Back to our roots: palliative care in the clinical setting.

Abstract

For the last ten years I have been involved in conducting research in palliative care across a variety of health care sectors in the Australian context. I have come to regard myself as a recent participant in palliative care after reading Lewis' (2007) book on Medicine and care of the dying: A modern history. His chapter on the development of palliative care services provides a comprehensive outline of the history of palliative care globally. Lewis highlights the remarkable achievements of palliative care champions across the western world. The efforts of many to recognise the needs of the dying and provide appropriate care, as articulated and practiced by Dame Cicely Saunders in the United Kingdom, created a ripple of change and led to a holistic philosophy of palliative care. Lewis's book demonstrates how far we have come to enact this philosophy and improve care of the dying.These champions of a systematic approach to care of the dying pressured health professionals and governments alike to broaden the focus of health care from cure to care. Through my own Australian research I have witnessed the influence of federal and state governments on increasing the availability of palliative care through a policy of'mainstreaming'. This policy aims to ensure that palliative care is available for all Australians rather than only for individuals located in urban areas close to a hospice or community palliative care service. It is evident that such an approach to care has also been adopted in other countries such as Sweden and UK.In Australia in the late 1990s when 'mainstreaming' began there was concern among the palliative care community that their philosophy and principles would be diluted, misinterpreted or even abandoned, in other health care sectors. Certainly the research Professor Street and I (Street & Blackford 2001) conducted at that time suggested that there were some inherent dangers in expecting all practitioners to provide palliative care within their own health care setting. It was evident that practitioners working in palliative care units located in acute care settings grappled with providing high quality endof-life care within an overarching philosophy of cure at all costs. In aged care facilities there was conflict with a philosophy of 'living in place' when a person was dying. In practice, living in place meant that health professionals needed to recognise that the aged care facility was now the elderly person's home. This encompassed the principles of the rights of older people to choose their care and be involved in decision making. Yet what happens when a person no longer is 'living in place' but 'dying in place'? Do they stay or go to a palliative care facility? When our research took us to the Australian bush, we found that to address palliative care needs of the local community a rural health service had created a palliative care space with facilities for the family to stay so they could be close to their loved one. Such space could also be converted to a birthing unit. The irony was not lost on us that limitations of resources meant that it was a shifting space from which a child entered the world and others departed.Since the introduction of 'mainstreaming' much has been done in Australia to educate and support health care professionals to be able to provide palliative care in various health care settings. The release of the 'Guidelines for a Palliative Approach in Aged Care Settings' (Australian Government Department of Health and Ageing 2004); programs such as PEPA (Program of Experience in Palliative Approach) (http://pepa education.com) which supports health professionals to undertake work placement in a palliative care service; as well as the work of various Palliative Care peak bodies such as Palliative Care Australia and Palliative Care Victoria, has lead to a further broadening of the availability of palliative care for all Australians.However in a climate of such success we cannot be complacent. …