Palliative Care The contemporary concept of palliative care has its origins in the modern hospice movement.

Beginning with Dame Cicely Saunders and the opening of St. Christopher's Hospice in 1967, the underlying philosophy of palliation included holistic care (emphasising emotional, social and spiritual needs) taken hand-in-hand with a progressive approach to managing end-of-life symptoms medically. The movement's success is reflected in how universally accepted these goals now are, if not actually universally available yet. Aims of palliative care:

To affirm life but regard dying as a normal process. To provide relief from pain and other distressing symptoms. To neither hasten nor postpone death. To integrate psychological and spiritual aspects into mainstream patient care. To provide support to enable patients to live as actively as possible until death. To offer support to the family during the patient's illness and in their bereavement.

Epidemiology Each full-time GP will have an average of about 20 patient deaths per annum. Typically, 5 will be due to cancer, 5-7 organ failure (cardiac, renal, COPD), 6-7 through dementia, frailty and decline and 1-2 sudden deaths. Palliative care will be appropriate to many more patients in their care (the average GP has 40 patients with cancer, for example) at any stage in the disease and treatment path from pre-diagnosis to bereavement or survivor support. Palliative care provision remains uneven in the UK. The 2004 House of Commons Health Committee's 'Inquiry into Palliative Care in England' found:

Gross inequality of access to hospice and other specialist palliative care services by diagnosis (95% went to people with cancer). National Institute for Health and Clinical Excellence (NICE) guidance on 'Supportive and Palliative Care for Adults with Cancer'[7] should be fully implemented and its underlying principles should be extended to develop palliative care for patients suffering other lifethreatening conditions. Issues surrounding choice of place of death: o Between 50-90% of patients with cancer wish to die at home but only 22% achieve this. Approximately a quarter of people express a preference to die in a hospice, but only 17% of those with cancer and 4% overall die there. o There has been a downward trend in home deaths, falling from 31 to 18% between 1974 and 2003. If the trend continues, under 10% of deaths will occur at home by 2030. o Dying at home is associated with low functional status, an expressed preference (and carer agreement), home care and its intensity, living with relatives and dependable extended family support.

Palliative care provision in the UK There are two distinct groups of health and social care professionals involved in providing palliative care:

'Nonspecialists' involved in day-to-day care and support of patients and their carers in their homes and hospitals. This group should be able to assess and meet the patient care needs under ordinary circumstances or to seek advice from/refer to specialist palliative care services in more challenging situations. Specialist palliative care providers (eg consultant palliative care physicians or nurse specialists). Delivery of care may be via hospice, day centres, hospital or community teams or telephone advice services. Specialist palliative care funding comes in part from the state and much from voluntary organisations, charities and local-fundraising. Only 35% of adult hospice income comes from the NHS.

1. Cultural characteristic and beliefs.

A. Importance of family and kinship in London? Having a wide circle of friends is important to psychological wellbeing, but a network of relatives is more important for men according to new study from the UK. The research, published in the Journal of Epidemiology and Community Health, found the midlife wellbeing of both men and women seems to depend on having a wide circle of friends, with a lack of friends associated with significantly lower levels of psychological wellbeing. The study, which included 6500 Britons born in 1958, found that a network of relatives is also important, but only for men, and for women, lack of friends had an even greater negative impact on wellbeing. It found being partnered is associated with large kinship networks, yet only men psychologically benefit from having an extended kinship network. Its interesting that this study, like others before, has found that being partnered or married is more beneficial to men than women, said Monika Merkes, Honorary Associate at the Australian Institute for Primary Care & Ageing at La Trobe University. The study states: The association between partnership status and psychological well-being was present among men only. However, further analyses showed that values of psychological wellbeing were actually higher in women, especially those who were not partnered, when compared with men.

Dr Merkes said the study did not go into possible reasons for this, but one might speculate that mid-aged womens caring role for older relatives and their own children or grandchildren adds stress rather than conferring psychological benefits. She pointed to a recent Australian study, which examined relationship quality and levels of depression and anxiety that found that only good-quality relationships bestowed mental health benefits over remaining single. The study, published in the Social Psychiatry and Psychiatric Epidemiology, also found that for women, being in a poor-quality relationship was associated with greater levels of anxiety than being single. More information on why those studied were not in a relationship would be useful said Richard Fletcher, senior lecturer in the Family Action Centre at the University of Newcastle. They dont differentiate on unpartnered people whether theyre separated divorced or single. You can imagine your networks would be reduced a bit if you were divorced, Dr Fletcher said. The study found one in seven had no contacts with relatives outside their immediate household, and around one in ten said they had no friends. This study adds support to previous studies that show being socially connected is good for wellbeing and mental health. In this context, it is of great concern that about one in ten people report having no friends at all, Dr Merkes said. The researchers asked about the number of relatives and friends with whom the research participants meet once a month or more, but Dr Merkes said it was not sufficiently clear what was being measured.

B. Health beliefs and practices of elderly Often foreigners will say they dress in such dark colors but really that is not true. In the winter when it rains the most you will see them donning coats that are not super colorful but in the small amount of summer they do have they will dress brightly with great patterns on the fabrics. You have to keep in mind their clothing reflects their climate and location where they live. You might see a farmer in coveralls, overalls, jeans and Wellingtons (like a rubber boot) and perhaps a heavy coat (like a Mac or heavier). Their food is unique too. Who else serves kidney pies? They even eat fish called kippers for breakfast and their bacon is different from other places. They love to eat fried fish and chips (a thick piece of potato fried). Tea is a beverage that is consumed as much as Americans drink coffee, soda pop and water combined. They even add milk to their tea which makes some Americans turn up their noses at the idea of putting milk into hot or cold tea. American prefer ice tea but the Brits prefer hot tea. The Brits who consume the high fat diets suffer from obesity,

cardiovascular diseases and early deaths. More and more children and teens have grown obese with the addition of American restaurants such as McDonalds. C. Social Security System Legal residents in the UK may be entitled, in certain circumstances, to a number of social security benefits. These include:

Income support Job seeker's Allowance Child Benefit Housing Benefit Council Tax Benefit Disability Living Allowance Invalid Care Allowance State Pension

Most benefits are managed by the Department for Work and Pensions (DWP) through Jobcentre Plus offices. Invalid Carer's Allowance Invalid Carer's Allowance is a taxable benefit to help people who look after someone who is disabled. The claimant does not have to be related to, or living with, the person for whom they care for. People eligible for Carer's Allowance include those who are over 16-years old who spend at least 35 hours a week caring for someone who is entitled to certain benefits. A person may not be able to claim if they earn over a certain amount and cannot claim if they are in full-time education. It is important to be aware that receiving the allowance may affect any other benefits that are claimed or benefits claimed by the person they care for. The amount is paid weekly and directly into the carer's bank account. State Retirement Pension A State Retirement Pension is paid to women aged 60 and over and men aged 65 and over. The eligible age for the state pension is due to rise to 66 in the future. To qualify, pensioners need to have paid enough National Insurance contributions throughout their working life. The amount they are paid depends on the contributions they have made. Basic State Pension

The basic State Pension is a regular payment from the government that you can get when you reach State Pension age. To get it you must have paid or been credited with National Insurance contributions. The most you can currently get is 107.45 per week. The basic State Pension increases every year by whichever is the highest:

earnings - the average percentage growth in wages (in Great Britain) prices - the percentage growth in prices in the UK as measured by the Consumer Prices Index (CPI) 2.5% The maximum you can get is 107.45 per week. If youre married or in a civil partnership and expect your basic State Pension to be below 64.40 per week you could top it up to that amount but there are qualifying rules.

2. Top ten diseases that inflict the elderly in London.

Diseases Coronary Heart Disease Cerebrovascular Malignant Neoplasm of Trachea Pneumonia Disease of Pulmonary Circulation Bronchitis, Emphysema and COPD Malignant Neoplasm of Breast Chronic Liver Disease and Liver Cirrhosis Diabetes Mellitus Hypertensive Disease

Crude Death Rate per 100,000 as of 2010 129.40 79.29 56.12 45.62 44.05 43.63 36.86 12.02 9.93 8.35

Rank 1 2 3 4 5 6 7 8 9 10

3. What are the ethics and legal issues?

A. Advance Directives In England and Wales, people may make an advance directive or appoint a proxy under the Mental Capacity Act 2005. This is only for an advanced refusal of treatment for when the person lacks mental capacity and must be considered to be invalid and applicable by the medical staff concerned. In June 2010, the Wealth Management Solicitors, Moore Blatch, announced that research showed demand for Living Wills had trebled in the two years previous, indicating the rising level of people concerned about the way in which their terminal illness will be managed. According to the British Government, every adult with mental capacity has the right to agree to or refuse medical treatment. In order to make their advance wishes clear, people can use a living will, which can include general statements about wishes, which are not legally binding, and specific refusals of treatment called advanced decisions or advanced directives. B. Euthanasia In law, euthanasia has no special legal position in the UK. Instances described as euthanasia are treated as murder or manslaughter. However, the Suicide Act 1961 makes a specific offence of 'criminal liability for complicity in another's suicide', while declaring suicide itself to be legal. In practice, however, the prosecution of euthanasia in the UK is distinct from other cases of unlawful killing - the consent of the Attorney General to prosecute is an explicit requirement of the Act, and sentencing is influenced by the often desperate and harrowing circumstances of individual cases. The law has been reviewed since 1961, but has not been substantially changed, despite regular attempts by backbenchers in Parliament.

Since the Human Rights Act 1998, however, campaigners have claimed that the denial of a right to release oneself from unbearable pain amounts to inhuman and degrading treatment (Article 3 of the European Convention on Human Rights), is a violation of privacy and family life (Article 8), amounts to discrimination given the legality of suicide itself, and that an individual's inherent dignity and 'right to die' is violated by the current legislation. Jurisprudence, however, does not recognise a parallel right to die implied by the right to life.

The Law in England and Wales Euthanasia is illegal in the UK and a person found guilty of active euthanasia (i.e. by an act as opposed to an omission) may be liable for murder. Despite this there are certain circumstances where inactive euthanasia will not result in prosecution, for example where life support is discontinued.

Although suicide itself is not illegal, the act of encouraging or assisting the suicide or attempted suicide of another person is a crime punishable by up to 14 years imprisonment. It is important to note however that proceedings against a person on the grounds of assisted suicide can only be brought by or with the consent of the Director of Public Prosecutions (DPP). The DPP will only take the decision to prosecute if it is in the public interest to do so, and therefore a person who assists another person to commit suicide will not always be prosecuted despite that an criminal offence will have been committed. The high profile case of Debbie Purdy raised the important question of whether a person commits an unlawful act by helping another person to travel abroad to commit suicide in a country where the law permits assisted suicide. Briefly the facts of Debbie Purdys case are that she suffered from incurable motor neurone disease, which is degenerative in nature. Ms Purdy therefore wanted the option of determining when and how her life should come to an end, but her condition was such that she required the assistance of her husband to do this. Ms Purdy thus fought tirelessly to seek unequivocal assurance from the DPP that her husband would not be prosecuted for aiding Ms Purdys suicide after her death. Ultimately no specific assurance was given by the DPP to the effect that Mrs Purdys husband would not be prosecuted. However Ms Purdy did succeed in persuading the DPP to produce guidance on the law on assisted suicide in England and Wales. This resulted in the introduction of an interim policy on assisted suicide which sets out various issues that the DPP will take into consideration when determining whether or not to prosecute for assisted suicide. The full policy can be found on the Crown Prosecution Service website. Whilst it may in certain circumstances provide persuasive evidence against prosecution, it should be noted that this policy does not change the law. Euthanasia and assisted suicide remain unlawful in England and Wales and so the policy cannot be taken as a conclusive assurance as to whether a prosecution will be brought in any given case. C. Organ Donation Within the European Union, organ donation is regulated by member states. As of 2010, 24 European countries have some form of presumed consent (opt-out) system, with the most prominent and limited opt-out systems in Spain, Austria, and Belgium yielding high donor rates. In the United Kingdom organ donation is voluntary and no consent is presumed. Individuals who wish to donate their organs after death can use the Organ Donation Register, a national database. The UK has recently discussed whether to switch to an opt-out system in light of the success in other countries and a severe British organ donor shortfall. In Italy if the deceased neither allowed nor refused donation while alive, relatives will pick the decision on his or her behalf despite a 1999 act that provided for a proper opt-out system. In 2008, the European Parliament overwhelmingly voted for an initiative to introduce an EU organ donor card in order to foster organ donation in Europe. Landstuhl Regional Medical Center (LRMC) has become one of the most active organ donor hospitals in all of Germany, which otherwise has one of the lowest organ donation participation rates in the Eurotransplant organ network. LRMC, the largest U.S. military hospital outside the

United States, is one of the top hospitals for organ donation in the Rhineland-Palatinate state of Germany, even though it has relatively few beds compared to many German hospitals. According to the German organ transplantation organization, Deutsche Stiftung Organtransplantation (DSO), 34 American military service members who died at LRMC (roughly half of the total number who died there) donated a total of 142 organs between 2005 and 2010. In 2010 alone, 10 of the 12 American service members who died at LRMC were donors, donating a total of 45 organs. Of the 205 hospitals in the DSOs central regionwhich includes the large cities of Frankfurt and Mainzonly six had more organ donors than LRMC in 2010.[ D. Advance medical technologist management Palliative care aims neither to hasten nor postpone death, and medical technology must not be used to prolong life in an unnatural way. If treatments are futile and unnecessarily burdensome the physicians have no obligation to continue them. Medical technology makes it possible to prolong life, but at the same time ethical questions occur such as the patient's right to refuse treatment, withdrawal of life-sustaining treatments and euthanasia. Nurses experience anxiety and sorrow to participate in unnecessarily aggressive treatments or the prolonged use of lifesaving technology. Medical technology can create ethical dilemmas in the decision of whether to withdraw medical treatments or not. Nurses consider neither they nor the next-of-kin are sufficiently involved in this decision making process, which implies that nurses sometimes make their own treatment decisions based on what they think is best for the patients. However, another study shows that physicians and nurses in intensive care units are united in the decision about the level of life support treatment. The use of nutritional treatments in end of life care differs depending on culture and attitudes among the healthcare personnel. The majority of the patients with home parenteral/enteral nutrition have a survival longer than four months after the treatments are introduced, which is an indication that these treatments are not introduced in late palliative phases.94 However questions may arise about what a dignified death is. Is it a death with a low or high technology presence? For nurses, the problem with the technology is not the technology itself, instead it is about what they and the patients consider is a humane, natural and dignified care and death. E. Last will Who can make a Will? In most jurisdictions you must be at least 18 years old to make a Will, however exceptions may be made for younger people if they are in the military, if they are married or if they have been legally emancipated. In addition you must be of "sound mind" to make a Will. Being of sound mind means:

You understand you are making a Will and you know what a Will is; You understand your relationship to those mentioned in your Will; and You understand what types of property you own, how much of that property you own and how you intend to distribute that property.

A will may not include a requirement that an heir commit an illegal, immoral, or other act against public policy as a condition of receipt. In community property jurisdictions, a will cannot be used to disinherit a surviving spouse, who is entitled to at least a portion of the testator's estate. In the United States, children may be disinherited by a parent's will, except in Louisiana, where a minimum share is guaranteed to surviving children. Many civil law countries follow a similar rule. In England and Wales from 1933 to 1975, a will could disinherit a spouse but since the Inheritance (Provision for Family and Dependants) Act 1975 such an attempt can be defeated by a court order if it leaves the surviving spouse (or other entitled dependent) without reasonable financial provision.