The Palliative Care of Londoners

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					        New WHO Guidance
     (1) Palliative care the solid facts
(2) Better palliative care for older people

              Irene J Higginson

• Intended audience, rationale, process of
• Content of two booklets
   – (1) Palliative care the solid facts,
   – (2) Better palliative care for older people
• Next steps
• Invite discussion of dissemination and what
  useful in your countries
• Floriani Foundation
• The Open Society Institute Network Public
  Health Programme
• The European Association of Palliative Care
• King’s College London
• The European Institute of Oncology (WHO
  collaborating centre)
             Acknowledgements –
              WH0 expert group
•   Janet Askham            •   Lalit Kalra
•   Elizabeth Davies (ed)   •   Karl Lorenz
•   Marilene Filbet         •   Joanne Lynn
•   Charles-Henri Rapin     •   Martin McKee
•   Kathleen M Foley        •   Miel Ribbe
•   Giovanni Gambassi       •   Jordi Roca
•   Irene Higginson (ed)    •   Joan Teno
•   Claude Jasmin           •   Vittorio Ventafridda
•   Stein Kaasa
Who is the guidance for?
            • policy makers
            • governments
            • health care planners

            • Professionals,
              voluntary, families -
              will be able to USE
              the guidance to
              advocate for
              palliative care
       Process of development of
Telephone conference calls
Meeting in Lago Orta, Italy
Meeting at EAPC conference
   in the Hague
Consultation, comment,
   EAPC, individuals,
   organisations (wide)
Evidence review – as part of
   WHO HEN document
Formal WHO review
                               THANK YOU
Drafting, contributions, re-drafting,
  images, WHO technical editor
              Why two booklets?
• Initial goal - to provide guidance on palliative care
  for older people
• But – how would we best reach policy makers?
   – Be part of a series - THE SOLID FACTS – which WHO
     Europe Office aims at policy makers
• But do policy makers know what palliative care is?
• Different people responsible for older and general
   – 2 booklets - independent but interconnected
          Content of guidance:
•   Short statements, key facts, pictures, figures
•   Definitions
•   Examples of good practice
•   Recommendations
•   Europe (relevant) focus (initially)

• There are many gaps in our knowledge, but it is
  a first step – ideally would be updated
Palliative care: The Solid Facts
 1. Changing populations
 2. Emerging needs towards the end of life
 3. Palliative care
 4. Rights and options
 5. Effective palliative care
 6. Vulnerable groups
 7. Improving services
 8. Educating professionals
 9. Educating the public
 10. Research and development
  Palliative care: The Solid Facts
highlights – implications for policy
    1. Policy-makers must invest in providing publicly funded
     palliative care services as a core part of health care and not
     as an “add-on extra”.
  2. Policy-makers must take steps nationally to ensure that
     unmet needs for care are identified for all common
     serious diseases, including cancer, ischaemic heart
     disease, cerebrovascular disease, chronic obstructive
     respiratory disease, end-stage liver and kidney disease,
     infectious diseases and dementia.
  3. Policies must also recognize the work of families and
     caregivers and support them to help care for the patient.
     Might include assistance similar to that often granted to those
     with maternity and paternity responsibilities.
  Palliative care: The Solid Facts
highlights – implications for policy
 1.    Public health policy must acknowledge peoples’ right to
    high-quality palliative care and to make decisions about it,
    whatever the nature of the disease they suffer from. These
    rights should be enshrined in health and social care legislation.
 2. Policy-makers should monitor the wishes of seriously ill
    people concerning place of care and death.
 3. Policy-makers should routinely monitor place of death as
    one interim measure of success of the system of palliative care
 4.     Policy-makers should encourage the health services to
    inquire of people their preference for place of care and
    death. Meeting individual preferences should be the ultimate
    measure of success.
Better palliative care for older
      people: overview
 1. Why palliative care for older people is a public
   health priority
 2. Palliative care: the needs and rights of older
   people and their families
 3. Evidence of underassessment and
 4. Evidence of effective care solutions
 5. The challenge for health policy- and decision-
 6. Recommendations
  Highlights - Predicted proportions
   of people over 65 years in 2020
Country          Year
          2000          2020
Italy     24            31
Japan     23            34
                                              2000   2020
Germany   23            29
                               United Kingdom 21     26
Greece    23            29
                               France          21    27
Croatia   22            26
                               Switzerland     21    32
Spain     21            27
                               Norway          20    26
                               Hungary         20    26
                               Slovenia        19    29
                               United States   16    22
       Highlights - Why is ageing
• Populations are ageing – this is fastest in
  developing countries
• People reaching 65 live on average 12 – 22 more
• Japan and France have highest life expectancies
• Proportion of those 80 years and over increasing
  fastest, already 4% this age in Germany, UK,
  France, Japan
        Highlights - Why is ageing
•   Most people who die are elderly
•   Shift from acute to chronic causes of death
•   New technologies and expectations
•   Changing family, culture, ethnic patterns
•   Likely reduction in available workforce
Highlights - From what will we die in 2020: worldwide?
Disorder                             Predicted   Previous
                                     ranking     ranking
                                     2020        1990
Ischaemic heart disease              1           1

Cerebrovascular disease (including   2           2
Chronic obstructive pulmonary        3           6
Lower respiratory infections         4           3

Lung, trachea and bronchial cancer   5           10
      Highlights - palliative care
• Those dying in old age are more often missed by
  palliative care services
• because of:
  –   nature of illness
  –   setting of care
  –   wishes of patients and families
  –   differences in treatment
  –   possible ageism?
             Pharmacological treatment of cancer patients with pain
             in US nursing homes according to the WHO pain ladder
             Source: Bernabei et al, JAMA 1998;279(23):1877-1822

             50                     65-74               75-84          85+

             40                                                                  Morphine or like substances
% patients

                                                                                4 out of 10 patients 65-74
                                                                                 1 out of 10 patients 85+
                                                                                         No analgesia
             10                                                                 2 out of 10 patients 65-74
                                                                                3 out of 10 patients 85+
                                                        Com bination
                     No analgesia

Highlights - Where do patients die
            by country
   0                                                                           Home

             and Wales



                                                                               Nursing home
                                                                               In-patient hospice
      Highlights - Illness in older
      people: multiple pathology
• Multiple problems, varying severity
• Minor problems may have greater psychological
• Cumulative effect may be much greater than any
  individual disease
• Additional problems of acute illness, physical or
  mental impairment, economic distress, social
Next steps
•   Document with printer
•   Approval of proofs and photos by WHO (and me)
•   Printing
•   Launch - ? Nov / Dec (or early 2004)
•   Dissemination – and use
•   Template of format / photos available from
    European Office - for translation and re-printing
    in other languages by those who wish
• Dissemination
   – Launches involving ministry are planned in some
     countries, e.g. Italy
   – What would be best way of disseminating for you
• Printing
   – How many copies would you like, and where are
     best repositories of copies – e.g. Mary Callaway's
     living room

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