. As Winston Churchill said, “There is nothing wrong with changing your mind as long as it is in the right direction.” If this is not the case, we will not support this text.

Mr. Speaker, Mrs. Minister, colleagues, the plenary session will then immediately proceed to the vote of a bill aimed at extending the definition of palliative care.

The central goal of the bill is to provide people with the highest possible quality of life during the final phase of their lives and in any way they wish. The current law on palliative care dates from 2002. Over the past few years, the call for a general approach to palliative care has grown increasingly, based on various studies from the KCE, the federal assessment cell Palliative Care and also recently the FLIECE studies. The various Federations of Palliative Care also asked to take their suggestions into account. The bill takes the formulated aspirations to broaden and deepen palliative care, with the aim of better taking care of people at the time they are most vulnerable, and also to align the definition and principles internationally with the definition and principles of the World Health Organization.

On the expansion of palliative care, we make palliative care accessible to anyone who is in an advanced or terminal stage of an incurable disease, regardless of life expectancy.

We break the misconception that palliative care is exclusively aimed at cancer patients during the terminal phase of their disease. We do this by taking the care needs and not the life expectancy of the aid-seeking as a guide.

We want to ⁇ that quality of life as high as possible through three priorities: first, through early care planning as an incentive to palliative care; second, through reducing therapeutic persistence with useless treatments and, third, through palliative care that is in line with the care needs and the needs of the aid seekers.

Those three spearheads, combined with releasing the life expectancy of the aid applicant as a criterion, have three important consequences.

First, there is a much faster transition from cure to care. Our last few weeks we spend too often clinging to machines, subjected to painful interventions in order to stretch our lives a little more. If someone knows he is about to die, does he not want to spend the last days at home as comfortably as possible? Belgian research shows that, if one takes the need for care of palliative patients as the central criterion, 19% of all patients in hospitals need palliative care, but today do not receive it.

The second effect is that it becomes financially more sustainable for the patient. The palliative package becomes more accessible to those who need it. According to figures requested by Minister De Block, in 2015 55% of applicants for a palliative package died within 60 days of their first application. In other words, 55% of applicants are unable to take advantage of the support they declare they need.

A third expected effect for academics and doctors is that the expansion of palliative care leads to a decrease in healthcare costs. A study by the KCE found in 2009 that the average daily costs during the last 30 days of life of patients who die in departments of geriatrics, cardiology and oncology are lower if their records indicate that they are receiving palliative care.

In short, we make a humane choice for better care, which as a positive side effect implies a reduction in the costs of the RIZIV.

In addition to the expansion, we are also seeking to deepen life care. To date, palliative care has been used to serve as an adjective to the terminal phase and to relieve physical suffering. Thus far, other real forms of suffering have remained unexplained. These are spiritual and existential suffering and questions about identity and meaning. Specifically, what will happen to my neighbors? Can I tell my children everything I want to tell them? In other words, is my life satisfactorily completed in all its facets, and am I at peace with it?

I note with great satisfaction that the opposition and the majority have met each other around the definition and that the debates have been very serene. They have evolved into a good common text. Such a law deserves prompt implementation. Both for the identification of the sick as being palliative and for the assessment of the needs of care, scientific instruments should be used and recorded with KB. The Minister has developed a good tool with the Palliative Care Indicators Tool (PCIT). We urge her to quickly convert this into a KB, with the advice of the Federal Paliative Care Cell. In this way, patients can progressively obtain both an official status and the adequate care they are requesting according to their care needs.

Colleagues, this law opens new beacons to assist people in their most difficult times. I am convinced that this law can bring about a mental shift in healthcare from cure to care, on a timely basis, and from overtreatment to care. The patient will go with it.

Mr. Speaker, colleagues, already during the previous legislature, the Knowledge Centre in its 2009 report called for a broader definition of the palliative patient. It advocated palliative care when the patient is in an advanced stage of a serious, progressive and life-threatening disease, regardless of life expectancy. More specifically, the Knowledge Centre pointed out the need to identify a wider group of patients as palliative, wider than the often oncological patients that today fall under the denominator of palliative patient.

The evaluation report “Palliative Care 2014” endorsed this goal and referred very specifically to the dementia as a group that deserves special attention. The proposal of colleague Els Van Hoof addresses this suspicion. The new definition provides for a broader definition of palliative patients and also allows them to resort to palliative care earlier. A few weeks ago, the evaluation of the PCIT also showed very clearly that there is already an instrument to identify that wider target group as a palliative patient at an earlier time.

Together with the Minister, we determined that there should be some additional adjustments for children and for the group of patients who are not detected as palliative but die within the year. Once the opinion of the Federal Assessment Cell Palliative Care regarding the statutes and the rights to be attached to them is completed, the Minister will be able to implement this legislation and introduce the various palliative statutes, which will allow the palliative care to gradually build up as the need for care increases.

In short, a very good cooperation has been established between the Parliament, which has amended the legislation, and the Minister, who at the same time has already made the necessary preparations to be able to quickly implement the legislative provisions.

At the same time as the bill, my motion of resolution was also approved. With the proposal for a resolution, we address the problem of the availability of palliative medicines for palliative patients receiving home care.

The experience of palliative networks teaches us that sometimes in urgent situations palliative medicines need to be given immediately to the patient. Today, the family or nurse who is still taking medicines must wait at the pharmacy or pharmacy, which often does not have the necessary amounts. A master trial in 2012 found that the waiting bags for palliative medicines in the pharmacies were only in use in four of the twelve networks. The companies developed their own alternatives. One is that the nurse of the multidisciplinary supervisory teams tracks surpluses of palliative patients who have died in the meantime and uses them to cater for the needs of other palliative patients. That is illegal. The use of these medicines is not permitted according to our legislation.

With the proposal for a resolution, we call on the Minister to work out a solution to ensure that, on the one hand, the palliative patient receiving care at home can receive the same quality palliative care as the palliative patient in the resting room or hospital and, on the other hand, that nurses are legally protected. Finally, the development of a safety system is also desirable for the protection of society. Palliative medicines are not innocent.

The proposal asks the Minister to follow two paths.

On the one hand, we ask the Minister to establish a list of palliative medicines that pharmacies should have at home in sufficient quantities. This makes it possible for the family and the nurses of the multidisciplinary supervisory teams to obtain as much as possible the relevant medicines from the home pharmacist.

On the other hand, we ask the Minister to draw up a legal regulation allowing nurses to possess and transport palliative medicines, so that in urgent cases nurses will always be able, upon the order of a physician, to immediately borrow the need of the palliative patient. This should improve the quality of care for the palliative patient as well as the legal status of the nurse.

At the same time, we ask the Minister to set up a safety system, so that the government can always check who to which patient has administered how much of which palliative medicine and what happened to the surpluses.

This is a quality element of good care. The Minister is sure to be inspired by the pilot project that is underway today in the Westhoek-Oostende palliative care network, which takes place in cooperation with the Flemish Federation of Palliative Care and the Flemish Pharmacist Network.

The Minister will ⁇ also take into account the framework conditions as formulated in the joint position of the palliative networks and the pharmacy networks. In this way, we can come to an arrangement that is feasible in every Community, that takes into account the division of powers and the specific characteristics of each Community and, importantly, that is also feasible in practice. I would like to emphasize that in both tracks the role of the pharmacist, the healthcare professional with expertise in the field of medicines, is important for us.

The dossier also taught me that palliative care is approached differently in different communities and regions. The proposal for a resolution with its two tracks is therefore the result of a proposal jointly carried out by the three federations of Palliative Care and the various pharmacy networks in our country. They also rightly emphasized the importance of good communication between the various actors: the doctor, the multidisciplinary counselling team and the pharmacist. Good communication can solve a lot of problems.

First of all, I will address the bill of our colleague Els Van Hoof concerning the amendment of the definition of palliative care. This text, which has gained widespread support within our committee, aims to broaden this definition so that this care is better integrated into health care. These are defined internationally, ⁇ by the WHO.

The proposal is an important signal to the public, patients and healthcare providers. By focusing on accompanying the end of life, the old definition was no longer suited to the current philosophy of palliative care. In fact, every day, the actors ⁇ to us that this design was reductive. Every patient, regardless of life expectancy, has the right to receive palliative care when he or she is at an advanced or terminal stage of a serious progressive illness that threatens life prognosis.

This change in the definition will obviously involve a new identification of patients who can benefit from a palliative approach. This must be done in a second time. The Minister of Public Health has pledged to find a pragmatic solution in consultation with the Federal Assessment Cell for Palliative Care. This solution will be able to rely on the Palliative Care Indicators Tool, the PICT, which has demonstrated that it can take into account patients whose life prognosis exceeds three months, regardless of the pathology they suffer from. It also aims to allocate resources proportionate to the complexity of situations. Therefore, the PICT proposes a concrete method. It can be the starting point for identifying palliative patients and their needs.

Let me say a word on the proposal for a resolution on the legality of the storage and transport of medicines for palliative use.

This proposal aims to find a solution so that palliative care teams can dispose of medicines in emergency or sedation kits and transport them under the supervision of a pharmacist designated for this purpose.

Along with our work, an initiative with field actors has emerged. The Belgian Pharmaceutical Association (APB) and the pharmaceutical sector, as well as the various palliative care federations, have agreed on a text of consensus to join in the search for this solution taking into account the specificities of the field. This consensus text will obviously be the basis for the solution that must emerge.

I will highlight the following points that will need to be found in the solution released: a non-binding response, a responsibility of all stakeholders in the chain, the supervision of a pharmacist assigned to this function, the security of kits, the necessary evaluation of the system.

These are the various remarks we wanted to make during this debate. I thank you.

Mr. Speaker, I think most of us will agree that the narrow definition of palliative care, as formulated in the 2002 Act, is indeed outdated. Therefore, we found it a very good thing that we could have debated in a serene way about extending this definition so that it would be more in line with current needs.

We do not pretend that we would have liked to have seen this a little more accurately and that the financial consequences for us are not yet quite clear, but we think this is a first step in the right direction. I agree with Ms Van Hoof that we have reached a good compromise.

We will therefore approve this bill. I think the discussions went in a very good atmosphere.

Mr. Speaker, colleagues, I myself participated in the birthplace of the law on palliative care in 2002, under the ministry of Magda Aelvoet. Our group has always closely followed the international developments and also ⁇ ined a very close and intense contact with the workplace.

In January, our group submitted a bill with a definition to broaden the concept of palliative concerns that is aligned with the World Health Organization, the European and Belgian federations of Palliative Care. The majority was clearly inspired by this and therefore, under the good initiative of Mrs. Van Hoof, in April 2015 came up with an analogous bill.

The extension of the definition is absolutely necessary, as palliative care does not begin at the terminal phase. As my colleague has already said, good palliative care has to do with the quality of care. Good palliative care also has attention to relatives, including mantle caregivers. The proposal will ⁇ prevent therapeutic persistence and ⁇ do not involve additional costs, on the contrary.

We have worked well together on this issue. It would still be missing, when it is about the end of life, or even about a period that is close to the end of life. Majority and opposition should not be obstacles. We have also discussed a number of amendments together, with which we have refined the wording and, among other things – I have since held a plea for the mantel caregivers – have included the mantel caregivers in the definition. That amendment was signed and approved by everyone, across party boundaries.

We will with our group absolutely approve the proposal, as it is fully consistent with the bill we had submitted ourselves.

I will address here two different texts. The first concerns the definition of the palliative patient, where the challenge is, as always in medicine, to start from the specific needs of the patient and not from the notion of end of life or a more administrative aspect. To be able to provide a patient with a care tailored to his needs only on the basis of a rule that refers to three months, as was the case until now, is not what is most suited to the patient’s situation.

The initiative of this text dates from the previous legislature. In fact, I had submitted a text that repeated exactly this change of definition. I put it here again. Even better if, in this way, I could convince other parties to move forward in this matter so that we can finally reach out on this issue. I would like to congratulate the Chairman of the Palliative Care Assessment Cell and the Regional Federations of Palliative Care, who have pledged in the same direction. It is to them that this work must be devoted which has resulted in this type of text.

There are still stages. The first is to be able to transpose the instrument of identifying the palliative patient and above all of assessing the severity of his needs and to be able to convert this scale of the simple, increased and complete palliative status since all this work was carried out by Dr. Desmedt of the UCL, with the three federations of palliative care and the Federal Assessment Cell. The priority for tomorrow is to be able to transpose this tool that they have set up.

Another step that awaits you, Mrs. Minister, is to resolve the issue of the means. When I hear your representative in the committee say that it is not possible to find additional budgetary resources for palliative care, it calls me to two headlines. First, I find that it is really ignoring the reality of the teams that today accept all requests, even though they are no longer funded in terms of package and that they therefore agree to take care of patients who are well beyond the quota for which they are funded.

The second thing, it’s also appealing to hear your representative say this on your behalf in a commission because, if these patients are not taken care of in palliative care, it’s to make them believe they’ll be elsewhere. Where will they be taken care of? Most often it is in hospitalization. But hospitalization, excluding palliative care, will cost at least as much, if not more. The argument used by the government is ⁇ inappropriate.

As for the legality of the storage and transportation of medicines for palliative use, in essence, the title does not well reveal the issue. What is it? It is no longer to find yourself in a situation where it is not possible to administer palliative care – I am talking about medicines here – for reasons that are obviously not valid even if they are understandable given the current organization. It’s important to recall here – I dare hope my colleagues are in the same mindset – that it’s not a fault in any way, teams. Since these are subject to certain laws, it was not possible, so far, to operate otherwise under optimal safety conditions.

by mr. Gustin is no more. It does not matter. Dear colleagues of the MR, long before this issue was addressed, the field actors, namely palliative care federations and pharmacists, were working to reach a consensus. Dear colleagues, the way you have done this is challenging. You came from an interesting pilot experience, and decided to impose it the same way everywhere. But there are different practices and, most importantly, you were explicitly informed that these working groups existed at the level of the field actors. I would like to point out the CD&V. In the committee, you have been to say that you weren’t aware that this work was being carried out. Even the cabinet said it.

I think it is a pity. It is a shame to always, in the matter, not want to be listening and working, especially, from the realities of the field by doing bottom-up. You are a strong supporter of top-down. They came to a text of consensus and as if that was not enough, you decided that you would rather stick to your text of the transposition of a pilot project that is transposed in the same way everywhere, rather than following the field actors, the consensus that truly brought together all partners, all the actors involved across the whole of Belgium.

I can only regret and denounce – I will go until then – that the majority is not listening to the field actors, this consensus position.

Of course today, in the expression, suddenly, you can see clearly that you are embarrassed by the surroundings. You are trying to make us believe that your text represents the same thing, and that it will be applied on the basis of the field consensus. The reality is completely different. The text you vote here will allow you to clearly do a work and approach based on this pilot experience, and at the same time without taking into account the diversity of field realities. I’m sorry, it’s really a shame and it’s a flagrant lack of respect towards the field players.

I will conclude, Mr. Speaker, by giving back a direction, not necessarily focused on palliative care because I think I said everything I had to say here. I would like to remind you of the question of the means. The teams are really overloaded today. I want to remind you that in this matter, what should be your priority, your direction, is to have a concerted policy that aims at the quality of the care provided to patients, the correct allocation of resources and respect for the teams. On the case concerning kits, palliative drugs, you have cruelly lacked respect for field teams.

That is why, Mr. Speaker, we will vote on the bill on the definition of the palliative patient since it is exactly the same as the one I filed during the previous legislature and at the beginning of this legislature; on the other hand, we will abstain from the resolution on kits and palliative medicines. The signal you gave to the field actors indicates a lack of respect. And I can assure you that I will be extremely vigilant so that you do not apply your unique proposal and that on the contrary, in the future, Mrs. Minister, you can have an approach that respects this ground consensus position.

Our priority is patients. The priority of the priorities is the actors who invest in it and not just a politician who wants to put a flower in his hat. I thank you.

Mr. Speaker, Mrs. Minister, dear colleagues, like my colleagues, I would like to refer – this is important – to the work that was carried out on the occasion of the review of the bills of 2002 (patient rights, palliative care, euthanasia, and affirmation of the right of patients to refuse treatment and to prohibit therapeutic hardening).

We join in this extension and the combination of concerns aimed at enabling everyone to benefit from the care they need in the most appropriate way. When we know that a patient has a disease that is known to be incurable, and that at some point, we abandon curative care to move to care that will allow to accompany the sick so that he suffers as little as possible, so that he can enjoy the best quality of life possible by trying to allow him to keep the maximum of autonomy, we knew that it was imperative to change the law on the status of the palliative patient since the latter referred to an estimated life span of three months renewable once.

Together with my colleague Anne Dedry, we submitted, in October 2014, a resolution and, in January 2015, a bill, following a series of meetings. I would like to join the thanks addressed to the Flemish, Brussels and French-speaking federations, but also to a whole series of actors, including general physicians, the medical houses who have associated with our reflections to try to determine the most appropriate definition possible to meet the different needs and allow the accompaniment of the person from the finding of his incurable disease until the end of his life, while preserving his right to refuse, at a given moment, any treatment, but also respecting his choice to request euthanasia.

When we presented these two texts in the Health Committee, the members of the said committee did not fail to mobilize. Hearing was held and members of the majority submitted a text, which we supported, since the important thing was to reach a solution and not to claim the maternity or paternity rights of the text in question.

It is the parliamentary majority-opposition dynamics that is always ubiquitous on these topics.

One element is missing in the text we have adopted and will need to be refined by the end of the year. The evaluation cell will continue its work and evaluate the budget impact of an improvement that we had included in our texts, Mrs. Dedry and myself, on these three stages of palliative care with different nature and intensity, thanks to this new needs assessment scale that is under completion. In the coming months, it will be important, on the basis of this evaluation, to supplement existing devices in order to be even more finely in the follow-up of patients.

I come to the resolution on the storage and transport of medicines. I must express my amazement, not about the need to make arrangements, but to allow, when the multidisciplinary teams of palliative care consider it necessary, transportation by a person who is not a pharmacist and who is not in the illicit. This person will be able to have this transport kit at their disposal because too often there has been a lack of availability of these medicines in pharmacies.

During discussions on this resolution, it appeared that parliamentarians who signed it did not seem to be aware that the problem was perceived differently in Flanders, Brussels and Wallonia and that the solutions to be brought were also considered in a completely different way. I can admit that some members were not aware of it.

But that the minister’s representative says to us, “There is only one solution to bring, which is to allow the generalization of the Ostende pilot project to the whole territory,” is not acceptable. A federal minister and his cabinet work for the entire country. Therefore, it is important to constantly consider what is happening in all regions.

You have accepted...

Mrs. Gerkens, I give the floor to Mrs. Somers for an interruption.

Mrs. Germans, I would like to intervene. If there is no exaggeration, I will be silent.

As a member of the opposition you can say what you want, but now you are really exaggerating. You really did not listen properly when I said in my presentation that during the discussion on this resolution it has been shown that palliative care is addressed in different ways by the Communities, that several proposals are made in the resolutions, that it is up to the Minister to consult with the Communities and that a solution that is good for the Communities and the Regions and practicable in practice must be found. These are five points that I have briefly cited in my presentation. However, you let something else shine out.

You are right if you say that the basis of this resolution was in a masterwork, which showed that four out of the twelve networks no longer worked and that there is a proposal from the Flemish side. During the committee work on this resolution, I have stated this clearly, and I have also stated this here.

What you are saying now is almost a flagrant lie.

Mrs. Somers, read the report again and honestly revive the way it happened! A work followed. Whether you submitted a proposal inspired by a model that worked and that works in Ostende and you said that that model is interesting and that nurses and members of the palliative care teams should be allowed to remain in legality when they carry these medicines, I agree with you. This is interesting and we need to answer it.

That you don’t know what happened on the French-speaking side and the claims, that’s one thing. What I did not accept, and I still do not accept, is that at some point, on the part of the representative of the minister, there was no such openness and that we have not previously sought to find out about what was happening in the three Regions. The minister’s representative did not seem to be aware. Nor did she tell us to be aware that a work was being done with all the federations and associations of pharmacists, to come up with a collective proposal.

It is because you have accepted, at the request of the opposition, that there is a request for opinion and that we have received this opinion co-signed by all the federations and pharmacists, that you have introduced amendments to your resolution. So much better!

These amendments are not sufficient. That is why we have co-signed an amendment that we re-submit here to add elements that, in a very clear way, not only advocate a concertation with the federations. This consultation took place because they gave a common opinion.

Our amendment further states in the draft resolution that it is important to take into account needs and solutions differentiated by regions and that it is important that in addition to legalizing the transport of a medication, via a palliative care team, it was also necessary to provide for the possibility that the pharmacies are organized differently in the storage of medicines, so that they are, in the best way, available to the teams and this, with a communication of needs and the identification of patients between the teams, the treating physicians and the pharmacists.

Mrs. Gerkens, it cannot be stated that the Cabinet was completely unaware of this. That is really exaggerated. The cabinet contacted a number of associations, of which they had letters and information. For example, the Belgian Association for Nurses. By the way, if you hear the word “Belgium”, it is true that it is all over the country.

By the Cabinet it was never stated. I clearly note that the initiative for the resolution came as a result of a master’s study, which, though, was done by someone in Flanders, and as a result of a pilot project launched in Flanders. I know that.

This will not be the first time that there are significant differences between the two countries in terms of public health. We will probably talk about this next week too. It will also be a litany.

Whoever understands that a minister must consult with the Communities in order to make the dossier concrete and adapted in practice, comes to a faulty resolution. I do not understand that no amendment to the resolution can still be submitted during the discussion.

Many of your proposals are also based solely on ideas from and knowledge of your country.

I would like to remind you of something, because this discussion seems to me surreal.

Madame Somers, I understand that you are embarrassed by the surroundings. If I were you, I would be even more than you. I understand your annoyance and your reactions. You get to tap on the bench so you get annoyed to tear out the word to the speaker who is still in the tribune.

I would like to remind you of two things. The first is that effectively, the cabinet of the minister has very clearly said that she was in no way aware of the working group that, however, already existed, with the three federations of palliative care, the APB and the SSMG. This is very clear.

The second is about the content. You have changed the text a little, but in a very partial way. I repeat it here too, you wanted to fully transpose a pilot project even though it did not stick to reality and that the federation, including Flemish, of palliative care did not agree. You pretended, you did not initially want to imagine that another approach was possible, and above all, a common approach to all actors.

On the other hand, you seem to say that you now agree with the field actors. If so, I will take you to the word. I recall that I submitted an amendment, co-signed by Ms Muriel Gerkens and Véronique Caprasse, so that the minister can move forward on the basis of the consensus that occurred between the relevant field actors. This consensus will not put you in trouble in anything. He will not make the minister’s life impossible, put her into a practical impossibility, or ask her for completely excessive budgetary resources. and no!

If you really agree now with the field actors, sign ... Sign if you want, but above all, vote on the amendment we propose to you. So this time, you will respect field work and you will be in line with a common approach that can be applied by teams wherever they work.

In conclusion, Mrs. Somers, dear colleagues, we have worked well on the bill on the definition of patient status in palliative care. If we have been able to work well, it is because we have authorized and organized hearings, and because the structures that organize the palliative care platforms bring together the platforms from the entire territory. Everyone was concerned about the respect and well-being of the patient. How to improve these palliative care so that they meet the needs? There is a majority, majority and opposition.

If we have a problem with the resolution on the transport of medicines, it is because at that time, the parliamentary game and the position of the cabinet work have not allowed to take account of this gathering of opinions and this collective work. This was accomplished by the field actors. That is what I blame. It is a shame, people have gathered together to try to find a solution that suits everywhere in the territory. They said that there were specifics, and that they should be taken into account, but that we would ⁇ the same goal, the same respect for the needs of the patients, the same meeting of the demands and needs of the professionals. Following the ten guidelines they proposed, the objectives pursued by the resolution, the specifics and needs of patients were met.

I am not intervening to create an additional community problem, as the actors come together and offer you something. But here, the pride of the parliamentary sometimes makes it impossible to take into account the joint work, while we charge these actors to work together, to give us opinions and to make us recommendations. When the work is done, we sometimes allow ourselves not to consider it sufficiently.

That being said, Mrs. Somers, we will vote for the bill, since, as my colleague Dedry said, it is a copy-paste of the Ecolo-Groen bill and it meets the needs. We will vote for the amendment that we both co-signed, because it takes into account the proposals of the three federations, pharmacists and general physicians.

Whether this amendment is accepted or not, we will also support the resolution, only to enable the Flemish actors to guarantee the people who carry a kit, i.e. essentially Flemish, that they will not be in illegality. Hoping that the first paragraph of our resolution, which was written in consultation with the federations, will take into account the proposal they have made. Considering also that parliamentary questions will be frequent, in order to verify that the diversity is well present in the facts and in the arrangements provided to the platforms to organize, in a specific and appropriate manner for each Region, the availability of medicines as well as their transport and storage.

I will be brief, because everything has already been said.

My party considers it time to extend the definition of INAMI-refunded palliative care. Such care could not continue to be limited to merely accompanying the inevitable diagnosed end of life in the near future.

It is necessary to integrate palliative care into healthcare at an early stage; to recognize the importance of the psychological, social, spiritual and existential aspects of patients whose life outlook is committed; not to rely on life expectancy, but on the needs of each individual patient; to take better into account their pain, dignity and emotional concerns. These approaches, which require a multidisciplinary approach, are essential for the approximately 10,000 to 20,000 patients who, every day in our country, are in an advanced or terminal stage of a serious or progressive disease, as well as for their relatives.

Therefore, we welcome the unanimity that has emerged around this high-human value-added bill. I am very pleased to vote in favour of this proposal. But, of course, I return to all that Ms. Fonck and Gerkens said: it was essential to listen to the different federations and pharmaceutical associations and to take into account their opinions, as they are field actors. We are their intermediaries, but we have not played the right role.

I would also like to add a personal comment. I worked for several years in a home palliative care association. To return to Ms Fonck’s financial statements, we need to produce a financial analysis of the support we can provide. We need to work with INAMI in this area. Then there are the full packages and the small packages. They are the ones that make the associations live. When the money is missing, you have to run behind the subsidies and donations. It is exhausting. You should know that nurses who work in palliative care at home are extremely courageous people, who constantly face death. It is, by the way, very difficult to recruit them, because their mission requires a lot of experience. We need to financially support these organizations. As Ms. Fonck said, this is a way to save money. When a patient has to end his life in a hospital, it involves a cost.

Certainly, some patients prefer to die in the hospital and feel safer there. But many are those who want to end up in the middle of their furniture and people they love. As I said, there is a need for financial encouragement. This is a small call from the foot that I make to the Minister.

Mr. Speaker, the members of the Public Health Committee have contributed in a positive way to take further steps.

One of the great merits of the bill is that it disconnects palliative care from the previously known term of the last three months of life. It is a strange way of working, to have to predict that someone will live for three months and not longer. In addition, palliative care may be needed earlier than three months before the end of life. In this regard, the bill provides clarification for both patients and healthcare providers. The matter is sensitive, but I am pleased that consensus has been found on a large part of the measures and proposals. Is this the last step? No, more steps will need to be taken. This is always so.

From the Cabinet I think that we have informed ourselves about and shown the necessary interest in the work of the members of the committee. I will carry out what will be approved here later.