Germany
A social health insurance system that made specialist home palliative care a legal entitlement and keeps tight opioid rules alongside high medical opioid use.
9 domains reviewed · 9 high-confidence · 0 dated estimates · 9 material gaps
WHO region: Europe. World Bank income group: Income group not yet retrieved.
- Domains reviewed
- 9 of 9
- Hospice: 4 of 4
- Backed by a primary document
- 0 of 9
- Open questions
- 13
- Sources behind this dossier
- 27
- Newest source 2026
Lessons from Germany
- A statutory, fully insured entitlement to specialist home care with a 24/7 call service did not by itself raise overall outpatient palliative care. Entitlements need active expansion of generalist care too.174,175
- A special prescription form, quantity limits and physician-only prescribing coexisted with the highest controlled opioid consumption among countries compared. Tight prescription rules do not by themselves prevent medical availability.172,170
- Mandatory undergraduate palliative teaching since 2009 has not removed ward staff inexperience with opioids. A curriculum mandate needs training for senior clinicians and supervised practice.178,173
- Insurance-linked entitlements left uninsured residents with poor access. Coverage rules need an explicit route for people outside insurance.176
- In Germany, hospital-to-hospice transfer rates followed regional hospice bed density and did not track outpatient palliative team density, so expanding home teams may not replace inpatient hospice beds.308
- Trained hospice volunteers can add unhurried presence at the bedside, and family caregivers at home also need income protection and workplace flexibility.508,512
- Specialist opioid recommendations only relieve pain if ward teams are trained and confident to implement them.173
- Siblings of children in home palliative care may need their own screening and support.721
Palliative care
Is morphine available in Germany?
Opioid supply. Is a therapeutic opioid physically available in the wards that need it? Every country on this question
Germany had the highest per-person controlled opioid consumption among countries in a 2015 to 2017 international comparison. Outpatient opioid volume rose until 2016 and has declined since. Bereaved relatives report needing help with out-of-hours care and pain management at home.169,170,171
How often do home palliative patients face delays getting strong opioids at night, at weekends or after discharge?
Help answer it:Search PubMedHow does Germany regulate opioids for pain?
Narcotics regulation. What licensing regime governs stocking and dispensing, and when did it last change? Every country on this question
Opioids are governed by the Narcotic Drugs Act and the Narcotic Drugs Prescription Ordinance, which set maximum quantities and require a special prescription form for all opioids except tramadol and codeine. Hospital inpatients receive opioids without formal prescriptions.172
What do current rules allow teams to leave with home patients for emergencies, and when did that change?
Help answer it:Search PubMedWho can prescribe morphine in Germany?
Prescriber authority. Who is legally allowed to prescribe, and can that group be widened? Every country on this question
Only physicians, dentists and veterinarians may prescribe opioids. Hospital palliative consultation services mostly recommend opioids while attending physicians prescribe and carry legal responsibility. Nurses help manage many specialist home teams but have no documented prescribing role.172,173,174
Do home palliative nurses adjust opioid doses under delegation, and how is that governed?
Help answer it:Search PubMedHow does palliative care reach patients in Germany?
Service delivery. Through what structure does care actually reach a patient at home? Every country on this question
Specialist palliative home care became an insured entitlement in 2007, delivered by physician and nurse teams with a 24/7 call service; generalist outpatient palliative care, mainly by general practitioners, followed in 2013. After the 2015 Hospice and Palliative Care Act, outpatient palliative care did not increase in one state's claims data.174,175
Why did generalist outpatient palliative care decline while specialist care grew after 2015?
Help answer it:Search PubMedWho pays for palliative care in Germany?
Financing. Who pays for the drug, the visit and the workforce? Every country on this question
Statutory and private insurers fully cover specialist home care through regional contracts. Insurance covers most of an inpatient hospice bed and donations the rest, and uninsured residents have poor access. Since 2022, insurers can co-fund regional network coordination if the municipality matches.174,176,175,177
Do varied regional reimbursement schemes produce differences in access or quality?
Help answer it:Search PubMedHow are palliative care clinicians trained in Germany?
Training and recognition. What credential exists, who awards it, and does anyone recognize it? Every country on this question
Palliative care has been mandatory in medical education since 2009, and specialist home care contracts require certified staff. Hospital consultation services still name ward staff inexperience as the main barrier to opioid therapy.178,173,174
How many physicians hold the additional qualification in palliative medicine, and does it change prescribing outside specialist teams?
Help answer it:Search PubMedHow does Germany prevent opioid misuse without blocking pain relief?
Opioid safeguards. How are misuse and diversion controlled, and are treatment and naloxone available, without blocking pain relief? Every country on this question
In a national survey, 35 of 39 hospital palliative consultation services said ward staff inexperience or reservations about opioids sometimes or often led to recommended opioid therapy not being implemented or given at lower doses. In one national insurer, 5.7% of insured adults without cancer received an opioid in 2021. Take-home naloxone pilots date from 1998, and prescription requirements and lack of funding still limit its spread.173,715,716
How many people receive opioid substitution treatment in Germany, and do narcotics prescription rules delay opioid access at hospital discharge or in the dying phase?
Help answer it:Search PubMedHow do children get palliative care in Germany?
Children's palliative care. How do children with life-limiting conditions get palliative care and the medicines they need? Every country on this question
Children with life-limiting conditions and complex symptoms are eligible for specialized outpatient palliative care delivered by teams with pediatric expertise. Studies in Hesse found access is often difficult for families and a care gap for children who need home palliative care that is less intensive. Siblings aged 11 to 17 in a large home care program reported lower quality of life than national norms.719,720,721
How many children receive specialized pediatric palliative home care in Germany each year, and how evenly are teams spread across states?
Help answer it:Search PubMedHospice care in Germany
How the hospice model works here, who can use it, who pays and who it reaches. Covered 4 of 4.
What does hospice care look like in Germany?
Hospice model. What does hospice mean here, who runs it, and in what settings? Every country on this question
German hospice care includes inpatient hospices for people who can no longer be cared for at home and outpatient hospice services that rely mainly on trained volunteers for psychosocial support. Day hospice services are a newer addition, and uniform experience with them is still lacking. Nearly 300 inpatient hospices were listed in 2025.308,309,311
When did the first German inpatient hospices open, and what share are run by church-affiliated, charitable or private providers?
Help answer it:Search PubMedWho can get hospice care in Germany?
Hospice eligibility. Who can enter hospice, on what criteria, and how late do patients arrive? Every country on this question
Admission to an inpatient hospice requires a medical certificate of a terminal illness expected to lead to death within weeks or months, with no curative treatment possible, and confirmation that care at home is not feasible. Hospice care excludes further life-prolonging therapy such as anti-tumor therapy. About one third of hospice admissions in 2023 came directly from hospitals.308,310
How many days before death do patients typically enter a German inpatient hospice?
Help answer it:Search PubMedWho pays for hospice care in Germany?
Hospice funding. Who pays for hospice care: a public benefit, insurance, charity or families? Every country on this question
Insurance covers most inpatient hospice costs, and charitable donations cover the remainder. The 2015 Hospice and Palliative Care Act raised reimbursement rates and expanded outpatient funding.308
What exact share of inpatient hospice costs must providers raise from donations?
Help answer it:Search PubMedHow many people reach hospice in Germany?
Hospice reach. How many dying people use hospice, and who is left out? Every country on this question
In 2023, 47,846 patients received inpatient hospice care, and one insurer's data from 2016 to 2019 showed 3.3% of deceased people used inpatient hospice, with large differences between federal states. Transfers from hospital track regional hospice bed density, and cancer was the main diagnosis in 68.8% of hospital-to-hospice transfers. Low-density regions have fewer hospice services, and in one regional stroke registry only 0.05% of stroke patients were discharged to a hospice.308,309,310
What share of inpatient hospice users nationally have non-cancer diagnoses such as dementia or heart failure?
Help answer it:Search PubMedWhat fills the gap in Germany
How people get care outside formal services: families, faith communities, volunteers, health workers, healers, other medicines and charity. Described, not scored.
- Family caregiving
Family members provide much of the care for dying relatives at home, and many cut working hours or leave work. In an online survey, 304 of 320 caregivers wrote about needing workplace flexibility, financial compensation for lost working time, and help with administrative barriers.512
National evidence- Faith communities
Among Muslim immigrants and their descendants in North Rhine-Westphalia, families often treat caring for a relative until death as an obligation and may decline outside care services. Religious framings such as hope for a miracle or illness as a test shaped treatment decisions, and participants asked for Muslim support services and spiritual care; one professional described death insurance and repatriation of the body as part of prepared practice.513
Subnational evidence- Volunteers and compassionate communities
Trained hospice volunteers in inpatient hospices and palliative care units describe their role as small acts of kindness, creating a family-like atmosphere, and attentive presence that respects silence or refusal. Evidence comes from interviews with 16 and 12 volunteers.508,509
Subnational evidenceGermany has a wide network of volunteer hospice homecare services; a 2012 survey went to 1,332 of them. Their volunteer training includes spiritual care, often taught by trainers with pastoral care or theology backgrounds, and outpatient hospice services also accompany residents in nursing homes, the second most frequent place of death.510,511
Mixed scope
Sources cited here
- 169Scholle OHF, Jobski K, Viebrock J, et al.
Prescribing of Opioid Analgesics in Germany: Opposite Trends When Different Quantification Measures are Used. Clinical Epidemiology 2026;18:580510. Outpatient prescribing prevalence fell from 2005 while morphine-equivalent volume rose until 2016, then both declined. Abstract read.
- 170Richards GC, Aronson JK, Mahtani KR, et al.
Global, regional, and national consumption of controlled opioids: a cross-sectional study of 214 countries and non-metropolitan territories. British Journal of Pain 2022;16(1):34-40. INCB data for 2015 to 2017; Germany highest per-person consumption. Abstract read.
- 171Kasdorf A, Voltz R, Strupp J.
Dying at home: What is needed? Findings from a nationwide retrospective cross-sectional online survey of bereaved people in Germany. Palliative and Supportive Care 2024:1-9. Caregivers needed support with out-of-hours care and pain management. Abstract read.
- 172Rosner B, Neicun J, Yang JC, et al.
Opioid prescription patterns in Germany and the global opioid epidemic: Systematic review of available evidence. PLoS One 2019;14(8):e0221153. Narcotic Drugs Prescription Ordinance and Narcotic Drugs Act; special prescription form; physician, dentist or veterinarian prescribing. Full text read.
- 173Mueller E, Gahr S, Schnell A, et al.
Challenges in opioid therapy implementation: national survey of palliative care consultation services. BMC Palliative Care 2025;24(1):262. Consultation services mostly recommend rather than prescribe; ward staff inexperience the most cited barrier. Abstract and full text read.
- 174Jansky M, Heyl L, Hach M, et al.
Structural characteristics and contractual terms of specialist palliative homecare in Germany. BMC Palliative Care 2023;22(1):166. Specialist palliative home care introduced 2007 in Social Code Book V; teams of physicians and nurses with a 24/7 call service; fully insured; regional reimbursement contracts; certified staff required. Abstract and full text read.
- 175van Baal K, Hemmerling M, Stahmeyer JT, et al.
End-of-life care in Germany between 2016 and 2020: A repeated cross-sectional analysis of statutory health insurance data. BMC Palliative Care 2024;23(1):105. Generalist outpatient care since 2013, specialist since 2007; 2015 act made palliative care standard insured care; outpatient palliative care did not increase 2016 to 2020 (Lower Saxony claims). Abstract and full text read.
- 176Zimmer M, Sahm A.
Palliative care for the people without medical insurance in Germany: an empirical ethical approach. BMC Medicine 2026;24(1). Hospice bed costs mostly insured with the remainder from donations; facilities do not regularly treat uninsured patients. Abstract and full text read.
- 177Röwer HAA, Doctor E, Buck C, et al.
State of development of regional hospice and palliative care networks in Germany and a descriptive comparison of the role of coordination: results of an online survey using a maturity model. BMC Palliative Care 2026;25(1). Insurers can co-fund network coordination with municipal match; financing the least mature dimension. Abstract and full text read.
- 178Dronia MC, Dillen K, Elsner F, et al.
Palliative care education and knowledge transfer into practice: a multicenter survey among medical students and resident physicians in Germany using a mixed-methods design. GMS Journal for Medical Education 2024;41(3):Doc27. Palliative care mandatory in the medical curriculum since 2009. Abstract read.
- 715Lappe V, Grandt D, Marschall U, et al.
[Opioid prescriptions for insured individuals without cancer in Germany: data from the BARMER]. Schmerz 2024;39(5):359-368. Claims analysis of 6,771,075 BARMER-insured adults without cancer in Germany (2021): 5.7% received an opioid and 1.9% long-term therapy, mostly from general practitioners. Single insurer. Abstract read.
- 716Fleißner S
The implementation of take-home naloxone in Germany. An interview study with professionals who offer overdose education and naloxone distribution. Health Policy 2026;172:105707. Qualitative interviews with 12 professionals implementing take-home naloxone in German drug services; prescription and distribution requirements and lack of funding hinder spread. Small sample. Abstract read.
- 717Ernst J, Köditz AK, Kleinhaus H, et al.
[Outpatient cancer counseling centers in Germany: A comparative analysis of the range of services, quality standards and structural features in 2015 and 2023]. Gesundheitswesen 2026. Two nationwide surveys (2015 and 2023) of German outpatient psychosocial cancer counseling centers; 117 of 191 centers took part in 2023, with gains in multi-professional staffing. Response incomplete. Abstract read.
- 718Carter S, Thiesbonenkamp-Maag J, Gerlach C, et al.
Psycho-oncology on wheels-a qualitative feasibility study of implementing home-based psychosocial support within specialist palliative home care (SPHC): a study protocol. Ann Palliat Med 2026;15(1):8. Study protocol for a German feasibility project in which psycho-oncologists make home visits through specialist palliative home care. Protocol only, no results; describes the care gap after clinic-based support ends. Abstract read.
- 719Engler J, Schütze D, Hach M, et al.
[Specialized outpatient palliative care for children, adolescents, and their families-the special needs of the target group. Results of the ELSAH study]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2022;65(3):357-366. Mixed-methods ELSAH study of specialized outpatient palliative care for children and adolescents in Hesse, Germany, with surveys, interviews, observation and team documentation data. One federal state. Abstract read.
- 720Schütze D, Engler F, Ploeger C, et al.
Specialised outpatient paediatric palliative care team-parent collaboration: narrative interviews with parents. BMJ Support Palliat Care 2021;12(e5):e664-e670. Narrative interviews with 13 parents on collaboration with specialized outpatient pediatric palliative care teams in Hesse, Germany. Small qualitative sample, one state. Abstract read.
- 721Dinkelbach L, Köhler M, Galushko M, et al.
Psychosocial Well-Being of Siblings of Pediatric Patients in Palliative Home Care. J Pain Symptom Manage 2023;66(6):630-637.e1. Cross-sectional survey of 44 siblings from 29 families served by one large German pediatric palliative home care team, compared with national norms. Single team. Abstract read.
- 308von Sass C, van Oorschot B, Sammer T, et al.
Hospital-to-hospice transfers in Germany: analyzing the impact of age and gender at the care transition interface. Front Oncol 2026;16:1743124. Nationwide cross-sectional analysis of 2023 German hospital billing data on transfers to inpatient hospices, with background on admission rules, funding and hospice numbers; no conflict declared in the text read. Full text read.
- 309Apolinarski B, Stiel S, Herbst FA, et al.
[Too thin on the ground? Regional disparities in hospice and palliative care in Germany]. Z Evid Fortbild Qual Gesundhwes 2024;190-191:53-62. District-level regression of 401 German districts and cities linking population indicators to numbers of outpatient hospice services, inpatient hospices and palliative services. German-language article. Abstract read.
- 311Kaiser U, Vehling-Kaiser U, Hoffmann A, et al.
The complex intervention day hospice - a quality-assured study on the implementation, realization, and benefits with model character for Germany (IMPULS) using the example of "Day hospice Adiuvantes". BMC Palliat Care 2024;23(1):18. Study protocol for one day hospice in Lower Bavaria; states that uniform experience with day hospices in Germany is lacking; authors evaluate their own day hospice (self-evaluation). Abstract read.
- 310Dasch B, Berger K, Lenz P, et al.
Frequency of discharge of hospitalized patients with stroke to free-standing hospice facilities-a register study from Germany. Ann Palliat Med 2022;11(10):3102-3122. Northwest-German Stroke Registry 2017 to 2020 (one region, 339,513 cases) showing very rare discharge of stroke patients to hospices. Abstract read.
- 508Nassehi A, Saake I, Breitsameter C, et al.
Adding spontaneity to organizations - what hospice volunteers contribute to everyday life in German inpatient hospice and palliative care units: a qualitative study. BMC Palliat Care 2024;23(1):81. Qualitative interviews with 16 volunteers from five inpatient hospices and one palliative care unit on what volunteers contribute to daily life. Abstract read.
- 512Pieper S, Kasdorf A, Voltz R, et al.
"What Do You Get? Nothing": A Qualitative Analysis of the Financial Impact of Family Caregiving for a Dying Relative at Home in Germany. Healthcare (Basel) 2025;13(7). Qualitative content analysis of open-text survey answers from family caregivers of dying relatives at home on financial impact. Abstract read.
- 513Bernhardt F, Banaz-Yaşar F, Salvador Comino MR, et al.
How is access to palliative care negotiated and accomplished among Muslim immigrants and their direct descendants in Germany, and what culturally and religiously framed narrative resources shape meaning-making in serious illness and approaching death? A multicentre four-group qualitative study using constructivist Grounded theory and Narrative inquiry. BMJ Open 2026;16(6):e119027. Multicentre qualitative study of 53 Muslim immigrants, descendants, relatives and professionals in North Rhine-Westphalia on access to palliative care and religious framings. Full text read.
- 509Müller C, Authier D, Steger-Arand C, et al.
Relational care in palliative care units: a qualitative study of low-threshold volunteer hospice conversations. BMC Health Serv Res 2026;26(1). Interviews with 12 trained volunteer hospice companions running low-threshold conversations on two palliative care units. Abstract read.
- 510Gratz M, Paal P, Emmelmann M, et al.
Spiritual care in the training of hospice volunteers in Germany. Palliat Support Care 2015;14(5):532-40. Online survey of hospice homecare services on spiritual care in volunteer training; 25% response (332 of 1,332); authors based in practical theology. Abstract read.
- 511Frewer-Graumann S, Teichmüller AK.
[Enhancement of hospice philosophy and palliative care competence in nursing homes for seniors through cooperation with an outpatient hospice care service : A practical example]. Z Gerontol Geriatr 2020;54(1):13-19. Qualitative study (23 interviews) of one nursing home cooperating with an outpatient hospice service. Abstract read.