The Public Health Approach to Palliative Care

All health services worldwide, irrespective of speciality, have a consistent policy and practice approach to their populations.  These are:  

• a population health approach involving education and community development;
• a primary health care approach involving non-specialist providers of health care as front line workers for initial assessment, support and intervention;
• a tertiary approach involving specialist health care providers and inpatient facilities such as hospitals, clinics, or in the case of palliative care, hospices.

Palliative care began and continues to emphasise tertiary level interventions that emphasise inpatient facilities and specialist service providers.  A primary health care approach is in evidence in some parts of the world with extensive use of general practitioners or community nurses providing initial assessment and sharing responsibilities with specialists in providing adequate interventions.  A population health approach to palliative care is the most under-developed at this stage of palliative care service development.  Yet, it is the approach that has the most potential to enhance the quality of life and sense of well being to the widest number of people in sickness and in health, in dying and in loss, and in all caring experiences toward one another.  Interest in a public health approach to palliative care has been growing worldwide and this is evidenced in the international literature in the field.

A broad public health approach involves ALL efforts to enhance health and address illness and disease and this must mean excellent direct service provision by medical and other health experts and also the appropriate inpatient and outpatient facilities and equipment.  However, the development of professionals, direct services and inpatient and outpatient facilities do not exhaust our responsibilities toward the promotion of health and wellbeing.  According to the World Health Organisation it is absolutely crucial that communities are involved in their own health and wellbeing and this must include their multiple experiences of death, dying, loss and care.  This 'new' public health is also known as health promotion.  Health promotion has the following characteristics:

A commitment to the following four concepts:

1. Prevention
2. Harm reduction
3. Early intervention
4. Sustainability

A commitment to the following methods:

1. Participatory relations
2. Community development
3. Partnerships
4. Education
5. Population Health Approach
6. Ecological/settings emphasis

For health promotion in palliative care this means directing attention of our prevention, harm reduction and early intervention efforts toward the social, psychological and spiritual morbidities and mortalities commonly associated with death, dying, loss and care.  These include, but are not exhausted by, the human experience of stigma and discrimination, sexual dysfunctiongrief and depression, lack of social support, suicide, meaning-making in the face of death and loss, lonelinesschoice over place of death, ignorance and therefore ignorant responses towards bereavementor overwork when caring for those with cancer or dementia at home.  However in all these efforts - whether these are educational interventions or community development initiatives - all of our projects must be sustainable.  The idea of sustainability means that, if we as clinicians or the services we represent, decide to withdraw from these projects, these positive impacts must continue without our input.  Part of the criteria for the success of health promotion is not only that are able to prevent ot reduce harms, and that we can successfully act early to do so, but that such efforts continue to work long after we have stopped supporting them.  Health promotion initiatives, if they are worthy if the name, are sustainable.

The six health promotion methods in palliative care translate into:

(1) Participatory Relations

Learning to work with rather than on people we care for.  A health promotion approach values the experience and expertise of other people aside from professional knowledge.  Knowledge of community, of workplace, of the social and psychological barriers to uptake of health ideas must be addressed as a partner to individuals, families and communities.  A didactic approach to care is eschewed.

(2) Community Development

To work with communities in defining their own needs and priorities in death, dying, loss and care for one another.  A community development approach to care is one that encourages communities to do the actual practical work of end of life care in consultation with leaders in health care, accepting that this care may be turned over to professionals in crisis or when community care sources are no longer available, coping or desirous of continuing.

(3) Partnerships

Learning to understand and work inside a community development initiative that has partners in schools, workplaces, churches and temples, art galleries and museums, the media, businesses and clubs and sporting associations.  We also need to recognise that palliative care organisations cannot do community development alone - we must forge partnerships with colleagues in community health organisations.

(4) Education

Just as health education has been crucial to the prevention and harm reduction strategies of those working in cancer care (sun screens, dietary fibre, anti-smoking campaigns etc), sexual health (contraceptive use, sex education etc) or in trauma medicine (bike helmets, car seat belts, occupational health and safety regulations etc) so to education about death, dying and loss will reduce ignorance and ignorant social responses, increases support and address anxiety about death, dying, loss and end of life care for families and communities.  Death education is essential.

(5) Population Health Approach

Although an inpatient approach emphasises face-to-face encounters with patients and families, and although a health promotion approach incorporates this, it goes wider.  A population health approach in palliative care requires engagement in community wide activities that promote death education and community support at the end of life to the widest public in society.

(6) An Ecological Settings Emphasis

This requires us, as clinicians to understand how physical and social environments promote health or degrade it (polluted water supplies, the presence of asbestos in buildings, cigarette smoke, etc) and that such principles also apply to experiences of death, dying, loss and care (community prejudice about AIDS, poor or overcrowded housing, suburban isolation, etc). Such physical and social conditions require work with local government, media, and neighbourhoods to bring about social changes for the improvement of end of life care in all communities.

A public health approach to palliative care is a health promotion approach to end of life care, one that views the community as an equal partner in the long and complex task of providing quality health care at the end of life. Just as health, according to WHO, is ‘everyone’s responsibility’ so too is death, dying, loss and care. All members of this association hold this principle to be true and commit their respective organizations to this value and vision of end of life care.