Transcript Changing attitudes and knowledge

Public Health Approaches to
Advance Care Planning:
Bruce Rumbold, 170610
Palliative Care Unit, School of Public
Health, La Trobe University, Victoria
Seminar Outline
• Introduction to ‘the series’: then to this
seminar
• Why a public health approach?
• Recent phases in end of life care
• A model for end of life decision making
• Strategies for decision making
• Research and evaluation tasks
• Conclusion & Discussion
LTU Palliative Care Unit Profile
Staff trained in social and spiritual care disciplines
Service:
Partnerships/joint programs with all but one Victorian health region
Training/consultation with all Victorian services part of DH health service
agreement
Teaching:
Undergraduate electives in death, dying, grief and illness & spirituality
Graduate entry program Bachelor of Pastoral Care
Graduate Certificate/Postgraduate Diploma HPPC by DE
Research:
Higher degrees by research
Social and spiritual care models
Community capacity building strategies
Health Promoting Palliative Care
Kellehear, A. (1999) Health Promoting Palliative Care. Melbourne, Oxford University Press.
Ottawa Charter
1. Enable, mediate, advocate
in pursuit of healthy public
policies and practices;
2. Create supportive
environments;
3. Strengthen community
action;
4. Develop personal skills;
5. Reorient health services.
HPPC
1. Provide education and
information for health, dying
and death;
2. Provide social support, both
personal & communal
3. Encourage interpersonal
reorientation;
4. Encourage reorientation of
palliative care services;
5. Create policies that do not
separate dying from living
Why public health approach?
• The epidemiology of dying shows that
palliative care addresses only a proportion of
end of life needs.
• Population health models typically used to
locate palliative care within end of life care
frameworks
• Public health: two streams – individual and
structural
The questions we’re asking..
 How can we develop and support flexible
ideas of “a good death” and minimise the
negative impact?
 How can the wealth of knowledge that
has been accumulated by palliative care
programs become more available to the
community?
 How can end-of life issues become more
a part of life (than just the end)?
Consortium logo
Phases in EoL Care
• Revival: the hospice movement
• Mainstreaming: hospice becomes palliative
care (and increasingly palliative medicine)
• Recognition of limitations to palliative care
practice models: the emergence of needsbased population models for end of life care
• Advance Care Planning as a governmentpreferred strategy for organizing end of life
care
What is Advance Care Planning
ACP is a process of on-going communication.
It enables individuals to :
 maintain a sense of control over their future
 express wishes about their future health care
in consultation with:
 health care providers,
 family members and
 other important people in their lives.
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What does ACP involve?
 Self-determination
 Respect for people’s wishes if unable to make these
decisions for themselves in the future
 Consultation with individuals, their family, friends and
the healthcare team
 Appointment of a Substitute Decision Maker
(Surrogate decision maker; agent; proxy; person
responsible)
 Involves (discussion leading to) Statement Of Choices
 Revision of plan as appropriate
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• Although advance care planning is generally seen
as a health care issue, it goes beyond healthcare
to encompass the legal sector, social services and
perspectives of citizens both as individuals and as
members of voluntary sector organizations.
Ideally, the broader societal dialogue about ACP
would include all of these sectors.
Implementation Guide to Advance Care Planning in Canada: a case
study of two health authorities [Internet]. 2008. Available from:
http://www.hc-sc.gc.ca/hcs-sss/pubs/palliat/2008-acp-guidepps/index-eng.php.
Ist International Conference on Advance
Care Planning, Melbourne, May 2010
• Focus on ACP programs; not on processes that
make programs credible or effective.
• Focus on end of life decisions; not on contexts
that make it possible (or impossible) to decide.
• Focus on medical needs whilst dying; little about
what’s needed to live constructively to the end.
• Focus on professional support to make end of life
decisions; little attention to mobilising the
support of the people who really know you.
How can we make this work?
Cannot keep adding professional services:
Need
Community development approach
 Build and strengthen partnerships
 Create more supportive settings
Consortium logo
Street AF & Ottman, G, ACP The State of the Science review www.careserach.com.au/
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Change processes
Regular review
Decision making
Reflective processes
Collaborative discussion
Changed knowledge & attitudes
Developing ACP decisions
ACP Decision review
ACP Decision making
ACP Decision strategies
ACP Decision support
ACP Decision environment
Café conversations
http://www.theworldcafe.com/
DECISION ENVIRONMENT:
Four Funerals in One Day Play
• A short play about the importance and value of
stories in Palliative Care and the value of talking to
loved ones about your preferences for end of life
care.
• Presented at community venues with facilitated
discussion by cancer & palliative care staff
Changing attitudes and knowledge
DECISION SUPPORT:
How to Care, What to Say
• Skills for caregivers:
professionals, family
members, friends,
‘unintentional hearers’
DECISION STRATEGIES: Evaluative Life
reviews combined with ACP discussion
• Combining ACP discussion in an evaluative life
review can assist people to consider their life
in focus and identify key values, trusted
decision makers and express future care
wishes.
DECISION MAKING: GP letters
Letters to GPs with the
wishes expressed as part
of the ELR/ACP process
Volunteers organise for
the person and their
trusted decision maker to
meet with a health
professional or lawyer to
complete a legal
document.
Research & Evaluation
• Community capacity can be measured: but the
link between interventions carried out and
capacity produced are not simple.
• Network analysis to identify pathways by which
interventions contribute to capacity.
• Comparative case studies to identify key enabler
of and barriers to systemic change.
• Action research to lead decision making through
the layers that link general awareness with
specific formalised end of life plans, policy
change, etc.
Network studies
• What are the effects of interventions?
– Changed behaviours
– Changed understanding
– Changed relationships
– Changed services
– Changed governance
Case study comparisons
• What capacities are being developed?
– Appropriate and timely use of services
– Effective informal care
– Partnerships with services and community
organizations in end of life care
• Comparisons:
– Between health regions
– Across states (Australia), regions (UK)
– Internationally
Dilemmas in public health
• Access to health care does not necessarily result in
health
• Social distance, resulting from social inequality, is a
key (negative) health determinant
• Declining public ownership of public services
• Risk discourse further individualising
structural/material determinants of health
• Policy, planning and research address today’s, not
tomorrow’s, populations
Governance issues
• Major health issues and major health
determinants (are deliberated) in fora to
which the public health community has little
or no access, and is not prepared for - such as
foreign policy, security policy, economic policy,
and trade policy.
•
Kickbusch, I. (2006) ‘Mapping the future of public health: action on global health’
Canadian Journal of Public Health 97 (1), 6-8.