Dr. Paul Gregan:

I will address a number of points. Deputy Kelleher's comments on out-of-hours services were well made. We have a large problem in how those services manage palliative care patients. They do their best under stringent, difficult circumstances. If one is in a house in the Kerry mountains at 2 a.m. trying to make a decision about a critically ill person who is not well enough to go anywhere, it is a difficult situation to manage.

The programme with which we are involved has examined this matter. We have considered two ways to help. First, services can be provided with information prior to attending a patient by means of an electronic palliative care summary e-mailed to them via a secure health link. Second, services can have access to a specialist palliative care physician via telephone, effectively providing a second pair of eyes to assist in making a decision. Of further help would be education programmes for GPs who work in out-of-hours services. Often, they are young and foreign. The programmes would update them on local skills and requirements.

Deputy McLellan asked about the Prague Charter. It has not been assumed into World Health Organization, WHO, or UN charters. It considers policy, the provision of essential medicines, training and the integration of the palliative care system. Internationally, there has been a major push to have the charter adopted by the WHO. However, it is still new and has not gained traction yet.

The Deputy also asked about a stand-alone entity to consider the provision of palliative care in the community. This would be a good development. It would need to involve the interested parties, for example, the Irish Association of Palliative Care, IAPC, the Irish Hospital Consultants Association, IHCA, and the Irish Hospice Foundation, IHF. Developing a group to act in an advisory capacity would be a good idea.

Senator Healy Eames asked about assisted dying. That is the polar opposite of what we in palliative medicine do. Palliative medicine is about assisted living and managing one's ability to remain alive.

The Senator also asked about informing the families of people undergoing palliative care. Routinely, that information comes from the individual patient. Most will be in a position to tell a palliative care physician whether they want their families to be informed. In the absence of a person being able to give consent, a GP or consultant must make the decision in loco parentis. However, it is good practice to keep a family up to speed with what is happening inasmuch as possible unless there is a specific direction from the patient prior to becoming ill not to do so.

Senator O'Donnell asked about support for general practitioners. The electronic palliative care summary is a good way of supporting general practice. A practise-based register of patients who are undergoing palliative care would be very helpful. We are trying to develop this idea. Under the gold standards framework in the UK, consideration is being given to comprehensive co-ordination of people deteriorating and dying, which helps to prevent people being unnecessarily admitted to hospital.

Education would also be helpful. A question was asked earlier in regard to the Irish College of General Practitioners. It provides education in this area. I was a palliative care tutor with the Irish college of General Practitioners for four years. The ICGP runs a course for GPs interested in this area. It would be useful to get them involved in the out-of-hours area. The issue of medical cards was also raised. Medical cards have been a hugely positive thing for patients on the ground. As palliative care physicians we often have to prognosticate and work out how long a person has to live. If we feel a person will die within six months then he or she will qualify for the service. However, we are not going to get it right every time. Based on unpublished research we believe that approximately 20% of the time the six month period will be over-run. We are currently running over by one or two months. To ask a person within a month or two of dying to reapply for a medical card on a means test rather than discretionary basis is inhuman. This has to change.