Professor Patrick Plunkett:

I do not know where to start. Deputy Sandra McLellan asked about pain relief and the key challenges. Is down to the usual. It is knowledge, attitudes and skills among staff. There are small groups of people who have great knowledge and skills and the right attitude, while the vast bulk of people do not have adequate knowledge or skills. That said, above all there is an attitudinal element which we can address much more effectively, certainly in the emergency departments, that it is the patient's pain. It is not one's own pain on which one must decide whether one is giving enough or not enough or one must not give any more. One must interface with the patient who will say when they have enough. There are problems with complexity of dosing, particularly with patients who are on multiple medications nowadays. There is always concern for toxicity.

People bring up the issue about concern for dependence on such medication, however if it is end-of-life care, dependence is hardly an issue. We need to get the issues related to pain relief sorted.

In regard to the reluctance to allow people to die in nursing homes, and my comments on Leas Cross, HIQA and the standards, if we could apply the standards adequately in the nursing homes, then I do not think we would have a problem. Again it is an attitude and knowledge issue. It is people running scared. People are frightened that they will be the people hung out to dry if they let the person, who is known to be dying, die from another issue such as an urinary tract infection. I think a great deal of work needs to be done to change those attitude. It needs a lot of support from both clinicians, support groups and HIQA.

Senator van Turnhout did not realise that the legal basis of "Do not attempt resuscitation", DNAR orders was not clear. Senator Colm Burke commented on the fear of litigation by litigious relatives. There are certainly issues in this regard but we must stand on our professionalism. Dr. Madden came up with this issue, if I am not mistaken, about family versus the competent adult and conflict in instructions. I have long held the position that if I am unable to communicate adequately with the patient or rather that he or she is unable to communicate adequately with me, my role legally and morally is to advocate on behalf of that patient. I do not have a role to advocate on behalf of the relatives. The relatives do not have the decision making capacity in general, virtually in every case they have no decision making capacity for a patient who cannot communicate. What I do is make it very clear to the relatives that I am interested and need to know what they think the patient's view would be, not their view, and I make it very clear to them that this is not their decision to make on whether to resuscitate, that it is my decision. I will make that decision and I will relieve them of that burden. I will not allow conflict to arise between members of the family because otherwise it may. The level of relief that brings to families is unbelievable because suddenly this burden has been taken away from them. They know they do not have the knowledge and skills to make those decisions and now they know they do not have the responsibility to make them either.

I think we must remember that all we are doing in resuscitation - I am coming away slightly from end-of-life care in one sense - is that we are postponing premature death. Death at the appropriate time should not be postponed any longer. It is appropriate. Coming back to Senator Colm Burke's issue about advanced paramedics arriving, two issue arise, one cannot force engagement in a futile resuscitation. That is immoral at the very least. The mechanism that the Pre-Hospital Emergency Care Council, PHECC has developed in clinical practice guidelines is that we work with machines which can tell us that it is futile to continue resuscitation. It is not simply an opinion plucked out of the air, it has a sound, solid scientific basis as well as everything else. It is vitally important that we ensure that control at all times, up to the point where it is no longer possible, remains with the patient. It is their illness, their life and death. Our role is as an assistant in that. We are there to advise and to assist people through their life. Ultimately we are all going on the same journey and perhaps we will end up in a similar place.