Adding Life to Years

chapter 3 THE JOURNEY OF CARE

Introduction

Ninety-five per cent of people aged over 65 stay at home. Most wish to continue to do so. When they become ill, they want easy access to the right kind of care, whether at home or in hospital.

Many episodes of ill health in older people are simple to diagnose, easy to treat and can be dealt with routinely by primary care and acute hospital services. However, particularly for the very oldest, care may be more complex. Diagnosis may be more difficult, multiple medical problems may co-exist, and care may be required from a number of agencies.

This section of the report recognises these difficulties and is therefore structured around the "Journey of Care" i.e. on the health of older people and the care actually experienced by older people at home, while attending acute hospitals, through hospital admission and on the return home or - in a small minority of cases - to other care settings.

This approach acknowledges that most people live at home and want to stay there or get back there as soon as possible, regardless of what the diagnosis is and however many problems they might have. The care of older people is the principal task for NHSScotland in the 21st century. Many health professionals and organisations are involved, but the focus should always be on the patients, not the providers.

Staying well

Most older people enjoy good health and wish to continue to do so. It is simply not true that growing old automatically means becoming unfit. There is a lot that the individual can do to remain fit and active, and, at a policy level, health promotion has a great deal to offer in reducing morbidity and promoting independence in the older population.

Exercise and Physical Activity

Exercise in later life can be both enjoyable and beneficial. Although muscle strength declines with age, it can be maintained and regained by exercise. Even in extreme old age exercise can restore function in ways that make the difference between being safely independent at home and losing that independence.

Systematic exercise training may achieve as much as 10 or 15 years' worth of "rejuvenation", and such exercise need not be particularly strenuous. Exercise classes offer social as well as physical gains, and are both popular and successful. Even without formal exercise programmes real benefits can result from regular exercise at the level of brisk walking (at 3 to 4 miles per hour).

There are also proven benefits to healthy ageing through staying socially and mentally active in older age.

Smoking

Older people are less likely to smoke than younger people, but around a quarter of the 65-74 age group smokes regularly. Giving up reduces risks of stroke, heart disease and lung cancer; and also reduces the risk of death as a result of respiratory infection. It is never too late to give up.

Alcohol

Many older people enjoy alcohol responsibly and in moderation. A few - around 6% of men and 1.5% of women in the 65-74 age groups - are problem drinkers and hence at risk of falls and injury, gastrointestinal disease and confusional states. Managing these problems is very complex and consumes resources. Compared to younger problem drinkers, they are more likely to drink daily than to binge, and more likely to conceal their drinking. Supportive interventions aimed at increasing socialisation can also help reduce problem drinking in later life.

Nutrition

Eating well contributes to health and well-being and recovery from illness. It is essential for the maintenance of immune function and wound healing.

Surveys of older people at home and in long-term care have shown that many are under-nourished. The recent National Nutritional Audit of Elderly in Long-term Care (CRAG, 2000) confirmed this. Undernutrition may impair older people's health and diminish their chances of recovery. Older people in hospital are poorly fed. Average weight loss during an acute stay is 5% of body weight.

Older people at home are most at risk if they are isolated, on low income and do not have easy access to sources of healthy food. People who retain their teeth in later life eat better diets than those who don't.

The frailest, including many in long-term care, may have little choice in what they eat. Their diets can be inadequate in energy terms and they may often require physical help with eating because of weakness or confusion.

ISD has in November 2001 published a feasibility study on the routine collection of data reflecting the nutritional status of older people in continuing long-term care in Scotland.

Our National Health - a plan for action, a plan for change commits NHSScotland to implementing the recommendations of the National Nutritional Audit, and also indicates that the Clinical Standards Board for Scotland (CSBS) will bring forward new standards on food and feeding in the NHS. This work is now underway: an expert group has been established and it is expected that the CSBS will produce standards for consultation in the first half of 2002.

New national care standards for care homes will be operated by the Scottish Commission for the Regulation of Care, and will include standards for ensuring that residents' nutritional needs are met.

Standard 13 states that care homes will guarantee older people that "Your meals are varied and nutritious. They reflect your food preferences and any special dietary needs. They are well prepared and cooked and attractively presented."

Oral Health

Poor oral health is common in later life and less than 30% of over 75s are registered with a dentist. Many - particularly the housebound and those in long-term care - encounter real difficulties in accessing dental care.

Mouth infections and gum disease are common complications of some of the commonest diseases of later life - such as stroke, Parkinson's disease and dementia - yet professional awareness of oral health is low. Examination of the mouth is neglected and treatable conditions are missed.

Footcare

Foot problems in the elderly are common. They reduce mobility and detract from the enjoyment of exercise. The incidence of diabetes and peripheral vascular disease also increases with age. The associated serious foot care problems can often be prevented by screening and regular easy access to skilled podiatric services.

Medication

Older people commonly need drug treatment and may greatly benefit from it, but adverse drug reactions continue as a major cause of morbidity and death. Although much is known about risk factors - such as changes in drug metabolism with age, high-risk drug groups and high levels of prescribing in long-term care - such knowledge is not always translated into practice.

Problems can arise because hospital and primary care doctors prescribe independently. Poor communication and co-ordination at the time of discharge from hospital creates especial risks. Further problems can arise because the patient may add over-the-counter medication. Critical review of medication reduces risks but, although widely recommended, is not widely enough practised.

Older people may find child-proof bottles and blister packs difficult to handle, and small print difficult to read. Drugs for older people should be prescribed and dispensed in ways that are physically accessible, with legible labelling and advice.

The National Care Standards for Care Homes for Older People include a standard for the administration of medication to older people in long-term care. This includes an assurance that arrangements will allow older people to manage their own medication safely and in a way that suits them best.

Disease prevention and disability reduction

Effective disease prevention measures for older people include:

• Vaccination against influenza
• Aspirin for secondary prevention of stroke and heart attacks
• Warfarin in atrial fibrillation, to prevent stroke
• Calcium and Vitamin D to reduce the risk of fracture in the housebound and those in long-term care
• Hip protectors for those most at risk of hip fracture - and who can comply
• Falls prevention

A number of disability-reducing surgical interventions are established as effective, and include:

• Coronary artery by-pass surgery
• Joint replacement surgery
• Cataract surgery
• Carotid endarterectomy

Effective rehabilitation also has a major impact on reducing disability in older patients, whether after acute illness, emergency surgery or elective surgery. It improves outcomes, minimises hospital stay and is highly cost-effective. Effective multidisciplinary rehabilitation must be available throughout the older patient's journey of care, and this is a recurrent theme of the report.

Recommendations:

• Older people should be encouraged to be physically and mentally active.
• Older people should have access to information about healthy life-styles, and health promotion campaigns should actively target and involve them.
• NHS Trusts, Local Authorities, voluntary and private providers with responsibility for long-term care of elderly patients are reminded of the recommendations of the National Nutritional Audit of the Elderly in Long-term Care and of the need to implement these recommendations.
• Older smokers should be encouraged to try to stop; and high-risk groups such as those with heart disease should be targeted for extra help in giving up smoking.
• Health professionals should be aware of the possibility of problem drinking in older people and be ready to help.
• Clinical examination should include assessment of oral health and appropriate referral when required.
• NHS Boards should ensure that older people who wish to do so have access to, and are registered with, an NHS dentist and are made aware that help may be available to assist with payment for treatment.
• Older people in hospital should be assessed to ensure that they can administer their own medications on discharge if that is clinically appropriate.
• Co-ordination of prescribing and drug provision for discharge from hospital should be improved.
• All older people who have repeat prescriptions should have a regular medication review.
• Medication for older people should be dispensed in accessible form, and with legible labelling and advice.
• Effective disease prevention measures should be advised to all older people, as appropriate.
• Disability-reducing surgery - e.g. for cataract and joint replacement - should be available on the basis of clinical need and appropriateness.
• Older patients have most to gain from good multidisciplinary rehabilitation in hospital and at home, and service organisation should reflect this.
• Multi-professional education should foster learning and innovation in service delivery.

Health Screening of Older People

Routine health checks are available in primary care for people aged 75 or over. They usually comprise simple assessments by a nurse or doctor, aimed at picking up new or worsening problems. However, the current arrangements have a number of disadvantages. They are carried out in different ways across the country. They can fail to identify growing dependency or deteriorating mental states. The information they provide cannot be put together to be used in the planning of services, either locally or nationally, for Scotland's one third of a million over 75s.

Recommendations:

• Screening of the over 75s should be reviewed, with a greater focus on identifying important problems such as falls, mental impairment, increasing dependency, oral disease, poor nutrition, poor foot care, tobacco and alcohol use.
• Standardised data from screening should be available to support planning better services for older people, enabling participation and independent living.
• Consideration should be given to linking screening with a check on uptake of benefit entitlements.

Supporting older people at home

Around 20% of over 65s in Scotland require regular help or care in order to stay at home, with the oldest age groups requiring most care. Such services, particularly for the most dependent, rely on good local co-operation between health and social work.

There are many examples of excellent practice across Scotland but much work is needed in order to generalise best practice.

A number of Scottish Executive initiatives over the last two years will support better joint working, higher standards of care, more responsive services and the spread of best practice across Scotland. These include:

• The Strategy for Carers in Scotland published in 1999, which set out a strategic framework to ensure better support for all carers, as part of a Programme for Government commitment to deliver person-centred health and community care.
• The report of the Joint Future Group Rebalancing Care of Older People, which recommends the single shared assessment and joint resourcing and management for services for older people at home. Its implementation, including the provision of rapid response teams, short breaks, and intensive home care, will enable more and more older people to remain at home - both through acute illness which might previously have required hospital admission, and despite increasing frailty which might otherwise have necessitated long-term care.
• NHS Boards and Local Authorities having in place by April 2002 joint budgetary arrangements for older people's services, along with single shared assessment of need. There is considerable potential therefore to be tapped into for more effective joint working on major resource allocation issues e.g. delayed discharge and care planning for individuals.
• The Scottish Commission for the Regulation of Care which, from April 2002, will have responsibility for national care standards in care homes, for day care and for care at home.
• The work of the Care Development Group which, in addition to implementing free personal care, also stressed the need to improve services in order to help older and frailer people to stay at home as long as possible.
• A National Strategy Forum which has been set up to deliver integrated equipment and adaptation services across Scotland to help people maintain their independence in their own homes.
• Additional funding - rising to £48 million by 2003-4 - which will enable local authorities to improve and expand home care services for older people as recommended by the Joint Future Group. These services will include rapid response teams, intensive home care, help with shopping, domestic tasks and household maintenance for low dependency older people, and free home care for older people leaving hospital.
• Additional funding to enable local authorities to improve the numbers and range of short breaks (respite care), to help sustain carers in their vital role in the support of very frail older people.

Carers are an invaluable resource in our society. Over 600,000 people in Scotland care for someone. Many are themselves no longer young: 30% are 65 and over.
Two-thirds of the people they care for are 65 and over.

Recommendation:

• Carers should be seen and valued as partners with the statutory agencies in the provision of care, and should themselves receive appropriate assistance.

Better Access to Services: the Single Shared Assessment

Too often in the past older people who need help in order to stay at home have not found it easy to obtain that help. They want to have convenient access to services no matter who is providing them, and they do not want to have to see, and be assessed by, representatives from every agency involved.

The Single Shared Assessment seeks to address these complexities. From April 2002, it will be used by all the relevant agencies in all settings across Scotland. It will focus on the needs of service users and their carers, and result in fewer visits, fewer questions and better assessment of need.

A single "key contact person" will co-ordinate the range of services needed more quickly. Bureaucracy will be cut, and resources will be used better. From the service user's point of view - by far the most important one - real improvements should result.

Improving Older People's Access to Health Care

Almost all of Scotland's older people are registered with a local general practitioner, are known to their doctor, and pleased with the care they get from that doctor.

Most health care for older Scots living at home is provided by 'their doctor' and the local primary care team, with only around 10% of consultations resulting in onward referral to specialist services. And in many rural areas small local hospitals run entirely within primary care offer excellent short-term inpatient services, including rehabilitation and respite care.

Primary care doctors also provide cover for patients in care homes, many of whom would formerly have been looked after in NHS continuing care settings. Such patients may be clinically unstable and at varying degrees of risk. There was broad agreement in the Expert Group that standards of medical care varied greatly across Scotland, and that this was unacceptable. The standard contractual model for GP cover does not appear to provide a reliable basis for good, pro-active care of such patients, and alternatives need to be explored.

Standard 14 No. 3 of the National Care Standards - Care Homes for Older People states, "During your first week in the home, and at least every six months after that, you will receive a full assessment to find out all your healthcare needs, and staff will ensure that these needs are met. Staff will record all assessments and reviews of your healthcare needs."

Recommendation:

• Older people at high risk in the community, including those in care homes, should be regularly monitored by an appropriate member of the healthcare team and relevant services and specialist care provided as necessary. NHS Boards should encourage and support such developments.

The traditional strengths of primary care in Scotland are now being supplemented by new and powerful developments designed to enhance local services, draw new skills into local multidisciplinary healthcare teams, and provide more and better care nearer the patient's home.

Local Health Care Co-operatives (LHCCs) have broadened the scope of primary care and encouraged the more active involvement of nurses, pharmacists and other members of the primary care team. Along with the new Personal Medical Services (PMS) contract, they offer new flexibility in service provision, with the potential for innovative arrangements covering such areas as home nursing support, health screening and local rehabilitation units for older people.

Older patients gain greatly from developments in primary care. As primary care continues to evolve many more initiatives can be expected. As these are observed, evaluated and adapted to local circumstances by LHCCs all across Scotland improvements will become far more widely available.

The MORI poll on public attitudes to the healthcare of older people in Scotland, published in conjunction with this Report, explored whether transport was a problem for older people in terms of gaining easy access to their GPs. It is for some (1 in 7 people) especially for those without access to a car (25% of respondents) and those aged 80 or over.

The study revealed that 1 in 2 older people travel to their outpatient clinic appointment by car, including a third who drive themselves. However, a quarter rely on buses. Fewer than 1 in 10 walk or are taken by ambulance to their outpatient appointments.

Avoidance of Unnecessary Hospital Admission

Some older people, many of them with only minor illness, are admitted to acute hospital care because the kind of care they need at home is not readily available. Simple domestic, nursing and rehabilitation support, combined with medical care from the patient's own GP, may provide a safe and welcome alternative to acute hospital admission - which, for the very frailest, may lead to permanent long-term care.

Recommendations:

• NHS Boards should ensure that older people in long-term care in the community have access to the appropriate care when required.
• LHCCs should lead the process of health needs assessment and primary care service planning in their areas; and recognise the potential of this process in improving local services for older people.
• Older people and their GPs should have access to multidisciplinary, multi-agency support teams to avoid unnecessary hospital admission, to facilitate safe discharge from acute care, and to promote rehabilitation of older people in their own homes.

Accident and Emergency Care and Short-Stay Acute Admission

When older people attend Accident and Emergency Departments or are admitted to short-stay units, the clinical problem may often be simply dealt with. A minority of patients will require more detailed assessment because of co-existing medical problems, poor mobility, or uncertainties about how they will manage on return home.

Admission may rapidly increase dependence. Special steps must therefore be taken to address the rehabilitation needs of older people in the earliest stages of acute care.

The Clinical Standards Board for Scotland, as part of its work on standards for Older People in Acute Care, will review the care of older people in Accident and Emergency Departments and Assessment Areas and publish findings in a national Report in 2003.

Recommendations:

• Older patients attending A&E Departments or admitted to short-stay acute assessment wards should be assessed to identify those with previous or recently increased dependency.
• Assessment should be multidisciplinary, covering likely risks and determining care needs (e.g. discharge, supported discharge or admission).
• A range of appropriate services should be available to facilitate safe discharge home, minimise unsafe discharge, and avoid unnecessary re-admission.

Acute Hospital Care

Already older people are proportionately the heaviest users of acute hospital services. As the numbers of the very old increase over the next 20 years, most hospital services providing acute care will be looking after increasing numbers of older, frailer patients. Older people are more likely to be re-admitted than younger ones, and to require multiple admissions.

Many older patients - particularly the previously fit and those without multiple medical problems already - can be safely managed in acute care settings without special arrangements. Special skills are needed to ensure that older and frailer patients, particularly those who already need support at home or have multiple problems, have their needs recognised and addressed.

Such patients should be identified early. Multidisciplinary assessment and early rehabilitation in the acute ward will minimise disability and maximise the chance of successful discharge home.

The majority of older patients, including a large proportion of the frailest, can be returned home safely from acute care by a combination of multidisciplinary rehabilitation, good discharge planning and management, and a collaborative approach involving both acute and community services.

Discharge management is a vital part of overall care management. It encompasses planning and delivery of services, and checking on both patient welfare and service delivery. It improves patient outcomes, reduces length of stay and minimises the risk of readmission.

Successful discharge management of frailer and older patients depends heavily on successful collaboration between acute and community health services and local authority provision such as home help and community occupational therapy services. In many areas community rehabilitation teams are in place and provide rapid access to high levels of supportive and rehabilitation care. Such schemes maximise the chances of a successful return home for even the very frailest patients.

Particular issues arise in remote and rural areas where acute services may be far from the patient's home. In such settings community hospitals can be a major resource for the local management of acute and sub-acute illness and in the rehabilitation (near home) of patients who have undergone treatment elsewhere but are not yet fit to go home. Active multidisciplinary care, with full use of local community services, can provide excellent journeys of care, minimising separation and unnecessary travel for both patients and carers.

The Clinical Standards Board for Scotland, as part of its work on standards for Older People in Acute Care, will review the care of older people in acute in-patient settings, and publish findings in a national report in 2003.

Recommendations:

• Older people being discharged from acute care should have appropriate access to pre-discharge assessment, multidisciplinary discharge planning, necessary community services, and follow-up to ensure their safety and well-being.
• Acute hospitals should take steps to improve the management of older people requiring multiple acute admissions, to improve continuity of disease management and to minimise repetition and duplication of investigations.
• NHS Boards should recognise that multiple admissions in older people are a problem and take strategic decisions to address this.
• NHS Boards should consider the appropriate recruitment, retention, training and development of specialist staff as part of their overall workforce planning to meet the needs of older people in acute hospital care.

The Confused Older Patient

Confusion is common in older people admitted to acute care. Pre-existing mild dementia is a common underlying factor. Following admission many other influences - including sensory difficulties, a strange environment, infection, sleep deprivation, dehydration, necessary drug treatment, and inadequate explanation of what is going on - can make things worse.

For people with more severe dementia, acute admission can be extremely stressful, as understanding may be very limited and their distress may be expressed in ways that are seen as disruptive. Care of such patients can be a considerable challenge in the acute setting.

However, most confusional states in acute care are self-limiting, or respond to straightforward treatment of underlying causes. Poor management of confusion e.g. inappropriate or excessive sedative drug treatment or - worse still - physical restraint, can greatly add to pre-existing difficulties.

All acute and post-acute hospital services now deal with older people who are confused. Knowledgeable and sympathetic management of such patients greatly diminishes their distress and is a very rewarding part of the acute and post-acute care of older patients.

Recommendations:

• All NHS staff should be aware that older patients may be confused, and should be sensitive to their needs.
• Clinical staff should be aware of the causes and management of confusion.

Post-Acute In-Patient Rehabilitation

A proportion of older patients admitted to acute care will recover quickly but be unable to return home timeously even with full access to ideal discharge management and community support services. Such patients do not benefit from a prolonged stay in acute care, and need access to rehabilitation in a hospital setting. Specialists have a particular role in managing these patients.

Multidisciplinary post-acute rehabilitation will maximise any chance of returning home; provide links to a placement service for stabilised patients who cannot return to their own homes but require long-term care, and - for a minority - provide palliative care in circumstances more appropriate than those of an acute ward.

The Clinical Standards Board for Scotland, as part of its work on standards for Older People in Acute Care, will review against the relevant standard the care of older people requiring further inpatient care following acute care, and publish findings in a national Report in 2003.

Recommendations:

• Patients who cannot be discharged directly from acute care should have the opportunity of further assessment and rehabilitation in specialist post-acute wards with multidisciplinary staffing, or - in remote and rural areas - in appropriately staffed local hospitals.
• Patients who cannot return home following acute care and post-acute rehabilitation should, until appropriate placement (e.g. in a care home) is achieved, have access to regular medical review and appropriate multidisciplinary care and rehabilitation while still in hospital care.

Delayed Discharge

Delayed discharge occurs when a patient - most often an older patient - who has been admitted to hospital care does not have access to other necessary care when and where that other care is needed. For each patient involved, it represents a gross disruption of the journey of care.

The Expert Group felt strongly that older people delayed in inappropriate and often poor-quality wards, usually without access to rehabilitation or diversional therapy, and often far from home, were experiencing care that was frankly unacceptable. They and their families are subjected to inconvenience, separation and distress at a time of great uncertainty and anxiety. The Group heard eloquent and deeply moving accounts of such experiences. Reducing delays in discharge is therefore a matter of the highest priority for all the agencies involved.

In service terms, delayed discharges reflect a failure to resource and balance a range of acute, post-acute, community and long-term care provisions in ways that reflect the needs of an ageing population.

The consequences for patients - inappropriate care sometimes complicated by multiple transfers from ward to ward, and the sense of rejection implied in the label "bed-blocker" - are unacceptable. The consequences for services, in terms of lost capacity and disruption of elective work, are well documented and also unacceptable.

Underlying historic causes include:

• failure over several decades to develop community, acute and post-acute services to meet the needs of a changing population
• acute sector dominance, resulting in a 'disposal mentality' aimed at clearing beds rather than caring for patients
• adversarial attitudes between different service sectors (health services vs. social work department; acute trusts vs. primary care trusts) with poor communication, mutual mistrust and resource protection resulting in disruption and delay in the journey of care
• poor identification by Local Authorities and NHS Boards of resources available for the care of older people, both at home and in institutional settings
• continuing difficulties - in some instances amounting to market failure - in the nursing home sector.

A number of recent developments, however, give grounds for optimism.

• The Joint Future Group has provided a framework for improved collaboration among health, social work services and housing.
• Developments in rehabilitation and intensive support packages in the community may serve to minimise or, in some instances, at least delay admission to acute units and the risk of delayed discharge for long-term care.
• Standardised documentation of delayed discharge has quantified the difficulties and allowed comparisons across Scotland.

• There is increasing recognition that, for the frailest elderly, acute admission to hospital may be avoidable, and that such patients run the highest risk of an acute admission resulting eventually in long-term care. It is therefore clear that improving services that might support older people through acute illness at home, where this is clinically appropriate, and might avert unnecessary admissions, is in their best interests.
• Following admission, a small proportion of patients will be identified as those with the most complex needs and at greatest risk of a prolonged and difficult journey of care. For them the Joint Future Group Report recommends intensive care management, with one key person having overall responsibility for managing - in partnership with the individual patient, their carers and the relevant professionals - the whole journey of care with a minimum of transition and delay.
• ISD now documents delayed discharge across Scotland in ways that facilitate comparisons and allow the monitoring of the effectiveness of means of reducing it. Over the next few years the impact of the implementation of good practice as recommended by the Joint Future Group - including that of intensive care management of those most at risk of delayed discharge - will be assessed and made public.

Recommendations:

• NHS Boards and Local Authorities should address delayed discharge as a top priority within joint management and joint resourcing of services, including community rehabilitation services.
• NHS Boards and Local Authorities should - as part of joint working - increase the transparency of resource use in the care of older people.
• NHS Boards, Local Authorities and the private and voluntary sectors should assess population needs and plan capacity to meet likely demands.
• NHS Boards, Local Authorities and the private and voluntary sectors should explore innovative means of addressing the problems associated with longer-term collaboration in service provision.
• ISD should continue to monitor and report standard comparative information to allow continuing scrutiny of problems and progress in the management of delayed discharge across Scotland.

Nearing the end of life

One result of increasing longevity and mass survival into old age is that mortality within our society is now largely compressed into the eighth and ninth decades. Good care of older people means also ensuring for them good quality of care as life approaches its end.

Many older people have only relatively brief periods of dependency and need for care before they die. A smaller proportion will - because of slowly increasing frailty - require increasing care in their last months or years.

Although most people - the vast majority of whom are old - still die in hospital or long-term care, more and more support is now available to patients who wish to remain at home as long as possible, or indeed to the end.

Where the necessary care can no longer be provided at home, the aim is to ensure that continuing care, in both care home and hospital settings, provides the maximum possible quality of life.

Within NHSScotland, the number of continuing care beds has been greatly reduced in recent years and their role has changed too. Patients are admitted with higher dependency than formerly, and are more likely to have active medical problems. In keeping with this, length of stay in NHS continuing care is now much reduced, being measured in months rather than years. In effect, NHS continuing care beds are now largely devoted to care near the end of life.

The goals of independence and dignity are no less important in the very last stages of life. Recent decades have seen a remarkable change in attitudes to palliative care, along with a series of excellent developments in service provision - in hospices, hospitals and the community - and in education and research involving a whole range of health professionals.

The National Care Standards - Care Homes for Older People support care in dying and death. Standard 19 states that older people should be "confident that staff will be sensitive and supportive during the difficult times when someone dies."

World Health Organization definition of palliative care

'Palliative care' is the active total care of patients whose disease is not responsive to curative treatment. The goal of palliative care is achievement of the best possible quality of life for patients and their families. Palliative care:

• affirms life and regards dying as a normal process;
• neither hastens nor postpones death;
• provides relief from pain and other distressing symptoms;
• integrates the psychological and spiritual aspects of patient care;
• offers a support system to help patients live as actively as possible until death;
• offers a support system to help the family cope during the patient's illness and in their own bereavement.

The Scottish Executive has made clear its commitment that palliative care should be available to all who need it.

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