Professor Declan Walsh:

I would like to respond to what Deputy Billy Kelleher said on the subject of pre-hospital care. In the case of a person who has been diagnosed with a chronic incurable illness, it comes back to the concept of having a defined plan of care agreed with the patient and the family. The plan of care should reflect the patient's wishes. The patient's care should be co-ordinated between the acute system and the community or post-acute system. In many cases, when somebody goes into hospital for a few days before going out into the community, these are random events, with no continuity of care and a lack of good communication between locations. The current evidence from the United States suggests earlier involvement of palliative care services reduces the average length of hospital stay and the likelihood of readmission to hospital. It is at the interface with community nursing homes that we can make sure the patient stays where he or she is best cared for. If he or she really needs to be in hospital, well and good. It is important that he or she should not have to go there because of some unanticipated crisis.

There is a continuing debate about the resources issue. If one has €100 to spend in a hospital, should one spend it on palliative care or intensive care beds, for example? We are not going to resolve that issue today. There is good evidence to support the general understanding that better resource allocation in hospitals will feed into the achievement of a better plan of care, thereby leading to earlier discharge from hospital and freeing up hospital beds for those who really need to be in hospital. This, in turn, will reduce the cost of care which is extremely expensive, as members will be aware.

The move towards seeing palliative care as a universal right has been addressed. The European Association for Palliative Care has issued its Prague declaration. All the signs are that this will move ahead through the World Health Organization, which we would all welcome.

I was also asked about the relationship with assisted dying. This is a very complicated issue and I suppose the short answer is to say the focus in palliative care and medicine is on the relief of symptoms. There is a minority of people who have intractable symptoms. In some of these cases, the people in question need to be sedated. This means that they are given drugs, or doses of medication, that render them unconscious. The objective is not to kill the person but to give him or her whatever medication he or she needs to relieve his or her distress. There is an important distinction. While it could be the case that these doses of medication might cause a person to die, the focus is on the therapy aimed at relieving whatever distress he or she is suffering. There is no question of somebody who is not suffering to any great degree being approached by a person with a dose of medication saying, "Now we are going to end your life." That is the distinction.

Most people who have worked in this field feel very uncomfortable about the manner in which the assisted dying debate is presented. The short way of putting it is that hard cases can make bad law. I have been working in the field for 30 years and the biggest issue I have had to deal with in that time is not that people want to die. People want to continue to live; that has been the overwhelming desire of nearly everybody I have seen in my professional career. One sometimes tries to persuade them to receive less medical care and fewer medical services. People will hold on to life with a grim determination. These issues need to be presented in a balanced way.

I am in favour of the Liverpool care pathway. I like pathways. I think it comes back to the issue of continuity of care. There should be a plan of care for each person. The Liverpool care pathway has run into problems because there has been a somewhat over-zealous application of some aspects of it. In addition, there have been some issues with the training of the staff expected to implement it. The devil is in the detail, as it is in many aspects of life. One might know what something looks like, but when one goes to put it down on paper, it becomes very black and white and may be open to misinterpretation. There is certainly an issue in that regard.

Advance directives are now mandatory in the United States. Every patient who comes into a hospital must have an advance directive. As a matter of routine, every patient must be asked about his or her wishes in that regard.