John Crown (Independent) | Oireachtas source

I thank our colleagues and, as someone who was recently told he was one of the leading referrers of people to the palliative services in the country, I just wish to state what an outstanding job they do. It has been a real pleasure to see this specialty and discipline growing over the two decades in which I have been back in Ireland. I have a couple of quick points to make and will ask a couple of quick questions. First, I deal with a large number of patients who die and in each week of my career I meet on average two people who definitely will pass away from the illness with which they came to see me, as well as some others who ultimately also will have that outcome, where it might not have been apparent that it was inevitable but where it still has happened. It has dawned on me that there is no real right way to die. It is very different. Some people clearly get phenomenal benefit from the warm embrace of being in a specialised purpose-built hospice, and that is really excellent. Some people - I believe an increasing number - wish to die at home, and I believe we should do everything we can to accommodate them. There also are people who wish to continue their care in a seamless fashion in the institution in which they have been looked after through the potentially curative phase of their illness. However, when that is no longer working and when, sadly, they are in the terminal care phase of their illnesses, for want of a better phrase, they would be quite happy to stay in the same institution in which they had been treated.

There is a real need to have a little flexibility and nimbleness in the way we develop our end-of-life services to accommodate those and facilitate the choice which is critical.

After the very sad conversation with a patient after the active phase of their treatment is over, they very often ask me if we are sending them to a hospice. I tell them we would be delighted to have them go to the hospice if they so wish. However, if they want me to continue being their doctor, we can give them the same care with the expert palliative services which we have in our hospital. It is critically important in developing the strategy that we acknowledge those three elements. Does the delegation believe there should be an emphasis on one direction rather than the other?

The second issue is one of cost. There is no doubt there is a significant amount of waste in the care of people who would not be thought of as formally palliative. Culturally and historically, palliative care has been regarded as cancer-related. That is changing, however. One reason is that the actual post-active treatment/pre-death phase of many cancer patients is quite short. Patients can be quite well, up and about and getting active treatment until that last treatment is no longer available to them. Often that final phase is shorter than expected. There is an increasing recognition that the extraordinary skills built up by palliative medicine doctors and care nurses would be beneficial for other people. I was delighted to hear Professor O’Shea refer to the needs of dementia patients. There are many of them who have been badly disabled by cerebrovascular disease or strokes whose quality of life is miserable, who do not want any more active medical treatment and whose primary concern is the symptomatic quality of their life. There is a real need to focus the energies and skills of the palliative services in directions which have not been thought of as classical palliative services.

With respect to cost, we often have a chat with a patient informing him or her that there is nothing else we can do to make the cancer shrink but we are not giving up and will look after them in a different way. When one does cross that Rubicon, the aspect of the cost of the hospital-based part of the care becomes a lot cheaper. This is apparent when one discourages the young doctors from enthusiastically ordering the extra tests they read about in medical school by asking them whether it will make the patient feel better or worse. It is also important to cost the different methodologies in end-of-life care.

With respect to the euthanasia debate, I always promise my patients that I will be with them as long as they want and I will not let them die in pain. If one takes that philosophy and undertakes to give whatever level of medication is required to make patients symptoms go away and guarantee patients will die comfortably, that is not euthanasia.

We must acknowledge that we have developed an extraordinary new national resource with one of the world’s true leaders and developers in the field of palliative medicine, Professor Declan Walsh. He has spent a long career in developing the palliative care unit at the Cleveland Clinic in the United States and has come to make his services available to us in Ireland. He is a resource all of us need to tap into in a big way.