Palliative and end-of-life care options in Spain

Terms used

• Médico de atención primaria — The médico de atención primaria is your family doctor in the public system and the usual first step to a palliative referral.
• Instrucciones previas — The instrucciones previas are a written advance directive stating your wishes about treatment for when you cannot decide yourself.
• Voluntades anticipadas — The voluntades anticipadas are the name some regions use for the advance directive.
• ESAD — The ESAD are Madrid's home-care support teams that give palliative care at home.
• PADES — PADES is Cataluña's palliative care programme, which provides home teams.

Key rules

• Cost: Palliative care is free if you have Spanish public health cover.
• Referral: Your family doctor or hospital specialist refers you, based on clinical need.
• Refusing treatment: You may lawfully refuse treatment, including life-prolonging treatment, and you should put it in writing.
• Palliative sedation: Palliative sedation relieves suffering that cannot be controlled and is not euthanasia.
• Regions: Regions run the services, so teams and waiting times depend on your area.

Palliative care is part of public healthcare

If you have cover under the Spanish public health system, palliative care is part of what it offers. It is free. It is available at home through primary care and in hospital through specialised care.

Each region runs its own services and sets its own details. The care is the same in principle everywhere, but the teams, staffing and waiting times differ by area.

How to get it

The usual route is your family doctor (médico de atención primaria) or the hospital specialist who treats you. They refer you to a palliative team. Referral depends on clinical need, usually advanced illness with limited life expectancy.

You may be referred to one of these:

• A home support team (equipo de soporte de atención paliativa domiciliaria), which visits you at home and works with your family doctor.
• A hospital palliative team, which supports you during a hospital stay or outpatient visits.
• A palliative unit or hospice bed, if care at home is no longer right for you.

Ask which of these suits you best. To find the team for your health district, contact your regional health service.

How regions organise it

Most regions combine home teams, hospital teams and some beds. Examples:

• Madrid: home support teams (ESAD), hospital palliative teams and some beds in a palliative or long-stay hospital.
• Cataluña: home teams under the PADES programme, hospital support teams and socio-health beds in sociosanitary centres.
• Andalucía: home-based support teams and hospital palliative teams working through primary care and hospitals.

Regional plans are renewed from time to time, so ask your regional health service what is on offer now.

Your rights at the end of life

You have the right to refuse treatment, including treatment that would prolong your life. This is lawful throughout Spain. Put your refusal in writing and give a copy to your doctor.

Palliative sedation is accepted good medical practice. It is used to relieve suffering that other treatments cannot control. It is not euthanasia. Ask your palliative team whether it could be used in your case.

You can also write an advance directive (instrucciones previas, or voluntades anticipadas in some regions). It records your wishes about treatment for a time when you cannot state them yourself.

Several regions have their own end-of-life rights laws. These include Andalucía, Aragón, Navarra, Galicia, Baleares, Canarias, Madrid, País Vasco and Valencia. They confirm your rights to refuse treatment, receive palliative care and sedation, and make advance directives.

Assisted dying is a separate matter with its own law and process. It is not part of palliative care or sedation.

What to do next

Follow the checklist below. The questions most people ask are answered in the FAQ.

Checklist

• Confirm that you have cover under the Spanish public health system, since palliative care is free for anyone covered.

• Ask your family doctor (médico de atención primaria) or your hospital specialist to refer you to a palliative care team.

• Ask whether a home palliative team, a hospital team or a palliative bed suits your needs best.

• Ask your palliative team whether palliative sedation could be used if your suffering cannot be controlled.

Check with your regional health service which team covers your health district, as details differ by region.

Frequently asked questions

Does palliative care cost anything in Spain?

No, palliative care is free if you have cover under the public health system. It is part of the standard public services, both at home through primary care and in hospital.

Is palliative sedation the same as euthanasia?

No, palliative sedation is not euthanasia: it is accepted medical practice to relieve suffering that other treatments cannot control. Assisted dying is covered by a separate law with its own procedure. Ask your palliative team if you want to know whether sedation could apply to you.

Can I refuse life-prolonging treatment?

Yes, you can refuse treatment, including treatment that prolongs life, as long as the refusal is put in writing.

Which regions have their own end-of-life rights laws?

Andalucía, Aragón, Navarra, Galicia, Baleares, Canarias, Madrid, País Vasco and Valencia all have laws on rights at the end of life. They cover refusing treatment, receiving palliative care and sedation, and making advance directives. If you live elsewhere, the national rules on refusing treatment still apply.