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1Example title for notes and handouts 15 April 2017Public Health Approaches to Advance Care Planning:Bruce Rumbold,Palliative Care Unit, School of Public Health, La Trobe University, VictoriaExample footer for notes and handouts
2Seminar Outline Introduction to ‘the series’: then to this seminar Why a public health approach?Recent phases in end of life careA model for end of life decision makingStrategies for decision makingResearch and evaluation tasksConclusion & Discussion
3LTU Palliative Care Unit Profile Staff trained in social and spiritual care disciplinesService:Partnerships/joint programs with all but one Victorian health regionTraining/consultation with all Victorian services part of DH health service agreementTeaching:Undergraduate electives in death, dying, grief and illness & spiritualityGraduate entry program Bachelor of Pastoral CareGraduate Certificate/Postgraduate Diploma HPPC by DEResearch:Higher degrees by researchSocial and spiritual care modelsCommunity capacity building strategies
4Health Promoting Palliative Care Kellehear, A Health Promoting Palliative Care Kellehear, A. (1999) Health Promoting Palliative Care. Melbourne, Oxford University Press.Ottawa CharterHPPC1. 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 & communalEncourage interpersonal reorientation;Encourage reorientation of palliative care services;Create policies that do not separate dying from living
5Why 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 frameworksPublic health: two streams – individual and structural
6The 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)?Consortium logo
7Phases 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 careAdvance Care Planning as a government-preferred strategy for organizing end of life care
8What is Advance Care Planning ACP is a process of on-going communication.It enables individuals to :maintain a sense of control over their futureexpress wishes about their future health care in consultation with:health care providers,family members andother important people in their lives.Page 8
9Example title for notes and handouts 15 April 2017What does ACP involve?Self-determinationRespect for people’s wishes if unable to make these decisions for themselves in the futureConsultation with individuals, their family, friends and the healthcare teamAppointment of a Substitute Decision Maker (Surrogate decision maker; agent; proxy; person responsible)Involves (discussion leading to) Statement Of ChoicesRevision of plan as appropriateACP –A process that recognises an individual’s right to autonomy in making their own health care decisionsAims 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 themselvesConducted in consultation with an individuals’ family, friends and the healthcare teamCommon elements are the completion of a statement of choices specifying types of treatment a person would and would not like to receiveie. Resuscitation orders, artificial nutrition and hydrationAlso 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 themselvesPage 9Example footer for notes and handouts
10Although 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:
11Ist 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.
18DECISION 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
20DECISION SUPPORT: How to Care, What to Say Skills for caregivers: professionals, family members, friends, ‘unintentional hearers’
21DECISION 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.
22DECISION 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.
23Research & EvaluationCommunity 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.
24Network studies What are the effects of interventions? Changed behavioursChanged understandingChanged relationshipsChanged servicesChanged governance
25Case study comparisons What capacities are being developed?Appropriate and timely use of servicesEffective informal carePartnerships with services and community organizations in end of life careComparisons:Between health regionsAcross states (Australia), regions (UK)Internationally
26Dilemmas in public health Access to health care does not necessarily result in healthSocial distance, resulting from social inequality, is a key (negative) health determinantDeclining public ownership of public servicesRisk discourse further individualising structural/material determinants of healthPolicy, planning and research address today’s, not tomorrow’s, populations
27Governance issuesMajor 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.