Palliative care: Planning for an ageing world A commitment to investing in those who are at their most vulnerable, those entering into life and those leaving life, is indicative of how nations value their people. It is a recognition that humanity is in and of itself valuable, not because of the potential of human beings to create wealth, or to contribute to knowledge or material production, but simply because of the intrinsic nature of human beings living relationally and in relationships within family, community and society. To honour the promise and the vision of universal health coverage (UHC), care systems need to be in place for everyone regardless of gender, race, citizenship, wealth, physical or mental ability, and also age. The concern of UHC for adequate geographical spread must be accompanied by a concern for adequate lifespan spread and this means ensuring appropriate, accessible and available coverage for those coming towards the end of their lives. Palliative care, therefore, is an essential but unrecognised component of UHC. As an integrated approach to care taken by all practitioners and health care providers regardless of clinical specialty or seniority, with appropriate resources including a skilled workforce and analgesia, palliative care is far broader than the care given in the last few weeks or days of life. Optimal palliative care starts early, as illnesses transition from curable to chronic deteriorating illnesses. It seeks to understand and reduce total pain; it is responsive to the cyclical nature of most illnesses, which rarely develop in straight lines of decline but in peaks and troughs of wellness and illness. It is proactive in interpreting care needs and reactive in responding appropriately, and it is hopeful: recognising that hope is not the promise of immortality, but the assurance of support. Such care is rarely seen in any health system and is frequently absent both in fragile systems, where efforts are focused on fire fighting disease with limited human and physical resources, and in highly technical health systems, where efforts are placed on aggressive treatment regimens to prevent death. Why is palliative care so important for the ageing? Those who are ageing have more complex health needs, more multi-morbidity and more treatment needs, and therefore have particular palliative care needs. The care they need is multidimensional, not silo-disease focused but patient centred, as few will die of only one illness as captured in Figure 1. Yet the focus of palliative care in the countries where it is available has traditionally been directed towards a single disease, namely cancer. Studies documenting the palliative care trajectories of those living with cancer, heart failure and liver failure show patterns of triggers that can provide indications of when to increase service provision. The physical trajectory of decline is mirrored by psychological and 26 Commonwealth Health Partnerships 2015 social trajectories of increased anxiety and fearfulness for the future. Hospital admissions following exacerbations of symptoms provide clear markers, with the sense of exhaustion and frustration often coming days after discharge, when the bustle of activity has dissipated and the patient is left coping, recognising that their illness has peaked and then settled, leaving them a little less well and with a little lower functionality than they had before. For many older people, a complex collation of illnesses muddies the traditional trajectories and calls for much more sensitivity and awareness of change. For the frail elderly, who don’t have exacerbations of illness yet are cognisant of a gradual decline in functionality, identifying their need for palliative care and the delivery of such care is much more difficult. Three sets of narratives among the frail elderly who required palliative care have been identified (WHO, 2014): the stable narrative, where the elderly person is able to hold onto their sense of self in the face of impending death; the regressive narrative, where there is a loosening grip on the self; and the tragic narrative, where the self is lost. An important feature of good comprehensive palliative care is its ability to strengthen the individual’s sense of identity and value, thus allowing those coming towards the end of their life to remain constant to themselves rather than feel that they are losing their self to a disease or a stage. ‘Clear physical illness offers explanation and legitimation of the physical and social position but also fosters a bridge between the old and new self. One can be “me with cancer”, “me with arthritis”, “me with kidney failure”, yet the degenerating body of old age and frailty becomes “me” – but with what?’ (Lloyd, 2015). With the passing of the resolution on palliative care at the 67th World Health Assembly in 2014, the advocacy for appropriate palliative care for all is now firmly on the global health agenda. The resolution called on member states ‘to develop, strengthen and implement palliative care policies’; to ‘support palliative care initiatives including education and training, quality improvement and availability of medicines essential for the provision of palliative care’ to ‘ensure access to essential medications’; and to ‘foster partnerships between government and civil society to increase access’, in order to develop and implement services that reach all (ibid). Data emerging on the palliative care needs of older populations as part of a larger programmatic investment in palliative care integration into health systems in four countries – Kenya, Rwanda, Zambia and Uganda1 – has identified four key issues that palliative care needs to address: Suffering. Older patients experience particular physical, emotional and spiritual pain. Analgesia for physical pain is largely missing from the limited battery of drugs available in many low-income Liz Grant
Commonwealth Health Partnerships 2015
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