How to improve palliative care

by Stephen Duckett

Legislation about assisted dying typically involves five key elements: four criteria for eligibility, and certification processes. The typical criteria are a prognosis or terminal criterion, a suffering criterion, an autonomy criterion, and a clarity criterion.

In remarks to the Queensland Parliament’s Health, Communities, Disability Services, and Domestic and Family Violence Prevention Committee, Grattan’s Health Program Director Stephen Duckett said the starting point of all criteria is the suffering criterion: assisted dying is limited to those who currently suffer.

Legislation in different jurisdictions adopts slightly different phrasing for these criteria, with adjectives such as ‘unbearable’ or ‘intolerable’ used to qualify the requisite pain. Often the criterion goes on to say that the suffering cannot be relieved by other strategies, such as palliative care.

But palliative care services throughout Australia are woefully underprovided. People are dying in hospitals when they want to die at home. In addition to being a personal tragedy, under-provision of palliative makes no economic sense.

It is heart wrenching to read through all the personal submissions to the Victorian Legislative Council Review of End of Life Care. There was story after story about the significant suffering of family member or friends; lack of access to good palliative care; and that patient needs were not met, sometimes for religious or values-based reasons.

The funding of palliative care in Australia needs reform because the funding design and espoused policy objectives are not in alignment. Payment models for palliative care should move toward activity-based funding using an agreed classification; funding should be uncapped, but performance monitored; and payment models should make explicit use of performance metrics and reporting.

Uncapped activity-based funding for palliative care is not a significant budget risk because demand for palliative care is naturally capped by need, related to the number of deaths. And in any event, good palliative care reduces the demand on other, more expensive services.

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