Leading the way: innovative health promoting palliative care.

Abstract

'Life is uncertain, death is certain' is a Buddhist teaching that captures a fundamental fact. We will all die. Death, loss and grief are all certainties that we will face over time. But this is where certainty ends. Although death is inevitable, many of the accompanying physical, social, psychological and spiritual issues are not. As palliative care services broaden their scope and become involved with a wider range of people living with, or affected by, a life-limiting illness, there is an increased recognition that not every one requires, or desires, the same level of specialist support over time. Taking a palliative approach means we can refocus palliative care policy and practice away from an individualised and medicalised approach to death and dying, to a health promoting and population based approach (Palliative Care Australia 2005). Such an approach recognises that only a few of us will actually need highly specialised palliative and supportive care to assist us through the dying process. Most of us will die in our local communities supported by primary health care providers, our family, friends, neighbours, elders and community connections.In this section of the journal we recognise that in addition to the resources of specialist, interdisciplinary palliative care services, there is a need to build capacity within our social and public health systems, to reduce the consequences associated with the dying process on individuals, carers and families and to work collaboratively with local communities and groups to foster community self-sufficiency. Therefore we not only need to develop individual choices about end of life care, but to place these choices within a broader policy and service framework that ensures equity for those vulnerable people who inhabit the margins of our societies. A population approach needs to ensure services are available for people who are refugees, or asylum seekers, or mentally ill, or homeless, or from isolated indigenous communities. Bearing this in mind, we need to ensure that our research practices are inclusive and do not factor out those whose language or backgrounds differ in order to get a homogenous sample.Likewise, a public health approach to dying is interested in enabling individuals, families and communities to become resilient in the face of tragedy, loss and grief, rather than viewing death through a private and pathological lens. Resilience has been well argued for decades with regard to the ability of some children and adolescents to cope well (bounce back) despite traumatic or adverse early life circumstances. However resilience has undergone a definitional drift; becoming less focused on coping with individual trauma and more directed to exploring ways that enable people and communities to cope with the stresses accompanying life transitions, with loss death and grief brought into sharp relief. A new book entitled Resilience in Palliative Care (Monroe & Oliviere 2007) argues that taking a narrow medicalised approach to the dying process, means the inevitable neglect of other needs central to living well until death. By contrast, taking a resilience approach supports individual strengths through communal capacity and partnerships that normalise dying and celebrate life.Tactics and strategies that strengthen the resilience of communities to care for their vulnerable members as they die are central to a health promoting approach to palliative care (Kellehear & Young 2007). Based on the metaphor that what happens upstream affects what happens at the mouth of a river, such tactics are commonly described in the health promotion literature as upstream (macro), midstream (meso) and downstream (micro) factors (Keleher, MacDougall & Murphy 2007). The more distal determinants upstream represent the population level determinants (public policy, death education, capacity-building, access and equity factors); the psycho-social determinants (social support, social capital, network creation) factors sit at midstream; and individual determinants (personal resources, spirituality, relationships, coping skills) are the impact at the mouth of the river. …