Since its start in 2000, the network
has expanded to 50 palliative care physicians, 100 palliative care nurses, and
15,000 trained community volunteers. In
recent years, having seen the value this
model has brought to the community, the
Kerala local government has started contributing funds to support the network.
Although Kerala has only 3 percent of
India’s population, the network is providing two-thirds of India’s end-of-life
services. This model has proved to be a
highly sustainable system that is owned
and operated locally and integrated into
the intricate fabric of local society.
Another example of a community-based approach to these issues is the
U.K.’s Community Nurse Development
Programme. 19 This program emphasizes
the importance of district nurses and the
integration of health care services provided to local populations. A specific
example of this program can be found in
Cambridge, England. A team of caregivers questioned and then changed how
they worked together and integrated
their care in order to better meet the
wishes of people in their end-of-life care.
Changes in the caregivers’ practices
included:
■ ■ Establishing regular meetings about
once every other month;
■ ■ Developing a patient list to include
anyone believed to be in the last year
of life with any underlying disease;
■ ■ Proactively discussing preferred priorities for care with patients and their
families;
■ ■ All caregivers writing in the same electronic notes; and
■ ■ Routinely updating out-of-hours services with patient information.
An audit of the program after a
22-month period showed that of the 57
patients who died, 91 percent were able
to die in the place of their choice, 67
percent were able to stay in their own
place of residence (vs. 35 percent national average), and only 12 percent died
in the hospital (vs. 58 percent national
average).
Providers
Aging is associated with the decline in
physical or mental capacity. Many will develop life-threatening illnesses in which
the progression of the illness inevitably
leads to death. This progression should
be matched by the nature of the care provided and the wishes and desires of the
elderly patient and their family. Therefore, patient engagement is necessary.
This engagement is already taking
place in several countries (see Figure
7). Unfortunately, there are still gaps.
For example, in China, cultural norms
are such that doctors rely on families to
make crucial health care choices, rather
than patients. 7
Increasing the training of health care
providers in the needs of the elderly with
chronic conditions who are near the end
of life can help align the progression of
the illness with the desires of the patient
and the end-of-life care plan.
The health system can also increase the supply of trained palliative care
providers.
FIGURE 7
Patient Engagement in Chronic Care Management,
Among Adults Age 65 or Older
Percent
100
90
80
70
60
50
40
30
20
10
0
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults in Eleven Countries
United States
■ Had a treatment plan for their condition they could carry out in their daily life
■ A health care professional discussed their main goals and gave instructions on symptoms to watch for in the
past year.
Australia Canada United Kingdom Netherlands
83
58
80
48
76
46
73
59
41
35
FIGURE 8
End-of-Life Preparation by the Elderly
Percent
100
90
80
70
60
50
40
30
20
10
0
Source: 2014 Commonwealth Fund International Health Policy Survey of Older Adults in Eleven Countries
United States
■ Had a discussion with someone, including with family, a close friend, or a health care professional, about
the health care treatment they want if they become very ill and cannot make decisions for themselves
■ Have a written plan naming someone to make treatment decisions for them if they cannot do so
■ Have a written plan describing the treatment they want at the end of life
Canada Australia Netherlands United Kingdom
78
67
55
66 62
46
59
53
31
43
16 16
39
47
20
