Allan Kellehear

Health-promoting palliative care: A practice example

Although the development and spread of health-promoting palliative care is well known in Australia, as a form of community support facilitated by palliative care services, little is known about its actual practice outside that country. This article summarizes the main rationale and concepts of health-promoting palliative care, lists some of the key policy and academic writing on the subject, and provides one example of its practice. Health-promoting palliative care translates hospice ideals of ‘whole person care’ into broader public health language and practices related to prevention, harm reduction, support, education, and community action. How these ideas express themselves in partnerships between palliative care and the wider community to enhance the quality of life of individuals and communities living with dying, death and loss is described from an Australian example.

The end of death in late modernity: An emerging public health challenge

Health promotion discourses often assume that death and loss are someone elses business—usually palliative care or bereavement care. Palliative care and bereavement care, in their turn, provide direct service, acute care approaches to death and loss. Between these two approaches, little health promotion is evidenced. This paper critiques the assumptions both make about death in late modernity arguing that death and loss are increasingly social experiences for people that require active support and community development from the ‘new’ public health. The past therapeutic emphasis and the secularized view of death are receding. A new approach to death and loss is needed and the new public health may have an important major role to play in addressing these changes.

Deathbed visions from India: a study of family observations in northern Kerala.

This is an interview-based study of 104 families and their observations of the last weeks and days of a dying family member. Forty families reported “unusual experiences and behaviors” from the dying person in their last period of life. Thirty of these dying persons displayed behavior consistent with deathbed visions—interacting or speaking with deceased relatives, mostly their dead parents. There were six cases of reported premonitions of death and five possible confusional states with one patient reported to have had both a deathbed vision and confusional experiences. Socio-demographic factors such as gender, age, occupation, or cause and place of death were not found to be significant. Hindu patients appeared to be more likely than Muslim patients to report these experiences. Use of opiates (or not) did not appear to influence reports. The findings are discussed with reference to past studies of deathbed visions as well as their implications for the future pastoral care of dying people and their families.

Bereavement care for the non-bereaved

Abstract This article outlines key approaches for a health promoting approach to end-of-life care. Although direct service provision for end-of-life care and bereavement are crucial to any public health approach to dying, death and loss, a broader public health approach – one that targets people in good health and outside acute episodes of need – is also vital to building a communitys capacity for resilience and self-care. The approaches described in this article include community development, death education and social marketing, partnerships between statutory services and communities, local policy changes and critical reflection. International examples of these approaches are described with the aim of stimulating discussion and debate about their potential and worth in bereavement care.

Public Health Approaches to Dying, Death and Loss

This article supplies an introduction to the epidemiology of death and dying with an emphasis on global patterns of end-of-life decline. The introduction is then followed by an outline of the principles of health promotion and especially health promotion in palliative care. The importance of community development is emphasized. The article closes with a discussion of the barriers and challenges to these public health approaches to dying, death, and loss.

A call to action: an IWG charter for a public health approach to dying, death, and loss.

The current systems of care for dying persons, the people caring for them, and the bereaved operate in ways that frequently lack sufficient sensitivity to their needs. We describe a new model for dying, death, and loss that adopts a public health approach. Specifically, we describe a deliberative process that resulted in a charter for a public health approach to dying, death, and loss. Modeled after the World Health Organizations 1986 Ottawa Charter, our charter includes a call to action. It has the potential to bring about significant change on local, societal, and global levels as exemplified by four projects from three countries. Public health and end-of-life services and organizations need to form partnerships with the community to develop a public health approach to dying, death, and loss. Learning from each other, they will affirm and enhance community beliefs and practices that make death part of life.

Sharon R. Kaufman, And a Time to Die: How American Hospitals Shape the End of Life , University of Chicago Press, Chicago, 2005, 412 pp., hbk no price, pbk (2006) US

order to see the whole person, not only the demented pieces. The authors point to the role of emotions in understanding and supporting people with dementia. Emotions remain intact longer than cognitive capacities in dementia, and as they are our guides for responding to unknown situations, they may help us understand, and support, people suffering from a dementia that constantly threatens to make the known unknown. This book has many strengths and it may seem unfair to point to its (minor) weaknesses. I missed a more critical reflection on ‘development ’ as a concept, and material on the repressive effects of religion (or politics). They are indicated, but given little attention compared to the assumed positives of religion (here mainly Christianity) and spirituality. I also missed the psychology of the body – as appearance and identity, not just as an instrument (frailty) or a risk (health). It is suggested that only a few of us will experience mental frailty in advanced old age (p. 150), and that only a small minority will enter institutional care (p. 178). In my view more than ‘a small minority ’ will experience the pains of advanced old age, and increasingly so when more of us are living longer. The only population data presented are projections of the older US population by age between 1990 and 2050 (p. 149). Is this because the book is aimed at the US market? Not a good choice. But buying this book is, and even better to introduce it to students who need to learn that psychology extends beyond the age of 40 years.

18.00 or £11.50, ISBN 978 0 226 42685 3.

Anyone working as a social science academic will notice the ongoing tension between the professions and the social sciences. Even among the professions that are also social sciences, such as psychology and psychiatry, there are slow brewing internal debates and conflicts about what is ‘‘normal’’ or ‘‘cultural’’ and, conversely, what constitutes ‘‘abnormal’’ or a ‘‘problem’’ within a culture. Occasionally these debates spill into more public view, such as the one that involved homosexuality and the American Psychiatric Association’s Diagnostic and Statistical Manual some decades ago now. I thought then, as I often do now, that there must be serious occupational hazards in working with, and balancing, a view of ‘‘social problems’’ with an understanding about the broader, pluralist, and changing society in which these are believed to arise. Inevitably, there are social science colleagues with no vested professional interest in social problems who claim that many, even most, examples of a particular deviant behaviour or social problem are simply normal or are being increasingly made abnormal, and this will raise the ire of many at the professional forefront in that field. Enter here, for purposes of illustration, Zinberg’s (1984) early study of controlled recreational use of heroin. He found a significant group of users of heroin who worked and played as everyone else did and, just like most of these others, resisted addiction to their particular drug despite long years of regular use. This was an unpopular observation. Even now, the suggestion that most of our legal drugs are more dangerous and addictive than illicit ones sit awkwardly for many drug and alcohol professionals, especially those with prohibitionist leanings. Closer to home, so to speak, in the fields of death, dying, and loss, I watched (as I’m sure did many other readers of this journal) as Tony Walter (1996, 1999) took a round of criticism, questioning, and even cautioning for suggesting that maybe grief was pretty normal and was being over-pathologized and decontextualized. Many others have voiced this sociological observation and criticism repeatedly since then in different ways. A significant and increasingly large group of Mortality, Vol. 11, No. 4, November 2006