20 Simon Communities of Ireland 2.12 End of life care56 The concept of end of life care is ‘broader in scope than palliative care and allows a longer lead time to death’. End-of-life care is intimately bound-up with quality of life issues and therefore needs to be flexible and responsive to the needs of older people living in acute and long-stay care settings, given that this is where the majority of older people die in Ireland.57 “The need for end-of-life care can arise far away from actual death, depending on the physical, mental and emotional state of the individuals and their families.” (p. 21). There is no agreement about when end of life should begin. End of life care for older people generally includes a mix of gerontological care and palliative care in order to address Froggatt’s (2004) three stages of end of life care in long stay settings: • The living and losses experienced in the care home • The actual dying and death • The bereavement that follows. There are various dimensions to the provision of appropriate support and care to older people faced with the issues of serious ill heath, death & dying including: the quality of care received; the location of the care and where relevant the acknowledgement or recognition of the approaching death on the part of the individual, their family and their medical team; individual choice; respect for the older person’s dignity; and appropriate responses to their vulnerability at this life stage58. Research shows that over two-thirds of Irish people expressed a wish to die at home, if at all possible, but the reality is that the majority die in acute hospitals or long-stay residential settings (Irish Hospice Foundation, 2004). People tend to die in acute general hospitals where there is an absence of dedicated end of life services. Facilities for end of life care in many acute hospitals are not always suitable and recent research found that more than half of people who died in acute hospitals or psychiatric hospitals died in multi-bedded rooms (O’Shea 2008). Where services are better developed, it is no surprise to find an increased incidence of death in a special in-patient unit (hospice) or home-care setting (IHF/HSE Baseline Study 2005). Key good practices identified by O’Shea for end of life care include consideration of the person’s wishes at all stages of the care process (including any advance directive made prior to the onset of incapacity). He argues that there is a role for an independent advocate in assisting the person to make a decision about their care and treatment. While there is currently no legislation at present to underpin advance directives, either formal or informal, they are a means of ensuring an individual’s wishes are clear and can be respected. He also makes the case for the development of written policies/guidelines on advance directives on end of life care for ethnic minorities in residential settings according to the researchers. It is likely that similarly dedicated guidelines could be developed for older people who are homeless. Challenges and barriers to the provision of quality end of life care include staff shortages, lack of privacy, resource constraints, capacity problems, infrastructural weaknesses, education deficiencies and poor attitudes and expectations in relation to quality of life for older people at end-of-life. O’Shea in his work argues that ageism within society generally and within the health and social care system in particular makes it difficult to sanction investment in end-of-life care for older people, with little engagement with quality of life issues for older people in long-stay setting (p. 20). There is also a small but growing body of research that argues that the dying and death of individuals in what is termed ‘the fourth age’ ‘defined as 85 years and older’ may have a different experience to younger individuals. Nicholson & Hockley59 argue that ‘this group are more likely to experience repeated hospital admissions, lack of preventative planning, 56 A decision was made for the purposes of this study to use the definitions provided and applied by the Irish Hospice Foundation. It should be notes that specialist palliative care uses a different terms’ palliative care needs’ which is not time bound. 57 O’Shea, Eamonn, Murphy, Kathy, et. al (2008) End of Life Care for Older People in Acute and Long Stay Care Settings in Ireland. Hospice Friendly Hospitals Programme and National Council on Ageing and Older People. 58 The New Ageing Agenda, The Ageing Well Network website http://www.ageingwellnetwork.com/The-New-Ageing-Agenda/health 59 Nicholson, C & Hockley, J (2011) Dying and death in Older People. pp. 101-109 in Death Dying and Social Differences (2nd Ed) (Ed Oliviere, D, Monroe, B and Payne, S. Oxford University Press.
Homelessness, Ageing and Dying
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