Professor Cillian Twomey:

I appreciate the opportunity to speak with the committee and recognise that as this is the last hearing the members have probably heard most of what has been said in some shape or form previously but it is useful to have an opportunity to stress some aspects of it.

First, I speak as a geriatrician, and there are many similarities between specialists in palliative medicine and specialists in geriatric medicine in that with the advancement of medical science many specialties now tend to be more single system specialties whereas geriatric medicine still retains a total person approach, which is important.

Second, in geriatric medicine mortality of patients under one's care is a more common phenomenon by virtue of the age of the patient group one manages. In our own department, for example, 43% of our patients are over the age of 80 although by strict definition one is elderly when one reaches 65; that usually insults most people who are 65, myself included. There is that total patient approach but there is a confusion of terminology. What is end of life care? What is terminal care? What is a patient who is dying, and are we good at picking up those particular elements of the life cycle? In some respects we are not, and that comes back to education and training and awareness.

Historically, in palliative medicine - members have heard a good deal about specialist palliative care and I support the strong call for its expansion where it is particularly deficient in numbers - those involved looked after patients only with cancer. Fortunately, that is no longer the case because as we all recognise, there are many illnesses other than cancer for whom there is a phase beyond the curative, which requires support. For example, in terms of somebody with advanced heart failure, and there is a gradation of heart failure, 70% of patients in the grade 3 or 4 heart failure category will die within 12 months but we do not suddenly announce 12 months before they die that they dying. Our approach to their management, as in specialist palliative care, will be to look after them to the best possible extent symptomatically through their final months but a recognition in that phase is important from an entire spectrum of issues. Have they sorted out their family arrangements? Do other family members realise the circumstances and so on?

We have heard already about the numbers of deaths and where they happen. Each death is unique, whether it is following a traumatic event, a murder, a car accident or an acute medical insult. A different set of activities might need to be activated in the context of a sudden unexpected death but there must be a series of policies to look after that particular case.

In elderly care medicine, most of the deaths are relatively predictable in the sense that they have multiple conditions that, ultimately and unfortunately, will be responsible for taking their life. My interest in this subject was energised considerably when I was invited to become a member of the Hospice Friendly Hospitals Programme steering committee in 2005. To some extent I was embarrassed that I had worked for 40 years as a doctor and never questioned the inappropriateness of multi-bed facilities in our hospitals. If any of us go to London for the weekend with our spouse and we put the card into the bedroom door we do not expect four other couples to be in the room when we arrive. Were that to happen we would be appalled but we think nothing of having sick people in multi-bed facilities.

In the context of end-of-life, it is essential that patients and their families have the opportunity of being in a private area but that is difficult to realise when the percentage of single beds in our hospital construct is so small. There is an infection control policy, which I support to some extent, to the effect that if somebody is readmitted to hospital who, in a previous admission, had MRSA up their nose, for example, which is of no injury to anybody unless they travel up their nose, they must be put into a single room on readmission to hospital. We do not have any such diktat stating that if somebody is dying we should put them in a single room. This event occurs 29,000 a year and I suggest it needs some addressing.

Roger Ulrich, whom I reference in my paper, has done a good deal of work on this area and the advantages are far greater than just dignity, respect and privacy for a patient and his or her family when they are dying but he has proven financial savings and greatly reduced hospital care infections by a single room policy. In my view every bed in a hospital should be a single, with the obvious exception of intensive care and high dependency units. That should be the target.

The benefits of hospice care are well-established and we are indebted to those in specialist palliative medicine for the degree to which they have raised our awareness of it. A different philosophy is required for dealing with patients coming towards the end of life. An interesting paper was published this year in the New England Journal of Medicine, which I reference, entitled Generalist plus Specialist Palliative Care. It states: "[M]any elements of palliative care can [and should] be provided by existing specialist or generalist clinicians [general practitioners and other health care professionals] regardless of discipline".

Who has responsibility in this regard? We all have responsibility. The national advisory committee on palliative care defines three levels which I instance in my paper. Level 1 is a core skill that every health care professional working in a hospital or a community care setting should be able to deliver. As a geriatrician I could not possibly be asked to look after every old person who is sick, and a specialist in palliative care cannot be asked to look after every person, regardless of age.

Let us not forget that dying in younger people is equally in need of this support. If there is a philosophy of understanding the core issues involved across the board there is a better chance of a total improved care, on the basis that a rising tide raises all boats. In fact, ironically, the care of those in hospital who are not dying will be enhanced if that culture and philosophy is pervasive. The ageing population is something to celebrate not to criticise as is sometimes the case when people talk about the “burden of older age” and “bed blockers” and so on. Most of us are lucky enough that we will be very healthy. There is therefore a need to acknowledge the fact that numerically there will be more older people, and certainly more aged over 75 and 85, who will have medical problems, multiple pathology, for whom there will be a phase when they are dying.

Some of the decisions one has to make are challenging. Should somebody who is in a nursing home, or their own home, with a debilitating stroke disease and perhaps dementia as well, be admitted or transferred to a hospital straight away because their temperature rises or they get another infection? If one calls the out-of-hours medical on-call service the team on duty from midnight to 8 a.m. is not necessarily familiar with the patient or the setting. There is a low enough reflex to press the ambulance button to transfer that patient. That reflects a lack of dialogue in that institution between the health care professionals about whether if Cillian, who has these awful irreversible end-stage conditions, gets a temperature, we can deal with that in our own setting and not be afraid.

Have we asked the patient? I agree with Dr. Madden that there is a presumption that the dialogue is between the clinician and the family members. That is an even greater presumption in older age. There is an automatic presumption that if one is 80 one could not possibly answer a question whereas as we all know that is quite untrue. One's first loyalty and commitment is to the patient. Very often a patient will tell the doctor not to talk to his son and to please talk to him. That is not uncommon. Have we asked the patient what he would like to do at the end of life? Not often. In the geriatric unit in Cork we have a "do not resuscitate" policy, which works quite well but it has been challenging to introduce it. The centre of gerontology and rehabilitation in UCC is undertaking a study led by Professor Willie Molloy which is studying advanced care planning and the impact that might have on the residents of three large residential care facilities in the Cork-Kerry region. We are educating the residents who are capable of participating in such an exercise about advance care planning, seeking their views on it. We are also engaging in an education programme for the professionals, the nurses and doctors in those areas. We will study a certain number who have been given this training programme and compare them with another group who have not been on the programme to see the outcome. It might inform the current Dáil statute discussions on advance care planning and on capacity.

I support the notion of strategy. It has to be part of every service plan that there is an end-of-life, bereavement, death package. We need local leaders. Of the hospice friendly hospitals programme, which involved 40 hospitals, there are only four coordinators of end-of-life care paid on an ongoing basis. We cannot function without leaders at local level. I commend the committee for holding discussions on this topic.