【July 2017】3- Geriatric Palliative Care in Taiwan: From the perspective of public health

Director-General Ying-Wei Wang (Speaker) / by HFT secretariat

Dr. Ying-Wei Wang is the Director General of the Health Promotion Administration at the Ministry of Health and Welfare in Taiwan. His talk focused on the public health perspective of geriatric palliative care.

Like many other developed countries, Taiwan has an aging population. Taiwanese elderly population is predicted to increase to 41% in 2061. Although cancer is the leading cause of death at 28.6%, more than half of the deaths are still non-cancer related. Thus, the care for the elderly will continue to focus on non-cancer illnesses. The unhealthy year (i.e., average age - healthy age) in Taiwan is similar to most developed countries at around 9-10 years, but Taiwanese healthy age (71) is lower than Japan (75) or Korea (73), so there is still more that can be done to improve health and decrease unhealthy years.

According to the WHO Aging and Health Report in 2015, the ideal trajectory of life consists of high intrinsic capacity until the end of life (活得老死得快). To achieve this trajectory, the public health framework for Healthy Aging requires prevention, early detection, and control of chronic conditions when capacity is high and stable. However, when capacity is declining, those can reverse or slow down. Lastly, when capacity is significantly lost, it is crucial to manage and support chronic conditions while ensuring dignity. During this whole aging process, capacity-enhancing behaviors should be promoted, barriers to participation should be removed, and loss of capacity should be compensated. With this public health framework, unhealthy years will decrease, which is also known as the compression of morbidity.

The health care system is not familiar with how to take care of the elderly due to comorbidities, multiple unclear symptoms, and busy, untrained staff. Thus, Taiwan has been pushing towards Age-friendly Primary Health Care as recommended by WHO in 2004 to prevent the pitfall of elderly health care. Elderly  people may have high usage of medical services, but sometimes they may result in adverse events. 

These issues are addressed in The Religions of the World Charter, Palliative Care for Older People. It defines the clinical rights, patients’ rights, families’ rights, human rights, and also clarifies spiritual and religious perspectives of geriatric care. Clinically, elderly people have the right to early access to high quality palliative care, which includes workers with appropriate training and education and capacity building in communities. From patients’ and families’ perspectives, quality of life, individual cultural norms and beliefs, and the person’s wishes and preferences should be respected. From human rights perspectives, palliative care is a human right that includes essential medicines and the elimination of ageism. The elderly have the right to freely consent to, refuse, or suspend medical treatment. Lastly, religious faiths can contribute to the support and training of religious leaders, spiritual care professionals, and other healthcare members.

Palliative care is necessary to live an enjoyable life, age slowly, and die with dignity. Palliative care embodies not only disease- and comfort-focused cares, but also psychosocial and spiritual support for patients and families before and after death. The new palliative care movement in Taiwan includes care for cancer, non-cancer, elderly people, and dementia in long-term care, ICU, and communities. Policies and promotion, like Advanced Care Planning (ACP) and Shared Decision Making (SDM), were implemented to help encourage culture shift and establish common language for palliative care.

Some challenges to providing end-of-life care for elderly people with frailty include different disease trajectories, multiple comorbidities, and issues with mental capacity. Based on disease stable years, prognosis, and needs, Dr. Wang noted the support matrices to provide tailored support for patients and family. There is also a frailty scale that can be used to assess patients’ ability and capacity.

Besides health services, palliative care from a public health perspective also needs to include public policy, supportive environment, community action, and personal skill. In 2007, WHO introduced a guide for global age-friendly cities that include accessible urban environment and promote active aging. As of 2015, Taiwan has 22 cities that continue to promote development of elderly friendly cities.

As an application of the WHO global age-friendly cities and health promotion palliative care (HPPC), the Compassionate Cities (CC) model was developed. In the CC model, the ultimate 

palliative care consists of caregivers, health professionals, volunteers, public health workers, and communities that normalize death, promote health, provide leadership, and SDM to empower patients and systems. Both the inner network of close family members and outer network of community work together to help patients and prevent caregiver exhaustion. Currently, the Taiwanese Department of Health and Welfare has multiple projects to implement the CC model.

The public health perspective of HPPC can help avoid social tragedies, like unnecessary deaths of sick elderly, because palliative care is “everybody’s business.”To achieve this, Dr. Wang recommended the 5 P's: Promotion, Prevention, Protection, Participation, and Partnership.