1. Example title for notes and handouts
15 April 2017
Public Health Approaches to Advance Care Planning:
Bruce Rumbold,
Palliative Care Unit, School of Public Health, La Trobe University, Victoria
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2. 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

3. 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

4. Health Promoting Palliative Care Kellehear, A
Health Promoting Palliative Care Kellehear, A. (1999) Health Promoting Palliative Care. Melbourne, Oxford University Press.
Ottawa Charter
HPPC
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.
Provide education and information for health, dying and death;
Provide social support, both personal & communal
Encourage interpersonal reorientation;
Encourage reorientation of palliative care services;
Create policies that do not separate dying from living

5. 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

6. 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)?
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7. 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 needs-based population models for end of life care
Advance Care Planning as a government-preferred strategy for organizing end of life care

8. 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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15 April 2017
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
ACP –
A process that recognises an individual’s right to autonomy in making their own health care decisions
Aims to ensure an individual’s healthcare wishes will be respected in the event that they become incompetent and unable to make/express their choices for themselves
Conducted in consultation with an individuals’ family, friends and the healthcare team
Common elements are the completion of a statement of choices specifying types of treatment a person would and would not like to receive
ie. Resuscitation orders, artificial nutrition and hydration
Also invovles appointment of a surrogate decision maker who is aware of a person’s wishes and can enact these on their behalf should they become incompetent and unable to express their wishes for themselves
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10. 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] Available from:

11. 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.

13. How can we make this work?
Cannot keep adding professional services: Need
Community development approach
Build and strengthen partnerships
Create more supportive settings
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14. Street AF & Ottman, G, ACP The State of the Science review www
Street AF & Ottman, G, ACP The State of the Science review
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15. Change processes Regular review Decision making Reflective processes
Collaborative discussion
Changed knowledge & attitudes

16. Developing ACP decisions
ACP Decision review
ACP Decision making
ACP Decision strategies
ACP Decision support
ACP Decision environment

17. Café conversations http://www.theworldcafe.com/

18. 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

19. Changing attitudes and knowledge

20. DECISION SUPPORT: How to Care, What to Say
Skills for caregivers: professionals, family members, friends, ‘unintentional hearers’

21. 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.

22. 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.

23. 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.

24. Network studies What are the effects of interventions?
Changed behaviours
Changed understanding
Changed relationships
Changed services
Changed governance

25. 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

26. 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

27. 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.