Improving Palliative and End-Of-Life Care for Older People in Ireland: A New Model and Framework for Institutional Care

IntheRepublicofIreland,justover27,000peopledieeachyear.Justoverthree-quartersofthemaremorethan65yearsold(1).Thisiscomparabletothe situation in the United Kingdom, wherealmosttwo-thirdsoftotaldeathsoccuramongthoseolderthan75(2).Internationaldemographicpatternsindicatethatinmostpartsoftheworld,people are living longer, and dying typicallyoccursinlaterlife(3);thesedemographictrendsarepredictedtocontinueinthiscentury.Epidemi-ologicalchangesinIrelandarereflectiveofthoseinotherEuropeancountries,where,increasingly,olderpeoplelivewithoneormorechroniccon-ditions—includingcancer,organfailure,anddementia—forsomeyearsbeforetheydie(1,3).Hence,asignificantnumberofolderpeoplemustnowcopewithoneormorechronicconditions—andsomeanawarenessofprolongedanduncer-taindying—foraconsiderableperiodbeforedeath.InIreland,40percentofolderpeopledieinacutecarehospitals,15percentinnursinghomes,25percentinpubliclyfundedlong-stayinstitu-tions,and20percentathome(4).Previousreportshaveexaminedend-of-lifecareinhospitalsandthroughspecialistpalliativecareservices—carethatislargelyfundedbyvoluntaryorganizations—anditsrelationshipwithcommunitymedicalandnursingservices(5-7).Theextensionofpallia-tivecareservicestomeettheneedsandprefer-encesofthosewithcancerorotherlong-termcon-ditionshasbeenadoptedasagovernmentpolicyaim,withoutreferencetotimescaleordefinitions.IntheIrishandBritishcontext,palliativeandend-of-lifecareareseenasservicesthatareofferedoveranextendedperiodoftime—uptotwoyears—duringwhichpatientsandtheirfamilieshaveanincreasingawarenessofapproachingdeath(2).Unlikeinothercountries,inIrelandandBritain,end-of-lifecareandhospicecarearenotconsideredtobeservicesthatarerequiredexclu-sively in the last few days of life. This moreextendeddefinitionofpalliativeandend-of-lifecarewillbeusedinthispaper.Itisreflectedintheadoptionofanend-of-lifecarestandardinthedraftNationalQualityStandardsforResidentialCareSettingsforOlderPeople,whichlinksend-of-lifecaretopalliativecareservices(8).Institutionsprovidingnursing,residential,andlong-termcareforolderpeopleareincreasinglyrecognizedasplaceswhereolderpeoplecanlivetheirfinalyears;theyarealsooftenseenasplacesthatwillprovidecaretoolderpeopleastheyaredying,althoughstandardsofcaremayvary(9).Overall,theevidenceindicatesthatthereisadiversityofprovision,withgeographicalinequityinthedis-tributionofservicesandlackofaccesstospecial-istpalliativecareforpartofthepopulation.Par-ticular concerns have been raised about thecoordinationofservices,especiallyinrelationtocommunitycareservices(9).Inthispaper,end-of-lifecareistakentomeancarethatlastsforanextendedperiod—forthetimeinwhichanawarenessofapproachingdeathcanbemeasuredindays,weeks,months,andyears.Itisnotconfinedtothehoursimmediatelybeforedeath(2).Ourfocusisonthecareprovidedtoolderpeopledyinginhospitalsandlong-stayinstitutions.IntheIrishcontext,thisincludesthefollowingstatutory,for-profit,andcharitablefacil-ities:acutecare,community,andpsychiatrichos-pitals;privatenursinghomes;andHealthServicesExecutive(HSE)extendedcareunits,aswellasHSEwelfarehomes,voluntaryhomes,andvolun-tarywelfarehomes(4).