I welcome the Minister of State at the Department of Health and Children, Deputy Áine Brady.
End of Life Care: Motion
I move:
That Seanad Éireann;
noting—
the publication of the new Quality Standards for End-of-Life Care in Hospitals;
that the majority of people now die outside the home, usually in some form of hospital;
that the first National Audit of End-of-Life Care in Hospitals indicated that the great majority of patients had been admitted via emergency departments and that one fifth could have died at home if sufficient supports were available;
the lack of single rooms and private spaces in our hospitals;
the significant regional deficits in hospice and bereavement support services;
the report of the Forum on End of Life initiated by the Irish Hospice Foundation which reflects Ireland's views, values and concerns regarding dying, death and bereavement;
considering—
the potential for more people to die at home rather than in hospital;
that hospice care is more cost effective and delivers better quality of care;
the lack of guidelines in some hospitals regarding end-of-life care;
the need for more training of hospital staff in end-of-life care skills including bereavement support;
the need to ensure that "no one should die alone, frightened and in pain";
the need to improve the physical environment of hospitals for people facing end of life;
the recognition that end-of-life care extends into bereavement care for those affected by death;
the need to ensure when people look for bereavement support they get the most appropriate help and not just the help that is available;
calls on Government to:
develop measures to allow people die in their homes rather than in hospital, where this is their choice;
allocate resources so that more people can access comprehensive hospice services in their community;
ensure that national guidelines are operational in all acute and community hospitals to address all key end-of-life care issues;
develop systems to enable effective gathering of data on deaths in hospitals;
ensure ongoing auditing of end-of-life care and the introduction of a system for review of deaths in hospitals in which bereaved families can participate;
ensure training for health care and support staff in end-of-life care skills, bereavement support and advance care planning;
establish a grants fund to support projects which will enhance the environment of hospitals and other locations where people face the end of life; and to
develop and resource a comprehensive end-of-life care strategy for Ireland which will incorporate and update the work of the National Advisory Committee on Palliative Care (2001) and the NOSP Petrus Review of Bereavement Support (2007).
Ba bhreá liom i dtosach báire fáilte a chur roimh an Aire Stáit. We may not wish to admit it but as legislators and as a society in general we are sometimes guilty of overlooking those whose voice is meek or who may have no voice at all. We are accustomed to hearing calls to protect the vulnerable and to respect the dignity of all human beings, yet we are not always willing to follow the logic of these principles. This is especially true where a given context provokes feelings of unease and uncertainty; so it is with the context of death and dying where our own anxiety about these issues may prevent us from giving sufficient thought to the reality that thousands of people are currently living their end of life.
Despite this and the fact that all of us have had some experience of a loved one living out his or her last days before our eyes, our society does not pay sufficient attention to the welfare and good of those who receive end-of-life care. Implicit sometimes in our thinking on this issue is the view that policy focus should centre on those with the majority of their lives ahead of them; that dying is a taboo subject better skirted around for the sake of avoiding awkwardness and offence; and that as people gradually lose memory, consciousness, bodily control and even hope, they also lose their dignity.
It is vital that these attitudes do not determine our thinking on end-of-life care. Dying is one of the most profound life experiences any person will ever go through and the level of end-of-life care afforded to a person should not be in any way contingent upon how young or old they are. Our understanding of what dignity means is crucial to a proper attitude towards dying and end-of-life care. For some, dignity means status, and people have dignity in accordance with how powerful they are, how much money or life they have, how conscious they are, how able-bodied they are or how well they are able to relate socially to others. In that view, when a person loses any of these factors, some dignity is lost.
This is emphatically not the understanding of dignity to be found in the great humanitarian text of our time, the Universal Declaration of Human Rights. There, dignity is understood as inherent in every human being as the basic and absolute value underpinning the fundamental human rights of all persons, regardless of distinction or status. Human dignity, in the context of human rights, is inviolable and irrevocable. It cannot be taken from a person.
Our actions may fail to respect fully the dignity of others but such dignity is never lessened. Human dignity ensures that no person is ever, to use a vulgar term, simply a "vegetable". This understanding of dignity — the true understanding — has its roots in Cicero and has been mediated to us today by a Renaissance humanism, Kantian moral philosophy and Judeo-Christian theology. Despite the intellectual attacks by Marx and Nietzsche, and against the atrocities of two world wars, human dignity survived to become the central concept underpinning human rights law in the 20th century on both the international and constitutional levels, and we would do well to acknowledge that our own Constitution blazed an important trail in this regard.
The question before us is how we respond to human dignity in the context of end-of-life issues. A minimalist approach will not suffice and we should not settle for simple minimum care such as the provision of nutrition or hydration, minimum pain relief such as that the person never screams but always hurts, minimum consultations that only occur after important decisions have been made on behalf of a patient or family or minimum compassion such as treating the person as just another patient or medical case and not as somebody going through a momentously emotional and spiritual stage of life.
Considering home end-of-life care, how can we apply the dignity of that concept to practical effect? We can begin by acknowledging the right of persons to receive end-of-life care in their own homes. Currently, two thirds of people die in some form of hospital, although at least a fifth of those persons, according to doctors, could have died at home if appropriate community supports were made available.
The hospitalisation of dying does not meet with the support of most Irish people. A 2004 survey found that given a choice, only 10% of people would prefer to die in a hospital and only another 10% would prefer to die in a hospice. An overwhelming majority of Irish people would choose to die at home and the reasons are clear. For most people home means comfort, security, family and friends; it is the natural place to live and die. No matter how good hospitals can be or compassionate hospices are, they cannot replicate the sanctity of the home for many Irish citizens.
The benefits of home end-of-life care accrue not just to the patients and families but also to the health service. There is a high number of people dying in hospitals, some 84% of whom are admitted through accident and emergency departments, and this puts unnecessary strain on hospital and accident and emergency services. The funnelling of end-of-life patients into the hospital system must change, especially as the vast majority of deaths occurring in Ireland are predictable; as their predictability allows for forethought and planning, they are more likely to be manageable within a community care framework. In order for this to be realised we must organise the service to suit patients rather than providers, allocating hospital resources to facilitate rapid discharge, night nurses and 24-hour short notice care teams.
It is true that not all end-of-life cases will be manageable within the home, and that is why hospitals, including psychiatric units, must ensure that end-of-life care is a core service on offer rather than an afterthought to more supposedly fundamental services. It is therefore heartening to see that HIQA's new draft standards for health care providers, to be introduced from 2012, make it explicit that end-of-life care ought to be a core hospital service. When the business of curing is beyond reach, the necessity of caring continues.
The figures show that end-of-life care in Ireland has some way to go before it can be considered a genuinely core service, although it is important to understand that internationally we compare fairly well. Over half of the patients profiled in the 2010 national audit on dying in hospitals died in multi-bed rooms, and only 20% to 30% received specialist palliative care, with as many as 25% dying alone. Only a third of hospitals have policies and procedures on end-of-life care, which may explain why multidisciplinary meetings were held to discuss patient care in only 44% of cases, why only 17% of patients and families were informed of the outcome of meetings at which they were not present and why only 15% of relatives were offered information leaflets on dying, death or bereavement. There is a clear need for national guidelines to be operational in all acute and community hospitals.
When I think of death I often reflect on the famous poem, "Death the Leveller", with the telling lines:
Sceptre and Crown
Must tumble down
And in the dust be equal made
With the poor crooked scythe and spade.
Death is a leveller that unites all of us but there is another levelling that we should consider. There are plenty of examples of best practice and there are hospital and care settings which have standards and approaches to end-of-life care. These succeed in the important business of providing end-of-life care that is both competent and co-ordinated, compassionate and communicative. The levelling we require should be upwards so that everybody should enjoy the same standard of hospice care, end-of-life care, communication, compassion, co-ordination and competence. There is a clear need for national guidelines to be operational in all acute and community hospitals.
There is also a worrying gap that should be noted and I am indebted to the Irish Hospice Foundation's audit of end-of-life care in hospitals for these challenging facts. The gap is between the levels of satisfaction expressed by health care professionals and the views of family members regarding the quality of end-of-life care treatment in Irish hospitals. When asked if the way a patient died was acceptable to relatives and families, 35% reported an unacceptable death, whereas the figure for nurses was 23% and for doctors was 20%. It should be noted in that context that at least a fifth of Irish people currently die in an unacceptable manner.
The comparative figures for pain relief are no less challenging. Some 23% of relatives — those closest to the patient — consider that their loved one had spent most of their last week in pain, whereas only 15% of nurses and 10% of doctors thought so. It is of great concern that, according to doctors and nurses, patient care is least satisfactory for patients who are frail or with dementia. We can all understand the reasons the challenges are particularly acute in such cases.
This unacceptable gap in perception between care providers and relatives suggests we have some distance to go before we can say people approaching death receive all that human dignity requires. We must bring hospitality back into hospital, not as something to be left to the discretion of individual hospital staff, many of whom deserve great credit and act with great selflessness and courage, but as a matter of established policy guidelines. We have to change the end-of-life experience. We must embrace a new phenomenology, one that encompasses such aspects as the architectural design of rooms, ease of movement between home, hospital and hospice, and the provision of proper bags into which to place the deceased's clothes, rather than a rubbish bag into which soiled clothes are sometimes put. These are practical items which say much about how we regard end-of-life care services.
There is the question of how hospital staff react when in the presence of a terminally ill patient or bereaved relatives. Far too many Irish people have had distressing experiences of their loved ones dying in an overcrowded, noisy, multi-bed ward in which privacy and respect seem to be completely absent, despite the bona fides and good will of care providers. This phenomenon has been described as "Mammy dies while Chelsea scores" and is indicative of the lack of thought put into end-of-life care in Ireland. We all have experience of multi-bed wards in which televisions compete with each other during some of the most acute and sensitive moments of people's lives. We must bear in mind that statistic, namely, that more than 50% die in multi-bed wards.
A number of years ago I had the good fortune to attend a talk given by Professor Roger Ulrich who spoke about the importance of hospital design in ensuring better outcomes. Central to the plan is that we move to a situation where we have single bed wards in hospitals. I am struck always by the comparison between hotels and hospitals. Unless we are young and in the whole of our health, backpacking and do not minding sharing hostels, we all expect as a basic minimum when we travel that we will be in a room of our own, yet how is it that when people are struggling to be well, this is not considered basic? We still have out-of-date infrastructure which oppresses people and frustrates the possibility of their being cared for in a way that fully recognises their dignity.
I commend the Hospice Foundation's design and dignity plans for a fund to help address these issues in certain places. I hope that, through the efforts of the Minister for Health and Children, whose intentions are to be appreciated, as per the recent establishment of the National Council of the Forum of End of Life in Ireland, we will see such a fund emerge, with support from the Government despite the challenges that face us.
Cén chaoi ar féidir linn dínit an duine a chur i bhfeidhm go praiticiúil i gcúram direadh saoil? Is é an túsphointe ná a aithint go bhfuil de cheart ag daoine cúram deireadh saoil a fháil sa bhaile. Faoi láthair, faigheann dhá thrian de dhaoine bás in ospidéal de chineál éigin cé go bhfeadfadh an cúigiú cuid acu ar a laghad, de réir a ndochtúirí, bás a fháil sa bhaile dá mbeadh tacaíocht pobail cuí ar fail. I suirbhé a rinneadh in 2004, níor chuir ach 10% de dhaoine in iúl gurbh fhearr leo bás a fháil in ospideal dá mbeadh an rogha acu, agus níor chuir ach 10% eile in iúl gurbh fhearr leo bás a fháil in ospís. Tá an chúis sin soiléir: don chuid is mó de dhaoine is ionann an baile agus compord, slándáil, teaghlach agus cairde.
Some of my colleagues will elaborate on other ways to improve end-of-life care in Ireland. I will briefly mention only a few. It is clear that more could be done about the proper administration of pain relief. It is neither unethical nor illegal to administer pain relief, even in large doses, once the motivation is to care, by treating pain, rather than to kill. Perhaps health care professionals are not fully aware of this distinction and see themselves as erring on the side of caution while administering pain relief. Great emphasis must be placed on "do not resuscitate" orders which allow a patient to die a natural death. In this context, I heard a story about an elderly lady who had her ribs broken during an attempt to resuscitate her.
Advance care planning, once it takes account of the ethical need for the delivery of basic and ordinary medical care, could go a long way towards respecting patient autonomy, decision making and ensuring peace of mind. Provision for such planning depends on and will strengthen communication between health care staff, patients and relatives. The systematic introduction of multidisciplinary review of death teams could strengthen the quality of care offered by the various health professionals and would help to create a culture of excellence in end-of-life care and offer relatives an opportunity to give feedback on end-of-life care to the relevant health professionals, thereby increasing accountability.
I thank the Irish Hospice Foundation, carers, the associations, clinicians, health care professionals and all those who dedicate their time and resources to serving the dignity of persons in end-of-life care. I pay a special debt of gratitude to the Irish Hospice Foundation for giving of its time, support and research informatin during the preparation of the motion. I look forward to listening to the debate with my Seanad colleagues and eagerly await the Minister of State's response. I would have preferred to have been in a position to discuss with the Government its proposed amendment. I am disappointed that it proposes the complete deletion of what I have prepared. It is always good to give credit where it is due, but that need not prevent us having a fruitful debate, during which I hope we will arrive at intense agreement. We should do so, given that it is a common experience to face death and be the carers and loved ones of those facing the end-of-life experience.
I am very happy to support the motion which is very important.
Is the Senator seconding the motion?
I am very happy to second it. I am delighted the Minister of State, Deputy Áine Brady, is present for the debate. However, like Senator Mullen, I am disappointed that there is an amendment, but I understand that is the way things are done in the House. Nonetheless, it is a shame.
I remember being a patient in the Mater Hospital for about five days more than 50 years ago. I thought I would never be able to pass a hospital again without thinking of all the people inside but soon afterwards never thought about it. The same applies to hospices. John, a friend of mine, died in St. Francis's Hospice about 15 years ago. I was with him the day before he died and he was able to say to me, "You realise I am dying. I won't be here at the end of the week." He was very peaceful and looked after so well. It had an amazing impact on me because I had almost forgotten as I drove past what was happening there. This year my sister-in-law died. Some weeks before she died she went into Our Lady's Hospice in Harold's Cross where I visited her practically every day. She was looked after so well. What really impressed me was the care and attention given to her and the interest and sympathy shown. It brought the subject back to my mind. What also impressed me was the very large number of volunteers. It was voluntary work being done by people who went to the hospice to help in both big and little ways. It was very impressive and I realised I had been walking past without thinking. I had been in a few times, mainly to see people in the hospice for respite rather than end-of-life care, but had not realised the amount of voluntary work being done.
I am delighted Senator Mullen has introduced the motion. What he has done today is ensure a wider circulation for the very interesting information available on the enormous amount of work being done in many areas in end-of-life care in Ireland. It is most worthy of consideration and I hope this debate will ensure a wider circulation than might otherwise be the case.
We must bear in mind that in this country we are much better off than many other countries when it comes to end-of-life care. Ireland is one of only approximately 15% of countries in which palliative care services are integrated into the national health service. We must remember also the key role Irish Aid has played in supporting the development of hospice and palliative care services in poorer countries, especially in Africa. However, there is much more we could do to improve the lives of loved ones who are dying. According to the quality of death index recently issued by the Economist Intelligence Unit, the United Kingdom was the best place in which to die. Ireland ranks fourth in the overall ratings. However, in terms of a basic end-of-life health care environment, Ireland is ranked only 17th. This category includes social security health expenditure, nurse and doctor numbers, GDP, dependency ratios, life expectancy and hospital bed counts.
We must bear in mind the massive physical changes that have occurred in recent decades, particularly due to changed lifestyles and improved medical care. Death used to come quickly to most. In previous generations people were taken out by catastrophic infections, at childbirth, by pneumonia or heart attacks. How one should die was never such a problem when the period between diagnosis and death was short, leaving just enough time to say goodbye and for the last rites to be given. How to die was never such a problem when the period between diagnosis and death was short, leaving just enough time for goodbyes and the last rites. People still die suddenly in their sleep, in the shower, at their desks or on the road.
However, most of us who live in industrialised countries such as Ireland will die much more slowly of chronic progressive illnesses such as cancer, heart disease, lung cancer or from the multiple effects of ill health in advanced old age. Thus we have plenty of time to consider how we want to use that time. With almost half of all people dying in hospitals, we need to take the issue much more seriously. In the late 19th century 85% of people died at home. The hospice friendly hospitals programme survey found that while most people wished to die at home the vast majority still died in hospitals, as Senator Mullen said. In 20% of cases, however, the diagnosis of death in Irish hospitals occurs five to six days before death. Also, nearly 25% die alone in acute hospitals. It is much more referable to die at home for a number of reasons.
Pressure on emergency departments is excessive and palliative care services are insufficient. In Ireland approximately 56% of deaths occur in wards where five or six other people are present. This is partially due to the small number of single rooms available in our hospitals. One must also remember that the distance between beds is often extremely close and curtains do not provide adequate privacy. This makes it extremely harrowing for both the patient and his or her loved ones. In addition it means there is no privacy for other patients in the ward, a point very well made by Senator Mullen. It is commonsense that single rooms should automatically be available to people who are dying in hospital.
A new study carried out by researchers at Dana-Farber Cancer Institute, a teaching affiliate of Harvard Medical School, found that cancer patients who died in a hospital or intensive care unit had a much worse quality of life at end of life compared to patients who died at home with hospice services. Researchers also found that hospital patients' caregivers were at higher risk of developing psychiatric illnesses, including post post-traumatic stress disorder, during bereavement than are home-care caregivers.
In terms of hospital, "living wills", competency to make decisions, resuscitation, clinically assisted nutrition and hydration and transplantation are all critical issues which have been highlighted by the hospice friendly hospitals programme. I have been advocating presumed consent for organ donation, which is another aspect of end of life that deserves proper debate. I hope the Minister for Health and Children, Deputy Harney, is making progress on this issue. It is interesting to note that the Irish Hospice Foundation's survey of end-of-life care in hospitals found that one fifth of seriously ill patients could have died at home if sufficient supports were available. There are shifts to end-of-life care from the hospital to the home. In the UK, the Conservative Party has indicated it wants to introduce a major overhaul of funding for end-of-life care, with a new system to be based on the number of patients requiring it. Under the plan, more money could go to hospices and other providers, using savings made from reducing unnecessary stays in hospitals for people at the end of their lives. The changes involve the introduction of a tariff system such as those operating in other areas of health care, so funding is awarded on a "per patient" basis.
We too, should be looking at passing on the savings made from people not staying in hospitals at the end of their lives, to help them die at home. We could also encourage nursing homes to try and stop inappropriately sending elderly dying patients to emergency departments, if they were given the support to do so. We also have to better inform people about end-of-life care. According to a new national survey published in the Journal of Medical Ethics, many of us are uncomfortable and ill-informed about end-of-life issues. The lead researcher, Dr. Joan McCarthy, of University College Cork, found that there was a deep need for better public education about the processes and terminology of end-of-life care, as well as for new legislation to clear up the confusion around the role of professionals and families in making decisions for dying patients. For instance, a massive 71% had never heard of an advance directive, although more people knew of it by its more popular term, the “living will”.
One of the most interesting aspects of that survey was that most people were more concerned about the quality of their dying than about death itself, and 81% said that if they were severely ill with no hope of recovery, the quality of life would be more important than how long it lasted. I support the call to develop and resource a comprehensive end-of-life care strategy to manage properly this critical aspect of being human which sadly is not being given the attention it deserves. As a society, we need to recognise that dying is a normal part of life, something as natural as birth and adolescence. With somewhat more imaginative planning many more people could die at home rather than in overcrowded hospital wards. No one should die alone, frightened and in pain. The challenge is to ensure every patient can die in comfort and dignity.
We avoided this issue for many years. It was something we did not talk about and we steered away from it. Perhaps the younger people are the more difficult it is to handle. The closer one gets to it perhaps makes it easier to understand. I had not understood this, however. Neither had I understood the willingness, as Senator Mullen mentioned, of giving drugs to relieve pain. It seems this is something we had not thought much about before. It is now well thought out. I have experienced in recent times the willingness to accept that if somebody is dying he or she should not die in pain. Steps are being taken in the right direction and I believe we have the intention to do the right thing. Let us ensure we do it.
I move amendment No. 1:
To delete all words after ‘Seanad Éireann' and submit an amending motion in the following terms:
"Commends the Minister for Health and Children on the dedicated funding made available in recent years by the Government for palliative care services, now in the region of €79 million per annum, welcomes the fact that Ireland was ranked second in Europe in a study of palliative care in the European Union for the European Parliament Committee on the Environment, Public Health and Food Safety and was recently ranked fourth overall in Europe in a recent Quality of Death report published by the Economist Intelligence Unit;
welcomes the launch on 23 September last by the Health Information and Quality Authority of draft national standards for safer better health care;
notes the first national audit of end-of-life care in hospitals commissioned by the Hospice Friendly Hospitals programme;
notes the report of the Forum on End of Life and the new quality standards for end of life care, initiated by the Irish Hospice Foundation.
Considering the need to take account of issues such as quality of care, standardised guidelines, clinical governance, training requirements, support services and infrastructural environments for people facing end of life and bearing in mind overall health service priorities and resource availability in the future for health and personal social services,
recognises the role of home care packages towards supporting end of life care in the community;
acknowledges the evidence based priorities set out in the medium term strategy for palliative care published by the HSE in July 2009, agreed by all relevant stakeholders;
acknowledges Palliative Care for Children with Life-limiting Conditions — A National Policy adopted by Government on 15 December 2009 and published in March 2010. Ultimately, this policy aims to ensure that all children with life-limiting conditions will have the choice and opportunity to be cared for at home;
notes the work of the joint performance information group, JPIG, of the Department of Health and Children and the Health Service Executive towards improving data on palliative care services;
acknowledges Department of Health and Children national lottery funding recently awarded to the Irish Hospice Foundation to support a pilot project to enhance the hospital environment for people facing end of life;
commends the importance given to end of life care in both the national quality standards for residential care settings for older people in Ireland approved by the Minister in February 2009 and the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009, which underpin the standards."
I welcome the Minister of State, Deputy Brady, and I am delighted to have an opportunity to contribute to the debate. I commend Senator Mullen for moving the motion. He is calling for more training for hospital staff in end-of-life care skills, including bereavement support and the need to improve the physical environment of hospitals for people facing end of life.
From my perspective I believe the Government is very committed to ensure that people live long, and we all know that. I commend the Minister of State and her Department for the enormous changes and improvements we have all seen in hospitals in that regard. It is a shame we did not have a copy of Senator Mullen's speech, as I should have liked to underline the various points as he went along. He talked about multi-bedded wards, people dying and no dignity associated with it. That is a horrible picture. I have never experienced anything like it. Both my parents died in hospital, although neither of them was sick. My mother died of an aneurysm to the brain. She was rushed into hospital and thankfully died very quickly, as she would not have had any quality of life had she survived. Like Senator Quinn said, I can only speak from my experience. Our experience was a terrible shock of losing a mother, yet it was very dignified because she died in intensive care in a very private setting. It was almost as if people were walking on eggshells, tiptoeing around us because it was a very distraught time for everyone. Indeed my father died, I would say, of a broken heart, two years later. He had no desire to continue living his life when my mother died. They had been married for well over 50 years. I would say he probably should not have died in a hospital, however.
Even though a patient might have the best resources at home, I believe that sometimes GPs like to put an elderly patient into hospital because they believe this might be better for the family, and for the patient too with professionals on tap to deal with him or her.
My father was in hospital for only one day, and we knew when he was going in that he was going to die. He was in a semi-private ward and there was another gentleman with him. It was a lovely experience for us and I commend the nursing staff. There is an issue I must mention although, again, I do not want to personalise things too much. My father had respiratory failure and we wanted him to have a nice peaceful death but the young doctor on duty that night could not prescribe anything for him because the drug would have instigated his death much more quickly. We certainly would have liked that. My father was an old man and it would have been so much nicer for him to go. It was a public hospital. The other experience I had was with my only aunt on my mother's side who had a beautiful, peaceful death in a lovely private room in a publicly run nursing home in Tullamore. Perhaps I am one of the lucky ones in that everything has been very nice for me when I have lost people, but that is not to take from what Senators Quinn and Mullen are saying.
We as a people have a great nature when it comes to birth and death. We are all emotional when there is a birth and we rejoice and celebrate. I am very emotional at weddings. There are always tears in my eyes and a lump in my throat, although I might not know the couple getting married. That is the nature of the Irish people, as was pointed out by Senator Quinn.
When it comes to death, perhaps the demographics have changed. Heretofore we — and I speak for most people in the Chamber, including those in the Visitors Gallery — always knew that if one was not seriously sick, one was not in hospital. One was looked after at home. People who had colds did not go to doctors but were nursed at home. I remember, as a child growing up, that there was always a saucepan for hot lemon drinks in the house. Any amount of lemons — they must have been very cheap — were piled into boiling water, and it was the cure for everything. I was one of a big family of 11. We were only brought to the doctor when there was a concern that an illness was serious.
Our grandparents did not go into hospital but were nursed at home and were in good form and good health right into old age. Even when they had dementia they were still kept at home. Unfortunately, life has changed and society as we knew it back then will never be with us again. The whole make-up of families has changed. We are no longer able, whether it is because of work or for financial reasons, to keep parents at home and they end up in a nursing home or in hospital whether they want to or not.
It is embedded in the DNA of all Irish people to want the nicest possible surroundings for their loved ones and for themselves when their day comes. I keep saying that I will be clear about how and where I would like to die and the people I want around me. Life moves quickly and one keeps putting it off while meaning to say it to someone. Then, all of a sudden, there is no opportunity. Even though our hospitals are very busy, they are centres for curing people rather than for end-of-life care. That is what we have always known them for. As I said, one went into hospital if one was seriously ill and stayed at home if one was not. Nowadays, the statistics show that large numbers of people die in hospitals. Hospital management, together with the professional health care teams, do try to make things as comfortable as they possibly can for people who have to die in hospital, but it would be much nicer if we could keep everyone at home. I know I would like to die in my own home, and if I do not, I certainly want to be waked in my own home. I am an old fashioned woman when it comes to these traditions.
I commend the Irish Hospice Foundation, the North West Hospice, which is my own local hospice in Sligo, the Carers Association and the health care professionals in our hospitals who do a tremendous amount of work under difficult circumstances. In particular, I thank the hospice movement for the wonderful facilities it provides for people, especially those who are terminally ill, and for the wonderful solace and peace they give to patients and their families who are ready to say goodbye to them. I would like to have had longer to explore this subject. Perhaps we could continue the debate another time. I commend Senator Mullen on bringing this to the Chamber.
I welcome the Minister of State to the House and thank Senator Mullen and his Independent colleagues for tabling this worthy motion for debate. I was interested in a study supported by the Irish Hospice Foundation. The foundation's website states: "The study paints a picture of a general public that is not very comfortable with or informed about the processes of dying and death." That is interesting, because the stereotype is that we are good around death, based on our tradition of wakes and the fact that families get a lot of support from relations, neighbours and friends during a loss or bereavement. It is interesting that when people studied this, they concluded that the public was not that comfortable with death.
In so far as we are becoming comfortable with handling death and supporting families, there is no doubt the hospice movement has played a major role. It has pulled back the curtain on the subject and facilitated a high level of discussion, particularly about the report on the end-of-life audit which it published. The information it is making public is incredibly important and offers us a real challenge.
The motion, with its details of the type of action that needs to be taken, shows us that while we are on the way, we have a lot of work to do. It is a detailed Private Members' motion, which is somewhat unusual as we often have more general motions. It specifies the kind of action plan that is needed. The key questions are whether these actions will be supported by the Government, what kind of support they will get, what kind of budget there will be and whether it will be cut. What can be done by changing attitudes, helping people to work better together, and ensuring our hospitals are more sensitive than they are to the issues highlighted by the hospice movement over the years? That is an important question. There is the possibility, as the motion states, that more people would want to be at home while suffering from a serious illness and, if possible, when they are dying. Given the number of people who reach the end of their lives while in hospital, there is a need for much more sensitivity and for every hospital to apply as many resources and supports as possible, along the lines recommended by the Irish Hospice Foundation, to the treatment of those at the end-of-life stage. Perhaps all hospitals now have this in their mission statements.
Senator Mullen explained in detail what needs to happen. It is surprising that there is still a need, as stated in the motion, to "develop systems to enable effective gathering of data on deaths in hospitals" and "ensure ongoing auditing of end-of-life care and the introduction of a system for review of deaths in hospitals in which bereaved families can participate". This is good practice and would be very helpful to bereaved families. A full plan exists and what is needed now is the political will to implement it and an action plan to ensure it happens and that there is support for it from medical authorities, the Department, the HSE and all concerned with this area. I doubt there is a Member in the House who has not experienced the dedication, commitment and top quality care provided by the Irish Hospice Foundation in hospices to people we know. We have all heard the stories and about the fund-raising that takes place. The hospice movement is worthy of the highest level of support. The public appreciates the work the movement has done at an educational and practical level.
The motion is timely. At a time when discussion is dominated by economics, banks and fiscal policy and the country is grappling with these major issues, it is vital that one does not forget it is the role of Government and politicians to steer society and its values. The motion brings us into the area of the important values of quality of life and care. The moment of death is an opportunity for society to demonstrate explicitly and implicitly how it cares and comforts its citizens in their final period of time on Earth. One of the founders of the hospice movement in the United Kingdom, Dame Cicely Saunders, summed up the attitude that guides us in the care we provide when she commented:
You matter because you are. You matter till the last day of your life. We will do all we can, not only to help you die peacefully, but to live until you die.
This moving comment deeply touches all of us who read and understand its meaning.
We need to consider a number of other areas. A significant number of children suffer from life-limiting illnesses. I frequently meet the parents of some of these children in my work. This week I was with a family with a young daughter with a life-limiting illness who is not expected to live beyond the age of five. The quality of care this family, which is supported by the Jack and Jill Children's Foundation, receives is extraordinary. Approximately 1,400 children in Ireland live with a life-limiting illness and approximately 350 of these die each year. It is critical we also focus on hospice care for families with children in this situation. We need to be conscious of the many different levels of hospice care and support required for people andfamilies.
Like with our health services, one of the key issues in regard to hospice care is how to ensure consistency and quality of care. It is clear from reports I have read that the level of service is uneven, although improving, and underdeveloped in some areas. The chairman of the hospice foundation said in a recent report that the recession is not a reason to stop working for good end-of-life care and that the people who now face death or will face death soon do not have time on their side. He went on to say that we need to develop shared responsibility with the State to reduce our reliance on voluntary funding. Like with many other organisations, it is critical to decide on the balance of funding to be raised through voluntary fund-raising and statutory support. This is not an easy question in the current situation but we must live up to our responsibility as much as we can in the months and years ahead. I look forward to hearing what the Minister has to say in response to the motion.
I join Senator Feeney in commending Senator Mullen on raising this issue. I acknowledge the increased recognition and dedicated funding that has been provided by the Government in recent times for palliative care services. This has been a welcome development. While we will always feel there should be additional funding and everyone in the Chamber can identify areas of need, some positive steps have been taken. I welcome the report and the goals set down by the Government in this area.
I have been struck by how much families with whom I have come in contact depend on the services provided by people such as those in the hospice movement. In my area I am often contacted by families who wish their family members could access the excellent support and care provided by the hospices in Harold's Cross and Blackrock. This situation is mirrored throughout the country and is testament to the tremendous work, expertise and skills developed within the hospice movement.
I am aware also of the excellent work that has been done to support families in settings other than hospitals by hospice outreach teams. The Minister of State should be aware that it is important we continue to support such practical measures. These supports can make a real difference to how people end their lives and provide support to families who would like to exercise the option of keeping their loved one in the family home or in a nursing home to which they have become accustomed. In a situation of which I am aware, a family member who had reached a difficult stage of illness and had wanted to go to a particular hospice had become very comfortable and settled in the nursing home. The hospice outreach team provided tremendous support to the nursing home staff, the individual and the family. We cannot measure the comfort that provided to the person and family at an incredibly sad time. Senator Quinn mentioned trying to address the fear of dying or of dying alone. Whatever measures we propose and undertake, we would like to ensure a system has been put in place to ensure that at an incredibly sad and difficult time for families, practical support is available to provide comfort.
There are other issues we need to address, especially with regard to children who suffer life-limiting conditions. I welcome the first hospice for children which is being constructed in Leopardstown with the support of the Laura Lynn Foundation. We hear from families concerned with this project that sometimes it is not just a question of having access to a hospice but of having the opportunity to access respite on a temporary basis to give the family a break or to access a support or outreach team which will help ensure the home can become a safe and comfortable place in which the person will end his or her life. This is about increasing awareness, recognition and our own skills, not just about funding. I pay tribute to those who have undertaken significant work to date and who set an example as a result of the word-of-mouth commendations following the experiences families had initially through the hospice movement. This has challenged us all to consider this issue and to consider what supports can be put in place. I commend Senator Mullen for tabling the motion and I ask the Minister of State to set concrete goals, to continue to ensure dedicated funding is made available and to include the experiences of family members in future service developments.
I join others in commending Senator Mullen on this timely motion, which calls on the Government to develop measures to allow people to die in their homes rather than in hospitals and to allocate resources in order that more people can access comprehensive hospice services in their community. With regard to this model, it is a case of one size fits all and there should not be inequities in the home care packages provided in various parts of the country. Currently, there are regional inequalities in the services available to people. The regional deficits, according to the Irish Hospital Foundation's review of staff and bed numbers in specialised palliative care in Ireland, released in June 2008, revealed continued and major shortages of hundreds of vital staff and beds across the country. A study on staffing levels in specialised palliative care in 2007 found that patient and family access to comprehensive services was still largely dependent on the region of the country in which the patient lived and Exchequer spending on care staff and specialist palliative care inpatient unit beds varied from €790per capita in the former South Eastern Health Board area comprising Waterford, Wexford, Kilkenny, Carlow and south Tipperary to €35 per capita in the former North Western Health Board area covering Donegal, Sligo and Leitrim. There was a great discrepancy in what was provided and in the services available.
This is a sensitive subject, which will face every one of us, as there is no avoiding it. Many valid issues were raised by previous speakers but it will be important to invest in palliative care in future. More than 6,000 people currently use hospice services every year and it is estimated up to 13,000 patients will require access to palliative care. Many hospitals are sensitive to the needs of patients and families where a death is expected and if it is possible, an attempt is made to meet their needs by transferring the patient to a unit where there is not as much traffic and which is less public, although this is terribly difficult. I worked in hospitals for many years and they all had a bereavement room or an area where people could go to have a cup of tea and meet staff members who had palliative care training. It is vital to be able to deal with the different emotions experienced by immediate family members, which can be very much dependent on the age of the patient. If somebody has lived to a good age, the loss is not lessened because the longer one has with somebody, the more likely it is that the or she has played a large part in one's life and one will miss him or her.
However, one of my saddest experiences during my training was when I worked in the paediatric unit. At the time the treatments for cystic fibrosis were not as good as they are today and depending on the severity of a child's condition, one could estimate his or her life expectancy when he or she was going downhill, as he or she reached various milestones through his or her response or non-response to treatment. I found it desperately difficult as a student nurse encountering that for the first time. When I became a mother, I realised how much greater such a loss was. I do not say women who are not mothers could not experience loss but having been a student nurse, a staff nurse and a midwife and undergoing training to deal with those who suffered loss there was an expectation that it was a normal part of life and we had to undergo further bereavement training, for which Senator Mullen has called.
Training and upskilling involve a cost, even if only in terms of time. Many nursing and hospice staff undergo training at their own expense because it is not something the HSE is expected to cover. However, there should be a comprehensive support programme for everyone involved, whether they are staff giving the service, patients or family members and family support systems need to be put in place to deal with issues relating to end-of-life care. We should not be found wanting in this regard. The Irish are famous for how they say goodbye to the people they love. The wake has long been considered a good send off. The best send off that can be given to people is to give them their dignity and the choice about how they want to end their lives. Where a patient is suffering, he or she should be provided with adequate pain relief and palliative care should meet all his or her needs. Where the need for pain relief can interfere with quality of life, a call must be made. For example, a decision on whether a patient should be resuscitated should be made on clinical need in consultation with the family. It is difficult because the decision can sometimes be about turning off a switch. These are highly charged, emotional issues and there is usually an element of suffering. Most people want to see an end to suffering and patients should not be left in accident and emergency departments where there is hustle and bustle and other people are coming in need of acute care or as hot admissions, as they might need to be resuscitated or to be sent for surgery.
One of the difficulties in some areas of the country is it is preferable to send a patient from a nursing home to an accident and emergency department because of the system. If the person was left in the nursing home, it would mean dealing with autopsies and paperwork. Sometimes it is preferable to send these people to a hospital. This is less than ideal for someone who has been a client of the nursing home.
I am glad to have the opportunity to make a contribution and I again thank Senator Mullen for his timely motion. I thank the Minister of State for her attention.
Sitting suspended at 6.30 p.m. and resumed at 6.43 p.m.
I propose a further suspension of the sitting until 7.05 p.m.
Is that agreed? Agreed.
Sitting suspended at 6.44 p.m. and resumed at 7.05 p.m.
With the permission of the House, I wish to share time with Senator Jim Walsh.
Is that agreed? Agreed.
Unfortunately, this debate has been curtailed and divided as a result of these pairing arrangements and is quite regrettable. This is a clear example of what happens as a result of long-time arrangements being curtailed.
Hear, hear.
The business of the House, at a very difficult time for the country, is being disrupted and this is an example of it.
I welcome the Minister of State for this important debate. This is a very good debate and I commend the Independent Senators for tabling this subject for debate in Private Members' time. Their points are very well made. The Government amendment shows that many of the points are being examined and I hope the debate will move things forward.
There are very few people who have not had experience of the need for palliative care or hospice care when people are dying. There are very few people who do not have experience of the significant and valuable work being carried on in the community, in particular fund-raising and helping out when older people are dying and looking after people who may not have family to help them through this difficult end period of their lifetime. Another speaker noted that Ireland is rated as the fourth best place in Europe in which to die, which may not be a statistic one should be counting. It is crucial we take seriously the difficult times people face at the end of their lives. The thrust of this debate concerns community care. The excellent hospice in Galway provides an excellent outreach service. Many other hospices do so also. If possible, everyone wants to die in their own bed. That is the optimum for anyone but is not always the best when people suffer from appallingly bad health and difficult times. Sometimes families cannot cope and one's own bed may not be the best place to die. In those cases we need inpatient hospices.
We need to up our game in respect of primary care teams and we are doing so. Sixteen of the 26 teams in the Galway-Roscommon area are now in place. This matter passes below the radar in terms of the health care debate. Implementation of community health care is being improved slowly and steadily. We can see the implementation of primary health care teams. This is something people are not talking about. It is going quite well. We need to aim to have the best community health care service in the world.
I had the honour of signing Galway city into the World Health Organisation healthy cities network. On that occasion, I went to visit the Finnish health minister in Turku, Finland, which has the best health service in the world. I am not clear how good it is in respect of palliative care but community care is the linchpin of the Finnish model. I have always believed community care is what we should aim for and that anything that can be done in the home, with support services, should be done there. For many years I have campaigned on home births. The community care aspect of care from the cradle to the grave should be the linchpin of our new health care model in Ireland. People do not want to travel great distances for any aspect of health care. They want to be in or near their homes when they die and in or near their homes when they are born and for all events in between. We should be bolstering our primary health care teams to ensure all aspects of living, dying and community health care are underpinned by the primary care teams we are putting in place. At present, primary care teams are not entirely multidisciplinary but they provide a structure that will allow that to be the case.
I commend the motion before the House and I take the point that we must do everything we can to ensure the maximum number of services are focused on allowing people to be in their homes when they die. Relation supports, respite care and other services should be put in place. This model is better value and more human. At the end of the day we want to see a more human health care service in this country.
I thank Senator Ó Brolcháin for affording me the opportunity to make a short contribution to this debate. I concur with what he said about pairing. It is a pity Members of the Opposition and Opposition parties do not reflect the regard the President has for the Seanad. They should reflect on this point. There is nothing to be gained from disrupting the business of this House because there is a vote in the Lower House. Senator Ó Brolcháin put this point very well and I support him on it.
I compliment the Independent Senators who tabled this motion. I listened in particular to the proposer, Senator Mullen, who made excellent points in respect of end-of-life issues. Many people working in this area have assisted the evolution of a very caring approach in palliative care through the Irish Hospice Foundation. I became familiar with this when I was involved with the New Ross community hospital. When our district hospital closed we reopened it as a community hospital and established a small hospice unit. The Minister of State is familiar with the hospital. I know how valuable it was to those who had to avail of it and those who were terminally ill. When they were not in a position to remain in their homes, they remained in the community and were accessible for visits from close relatives. This is of great importance to those who are ill and to their nearest and dearest. This is the caring approach I would like to see pursued.
The Minister of State has not yet spoken but I would like if she could provide reassurance. Some elements of society are appointed to various ethics committees and other bodies to chart a way forward with regard to this particular topics. We have seen this in the area of embryonic stem cell research. People of questionable views are able to articulate them and shape public policy as a consequence. We need to safeguard and ensure people appointed to such bodies are objective. I would like assurances that there are no people with preconceived ideas involved in the formulation of policy with regard to assisted suicide or euthanasia. These are alien to the dignity of the human person, which was so eloquently espoused and set out by the Pope on his recent visit to England. We should follow much of that philosophy about the value of human dignity. I refer in particular to those who are most vulnerable, including the very young and very old, who are ill and sometimes unable to articulate their needs.
I congratulate Senators Mullen and Quinn on tabling the motion. It is very difficult to tackle taboos of this sort in the political environment and it is in the tradition of this House to do so. One of the more notable aspects of this debate is the great agreement we have had during the debate from people on the opposite side of the House, which makes it ironic and a great pity that the Senators on the Government side have tabled an amendment. There has been very little disagreement in what has been said and it appears the aspirations in this motion will not be agreed and implemented by the Government for reasons that are obscure, to say the least. I hope the persuasive arguments made on this side will induce the Government to take the measures necessary.
One of the more notable aspects of this argument is that made by the Irish Hospice Foundation, which has briefed Members on this issue. Much could be done without great cost to improve hospice care. The foundation's convincing briefing document states that the reallocation of hospice care could be done at very little cost but the HSE has not taken this on board. Last year there was a proposal for a large amount of expenditure and expansion in this area and it was turned down by the HSE because it said it had no more money. If no more money is necessary, presumably the HSE will look carefully at the submission by the Irish Hospice Foundation which says this can be done through the reallocation of resources and by putting more emphasis on people receiving hospice care at home rather than in hospital, which is more expensive.
In that respect, I was delighted to hear today that the hospice foundation in Wicklow, where I live, received a donation of €1 million towards a hospice in the county. That will contribute towards the target of €3 million for the fund which was set up one year ago. The people of Wicklow have raised approximately €250,000, which when added to the €1 million means they are nearly half way there. On top of that the Columban Sisters have given a site for a hospice. That is the type of voluntary work which is terribly important. The State and the HSE should acknowledge that when that sort of funding is raised by at least matching the contribution. I would welcome a response to that point today to what is only a one year old effort.
An interesting statistic has been produced by those who advocate more hospice care. They say the mid-west region has received preferential treatment for reasons which are difficult to ascertain. The statistics indicate that 70% of those who die of cancer, for instance, in Limerick die in hospices whereas in Wicklow 70% of those who die of cancer die in hospitals. I am not trying to make a regional argument. What I am saying is that if there is a reallocation of resources and if it is revenue neutral or expenditure neutral, that should be done. It should be our aim and aspiration that those who would otherwise die in hospitals should be moved and be allowed to die at home or in a hospice. That is a very simple message which has been coming through all the time from the Irish Hospice Foundation. What is necessary is for the HSE to set up a reconfiguration team to respond to the Irish Hospice Foundation's submissions and agree to do so at no cost. The HSE is set in its ways on this issue, as it is on many other issues. The resources are not being allocated on the basis of objective need. They are being allocated on another basis which is inefficient and unfair.
If we are serious about tackling the problem which Senator Mullen has so eloquently addressed, we should listen to the people who are advocating locally rather than those bureaucrats who can see where money is going but are unwilling to take themselves out of a straitjacket. We are talking about something which we rarely talk about, namely, the deep emotional needs of human beings. We are very keen and prone to talk about facts, figures and accounts in a forensic way. That is the nature of the HSE beast, but this is a deeply difficult subject to discuss. It is a deeply emotional subject for the individuals involved and it is one which people are reluctant to discuss. I have been struck by the fact that, unusually in this House, several Senators have spoken of their personal experiences of the deaths of people who were very close to them, of their needs and the good and bad things that happened. The message is that we should listen to the feelings of the people involved rather than the figures. If the HSE were to send in a reconfiguration team, which would mean a reallocation of resources, to try to meet the emotional needs of people in this sphere, the problem would be tackled.
I congratulate the proposers of the motion, in particular Senators Mullen and Quinn, on bringing the subject to the House because it is an unusual and difficult subject to tackle. Although the contributions of Senators Corrigan and Walsh were heartfelt and useful, it is a pity the Government side is taking the attitude that the motion needs amendment because it is one that could have been agreed in a non-political context.
I wish to share time with Senator Norris.
Is that agreed? Agreed.
I welcome the Minister of State, Deputy Áine Brady, to the House for what is an important debate. I compliment Senator Mullen on proposing the motion and bringing the subject matter into the public arena for debate by parliamentarians and national representatives. As other speakers have said, end-of-life matters are very emotive, personal and sensitive. Many families have been devastated by the death of a person close to their hearts, that death being at times dignified but at other times less dignified. In speaking of the good facilities, resources and services that exist we must also acknowledge the weaknesses in our health system and, where there are deficits, address issues such as end-of-life care.
I compliment the Senators on the motion which is very detailed. It provides a clear roadmap to address the deficits and lack of resources to support those with end-of-life issues. There is no doubt that families are at their most exposed and vulnerable when a family member is terminally ill. The objective is to allow the person to die with dignity in the bosom of the family where possible and, where that is not possible, there should be access to the next best thing, namely, a dedicated hospice unit in the community or as close as possible to home so that families and friends can visit and spend time with the person in their last days.
It is important we acknowledge the hospice movement and the considerable and consistent voluntary effort of its members. I can only speak about the evidence I see in Waterford. I am very proud of the people involved there on a voluntary level. They have to raise more than €500,000 per annum to deliver specialised palliative care services in the home. They have been the crutch for the families to whom I referred. Those volunteers identified the shortfalls in our public health system many years ago. The Waterford hospice movement was set up in 1988. After almost 22 years it seems the reality of a dedicated hospice unit based at Waterford Regional Hospital is about to happen. I introduce a word of caution. The unit was promised three years ago and very little has happened in the intervening period, but plans are now on the table and a site has been allocated. Fund-raising is taking place to come up with the charitable contribution towards the service. I have no doubt it will serve Waterford, south Kilkenny and the entire south east very well when it is built. I urge the Minister of State, Deputy Áine Brady, to ensure the HSE and the Department keep the unit as a high priority because volunteers have been working in Waterford for more than 22 years and they need a dedicated unit so that they can concentrate on delivering specialist care in the home, to which many speakers referred.
I will not go into the detail of the specialist care provided by the hospice movement. Other organisations such as the Solas centre in Waterford provide bereavement counselling and therapy sessions not only for those who are ill but for their families as well. They are vital human resources that we must put at the disposal of people when they are most vulnerable.
I welcome the debate because despite the economic crisis and the trauma we are all going through, we must never forget the real life trauma of people who are very ill, because when one is very ill, economics and such issues do not matter. What is important is one's health and having family close. That is something we as politicians and officials in the Department and the Health Service Executive must keep in mind. They need to support the volunteers who have been striving year on year. No one expects someone to wave a magic wand and have the hospice unit built overnight but they need to see real progress in getting closer to having that unit open and available to sick people in their communities. This is an issue we must not lose sight of, which is why I welcome the motion. It identifies clearly from the quality standards an end-of-life strategy for all citizens. Although the Government has moved an amendment, it would do no harm to follow this closely and use the guidelines to reach the service our citizens deserve.
I am grateful to Senator Coffey for allowing me this time. I am especially pleased that Senator Mullen has tabled this motion, which is very important. The length and detail of the motion shows the complexity of the situation. I am glad to speak on this issue as I was asked to deliver the Mary Redmond Foundation lecture in February last at the St. Francis Hospice, which I did. It was a deeply religious and deeply spiritual place. I had a very interesting exchange of views with the people there and I agreed with them on most things because hospice care is very important.
There has been a huge cultural shift. A total of 30,000 people die in Ireland each year, nearly 80% of whom die in hospital, most of them in wards containing five or six people, which is not always appropriate. A friend of mine in my local area was married to a distinguished artist who died after being taken to the casualty department of a hospital. She was told her partner was dead and was brought into the room where the hospital staff tried to resuscitate him. Eventually, they produced a priest who had no idea who this man was and referred to his wife as his daughter. Two orderlies then appeared who did not know who she was and who were laughing and joking. There was a complete lack of dignity; it was extraordinary. This person wrote an article in The Irish Times stating that no one present had any training in how to deal with someone who is suddenly bereaved.
Hospitals do not do death. They see it as a failure and not as a natural thing that happens. That is the difference with a hospice. Many have spoken of their personal experience. I have had personal experience, although I do not have the time to highlight it. There has been a huge cultural shift. A total of 80% of people now die in hospitals whereas at the beginning of the 20th century it was only 20%. We are very lucky to have a hospice movement and it is very important we do.
I compliment Senator Feeney, who I heard from my office talk about the death of her father. She said she wished for him to have certain treatments involving the application of pain controlling drugs but this was forbidden under some ethical consideration because it would lead directly to his death. Why not? What arrogance and impertinence for outsiders — third parties — to consider they had the right to dictate the manner of death, the most intimate, personal moment of any person's life.
I recognise there is a difficulty. I read with great interest the statement from the Roman Catholic hierarchy in Britain which referred to the dangers of giving too much pain control. They made one very interesting point. The patient should be consulted because sometimes pain control interferes with the patient's capacity to deal with their family and friends. If the family, friends and person wish for this, they should be allowed that capacity.
We need to know what is a good or happy death. Perhaps the Minister of State knows the story, A Happy Death, by one of our greatest artists, the late Mary Lavin. A British woman had mistreated her husband who was a dreamer. When the man collapsed and was taken to hospital, the woman did not know what to do. She saw some of the other patients were having fruit delivered, so she got fruit, chocolates and magazines. The man was beyond it. There was blaspheming and screaming from the next ward but suddenly it stopped. One of the nuns came in and said was it not wonderful that God had vouchsafed this man, this blasphemer, a happy death. The woman thought that was it, she would get him a happy death. She got priests, rosaries and all the rest. She came up to him and whispered an act of contrition into his ear, saying she was heartily sorry. He woke up and said he was not a bit sorry, that it was wonderful, that he always loved her and that it was worth it. The woman went away grieving because God had not given her husband a happy death. What an irony. Of course, he had a happy death. That is what the hospice movement so wonderfully helps us to give to our fellow citizens.
Cuirim fáilte roimh an rún seo. Is maith an rud é go bhfuil ant-ábhar seo á phlé againn ar ár gcéad lá ar ais sa téarma seo. Molaim an Seanadóir Mullen fá choinne an rún seo a chur chun tosaigh ar son an ghrúpa Neamhspleách. I welcome and fully support the motion. It is a very important issue. It is interesting that we are discussing end-of-life care in hospitals as the Dáil has just finished discussing the end of life for the Government. While the Government intends during the debate in the Dáil to increase its lifespan until April, when it indicates the by-elections will take place, it is apt that we are discussing the same theme in both Houses today, although this one is much more serious than the pending elections.
The motion refers to the audit of end-of-life care in hospitals published last May by the Irish Hospice Foundation, which does excellent work and needs to be commended in this House. The audit found that one in five acute hospital patients could have died at home if enough supports had been provided for them. It is one of the greatest scandals of our health system and our social services that far too little has been done to provide the necessary supports for older people in particular to live and die in their own homes, if that is their wish, instead of in nursing homes or hospitals. We now find that the improvements that have been made are beginning to be cut back.
Prominent in the news this week is an issue that affects my own region, namely, the savage impending cuts to the health service in the vast HSE west region which stretches from Limerick to north Tipperary to my own home county of Donegal. We heard in the news yesterday SIPTU addressing the cutbacks that are happening in County Mayo in home help services. The union described the cuts as brutal and said that €500 million is being withdrawn from home help services in that county alone. I disclosed in the House not only this year but last year the cuts taking place in my home county of Donegal where 78,000 hours of home help support have been stripped away this year. This is support that helps people who have taken the decision to stay at home to die because that is their wish. The type of cuts to which I refer in Mayo and Donegal is reflected across the other regions.
Is é ceann de na polasaithe is lochtach, is salaí agus is tromchúisí atá ag an Rialtas ná an cinneadh ciorraithe a ghearradh ar dhaoine atá ag deireadh a saoil agus ag lorg tacaíocht ón Stát. Thóg na daoine sin an tír seo. Bhí siad anseo le linn an Chéad Chogadh Domhanda agus an Dara Chogadh Domhanda. Bhí ar cuid acu imeacht ó bhaile, dul ag obair thar sáile agus airgead a sheoladh ar ais go dtí an teaghlach chun tacaíocht a thabhairt don chlann agus don phobal. Níl an Stát ag tabhairt aon tacaíocht dóibh, agus iad ag deireadh a saoil, chuncuidiú lena gcinntí bás a fháil ina gceantair dhúchais, bailte agus teaghlaigh fhéin a chur i bhfeidhm.
The measures proposed in the motion should have been undertaken in the past decade when the Government was boasting about the health of its public finances. We now know it squandered those finances and created the economic crisis we are faced with. It is the old, the infirm, the sick, the disadvantaged and the marginalised who are paying for the crisis, not the people who caused it.
It is a false economy because the savage cuts are taking billions out of the economy and depressing it further. The Government has operated the same type of false economy with regard to health care and social services rather than providing the supports for terminally ill people to remain at home in their communities or in hospice care. Government neglect means that their lives end in acute hospital wards that are often overcrowded, which is distressing for themselves and their families and loved ones. It lacks the dignity and comfort which could be theirs in more appropriate settings.
If we want to consider this in purely economic terms, which is not the way we should measure it but the way the Government seems to consider everything these days, it is far less cost effective in the long term. The Irish Hospice Foundation audit identified significant weaknesses in how the hospital system responds at each stage of the patient journey from admission to death. There are variations not only between hospitals, specialties and wards but also within them. There is also variation in what is called the quality of dying in hospitals, with the experience depending on the patient's disease. It is surprising that most hospital staff receive little or no preparation for the death of patients. It is not surprising, only sad and tragic, that the poorest experience was for the patients with dementia or frailty. According to this report, in the case of sudden deaths, one third of relatives do not seem to be informed as to the reason for post mortem examinations.
These are small but distressing elements that could be rectified simply. The Government should accept the motion and, more importantly, act by implementing the quality standards in end-of-life care in hospitals without delay.
Gabhaim buíochas leis an Seanadóir Mullen as an rún seo agus an t-am seo a ghlacadh leis an cheist fíor-thábhachtach seo a phlé sa Seanad.
In the past 50 years life expectancy in Ireland has climbed steadily from just under 70 years in 1960 to just under 80 years today. This is a phenomenal improvement in a relatively short time. Consider for a moment the improvements that will be made in the next 50 years. It is reasonable to expect that children being born now will routinely live into their hundreds. Such improvements in life expectancy allow us to push death away to a distant place where we can believe that it affects others and not ourselves. Whole industries are devoted to making us look and feel younger than we are. In our increasingly obsessive quest for the elixir of eternal youth, we are in danger of compartmentalising death, shutting it away in some dark cupboard and only opening the door when its inevitability is staring us plainly in the face. Approximately 20 years ago, a newspaper article on longevity had to remind us that the mortality rate in this country is 100%, that we all die eventually and that in a typical year, 28,000 people — our family, friends and neighbours — will die. Included in this figure are the 400 children who will die before their 18th birthday.
Death should form part of our everyday lives rather than it being isolated and hidden away. This motion is a welcome opportunity to debate the issue of death and how we care for our dying. I thank Senator Mullen and his colleagues on the Independent benches for choosing to use their Private Members' time for such a debate.
The Irish Hospice Foundation, IHF, has done us all a great service by carrying out extensive research into the needs of the dying and coming up with practical and sensible suggestions that, if acted upon, would allow our people to die in dignity and surrounded by those they love. Two clear lines of thought emerge from the research. First, it is more than clear that the majority of people would prefer to die in their homes. Second, it is also clear that we have much work to do to enhance the environment of hospitals in order that we can allow our people to die with the dignity and level of care they deserve. The IHF survey of 2004 found that more than two thirds of people wanted to die in their homes. Only 10% expressed a wish to die in a hospital setting. The statistics tell us that more than 70% of us die away from home.
We need to work genuinely towards providing people with the choice to die in their homes, primarily because it is the right thing to do but also because the choice to die with dignity at home will create real savings for our health service. The average person consumes health services valued at €300,000 in his or her lifetime, approximately €70,000 of which occurs in the last year of life and €28,000 in the last month of life. People in the last year of life comprise only 15% of the population, but they account for almost 30% of all hospital expenditure. People using hospice services are mostly cared for and die at home, use fewer acute hospital services and live longer in greater comfort and dignity. They also consume at least 25% fewer medical resources than those who access hospital care. An interesting study in Barcelona concluded that the use of hospital resources by patients with incurable illnesses fell by 61% in that region once a comprehensive palliative care programme was put in place, length of hospital stays was reduced by 25% and the use of emergency rooms, always a crisis issue in Ireland, was reduced by 42%.
Evidence in Ireland reveals that cancer patients who use a developed local hospice service die at home, which is what most people want, while those patients in counties with limited or no hospice services tend to die in hospital. We all know of the excellent work being done by the hospice movement. For example, the Milford care centre in Limerick provides hospice services in the mid-west. In 2006, 31% of people with cancer in that region died in a hospital. The figure rises to 70% in areas not served by comprehensive hospice services.
We can only conclude from these statistics that it makes sense to extend a comprehensive hospice service to the whole of the country. Our people can die with the dignity they deserve in their own homes surrounded by the people who care for and love them. They would be in the place they want to be in their final days. As Senator Doherty alluded, doing this would not only be right and just but would also provide a significant saving for the health services.
For those who die in hospital, we need to provide a hospital environment that allows staff to deliver the dignified care they deserve. The IHF has produced an excellent set of guidelines on how best we can design the physical environment of hospitals to care for our dying. It is anticipated that these guidelines will be used primarily in the development of new hospitals, but they should also be used in refurbishments.
More than half of those who die in hospitals die in multi-bed wards. In the very last hours of their lives, they often must experience others dying in beds around them and listen to the anguished cries of bereaved relatives. I have personal experience of this occurring. It is not the environment in which any of us would choose to spend his or her last days and hours. If we genuinely believe in real equality, none of our people should be subjected to such a traumatic environment when at his or her most vulnerable.
I call on the Government to engage actively with the IHF in seeking to extend our palliative care services and supports to the whole of Ireland. It makes sense on every level to allow our people to die at home. The Government also needs to incorporate the foundation's design guidelines into any new hospital development. Let us give our dying the dignity they deserve.
I will conclude with an apt quote from the founder of the hospice movement in the UK, as cited by Senator Fitzgerald. The founder stated:
You matter because you are. You matter till the last day of your life. We will do all we can, not only to help you die peacefully, but to live until you die.
I thank Senators Mullen, Quinn and Ross for raising this issue and all Members who contributed to the debate. I acknowledge the intention of the motion proposed by Senators Mullen, Quinn and Ross and agree that we are not far apart. The Government proposed its amending motion to clarify the current position on palliative care and the level of the Government's commitment to it and to demonstrate the considerable progress made by all parties in the spirit of partnership culminating in favourable international rankings.
Palliative care, as defined by the World Health Organization, WHO, in 2002, is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness. Ireland has a long tradition of involvement in palliative care and was the second country in Europe to recognise palliative medicine as a distinct specialty. In a recent report for the European Parliament, Ireland was ranked second after the UK for palliative care services in Europe. Ireland was also ranked fourth overall in Europe in a recent report, The Quality of Death: Ranking end-of-life care across the world, published by The Economist Intelligence Unit, a research and advisory arm of The Economist newspaper.
The HSE has committed through its national service plan 2010 to delivering services within its Vote. Significant resources are provided annually by the executive for the delivery of services by a range of statutory and non-statutory providers. The investment being directed to palliative care allows for the provision of a wide range of supports, including specialist inpatient beds, other palliative supports in acute hospitals and the provision of community based services. These include 25 palliative care consultants and 26 home care teams nationally.
A number of speakers raised the issue of palliative care for children. In Ireland approximately 1,400 children live with life limiting conditions and in the region of 490 childhood deaths occur each year. Of childhood deaths due to life limiting conditions, the majority occur in the first year of life, with approximately 350 deaths each year. Palliative Care for Children with Life Limiting Conditions: A National Policy was adopted as Government policy on 15 December 2009. It provides a foundation on which palliative care services for children can be developed in the Republic of Ireland. The HSE is progressing phase 1 of this policy, the appointment of Ireland's first paediatric consultant with a special interest in palliative care and the appointment of eight outreach nurses, or two in each HSE region.
The palliative care services five year medium-term development framework was published by the HSE in July 2009. It describes the actions and initiatives required to address the gaps in palliative care service provision against the background of the recommendations set out in the 2001 report of the national advisory council for palliative care. It takes a patient-centred approach and ensures the unique needs of patients are addressed in a holistic manner. In line with recommendations of the strategy, the HSE has recently established an implementation and development committee to monitor progress in the implementation of the strategy at national level. The committee is chaired by the HSE and the membership includes representatives of organisations previously represented on the national council for palliative care, including the Irish Hospice Foundation and the Irish Association for Palliative Care.
The care of a person dying in a hospital is obviously different from that of a person admitted for other procedures. For example, issues of space and privacy may be more to the fore. In addition, spiritual issues may arise in complex ways, sometimes as much for family members and hospital staff as for the person facing the finality of death. A five year national programme, the hospice friendly hospitals programme, was developed by the Irish Hospice Foundation in partnership with the HSE and launched in May 2007 with the aim of ensuring high quality end-of-life care for patients and families by bringing the ethos of hospice care into hospital settings.
The quality standards for end-of-life care in hospitals were launched by the Minister for Health and Children in May and advanced as part of the hospice friendly hospitals programme. They aim to support and enhance the provision of quality patient-centred end-of-life care within all hospital settings, particularly in acute care facilities. They set out best practice on end-of-life care and have at their core the need for greater engagement by hospitals in issues of dying, death and bereavement. They are supported by HIQA which on 23 September launched a public consultation on its draft national standards for safer better health care. These standards will outline to the public, those who use health services and health care providers what is required for high quality, reliable health care services and describe what a good and safe service should look like. When the standards are finalised, HIQA will monitor compliance to assess how they are being followed in practice. In 2012 the authority will prepare for the commencement of licensing as the designated licensing body for all health care services.
I am pleased to announce that the Minister has recently decided to make available national lottery funding of €250,000 to enable the Irish Hospice Foundation to undertake, in conjunction with the HSE, the design and dignity challenge to fund small projects to enhance the physical environment of areas of hospitals relevant to end-of-life care. This money is additional to the €350,000 already awarded to hospice friendly hospital projects for 2009.
The Department, the HSE and the voluntary sector are actively involved in planning for the development of palliative care services in line with the recommendations of the 2001 report. The Irish Hospice Foundation and the HSE undertook an extending access programme and subsequently published the report, Palliative Care for All: Integrating Palliative Care into Disease Management Frameworks, in 2008. The report seeks to identify mechanisms, whereby those who have life limiting conditions other than cancer can ensure their palliative care needs will be met. It focused particularly on three life limiting conditions, chronic obstructive pulmonary disease, dementia and heart failure. Pilot projects are in operation to examine mechanisms of shared care in developing best practice models. The programme has also established links with other chronic diseases where the need for palliative care services at different times of the disease trajectory is recognised. When they are fully under way, a steering committee will be established to guide, direct and co-ordinate the projects.
The report of the national advisory committee on palliative care recommends that bereavement support should be an essential part of all specialist palliative care programmes and offered in all specialist palliative care settings. All HSE regions have a bereavement support service at each of the three levels indicated in the report of the committee. In different hospice settings these bereavement services may include services of remembrance, bereavement information lectures, bereavement groups or individual bereavement support sessions and counselling. The distinction between end-of-life care and palliative care is becoming increasingly blurred. The World Health Organization now promotes a wider application of palliative care to make it relevant to all those with chronic illness and their families in different care settings from the early stages of illness.
The national standards for residential care settings for older people which were approved by the Minister on 17 February 2009 provide a blueprint for the provision of a higher standard of care in nursing homes. The standard of care provided in residential centres is measured against a set of understood criteria. All residential centres for older people, whether public, private or voluntary, are subject to the same core standards on quality and safety. A standard on end-of-life care is specifically identified. It requires that residents at the end of their lives continue to receive care which meets their physical, emotional, social and spiritual needs and respects their dignity and autonomy. The 16 criteria against which this standard is assessed require, among other things, that the resident's palliative care needs are assessed, documented and regularly reviewed; the resident's wishes and choices regarding end-of-life care are discussed and documented and, in so far as possible, implemented and reviewed regularly with him or her; every effort is made to ensure the resident's choice as to place of death, including the option of a single room or returning home, is identified and respected; the resident's family and friends are facilitated to be with him or her when he or she is very ill or dying and overnight facilities are available for their use; following the death of a resident, support is provided for other residents and staff; and staff are provided with training and guidance in end-of-life care as appropriate to their role. The standards are underpinned by the Health Act 2007 (Care and Welfare of Residents in Designated Centres for Older People) Regulations 2009. The regulations, with those covering the registration of residential centres for older people, came into effect on 1 July 2009. Under the regulations, the chief inspector of social services who is part of HIQA registers and inspects all centres providing long-term residential care for older people.
Further developments have been made in end-of-life education and research through the recent instigation of an all-Ireland institute for hospice and palliative care. The combined efforts of hospices, health professionals and academics North and South intend to address end-of-life education needs and put a full research programme in place. The institute will come on stream later this year.
The overall thrust of Government policy on older people requiring care is to offer a range of supports to help them live at home and in their communities for as long as possible. Where this is not feasible, access to modern, high quality long-term residential care services is available. These packages can often include elements of a palliative care or end-of-life approach.
Anyone who has seen a family member or a close friend battle through the latter stages of serious illness will know the trauma it can be for the patient, families and friends. That person would also know of the support and encouragement which the members of a palliative care team provide. There is no doubt that the work of all those involved in the development and implementation of palliative care policy and the provision of services has brought hope and comfort to families and individuals.
The provision of quality care for people living with life-limiting conditions and for their families and carers requires a partnership approach between the statutory and voluntary sectors. It is this very strong partnership approach, which exists in Ireland, that has seen the country rise to the top ranking in Europe in the provision of palliative care services.
The distinction between end-of-life care and palliative care is becoming increasingly blurred. The World Health Organization also now promotes a concept of palliative care for all with chronic illnesses, and their families, in different care settings from the early stages of disease. There is no doubt that there will be a growing demand for palliative care services as the population ages and life-prolonging treatments are developed further. There will be challenges ahead as services change and evolve to meet the needs of our society. Services will have to adapt and be more flexible in their use of funding while maintaining at their core the person-centred approach synonymous with palliative care.
Some facts are very clear. The majority of people will die while in the care of the health services, be it at home, in hospital or in long-stay care. The need for health care professionals and all those working in health care settings to have knowledge, understanding and sensitivity towards palliative patients is fundamental. The principles of end-of-life care and palliative care should be integral in the basic training criteria of all professions and those working in palliative care settings.
I will refer directly to some of the issues raised. Senator Feargal Quinn spoke about living wills and advance care directives. These issues are being considered by the Department of Justice and Law Reform in the context of mental capacity legislation. There is no legislation covering them and there are legal and ethical issues to be carefully considered.
Senator Ó Brolcháin mentioned primary care teams and palliative care. A HSE primary care national steering group for palliative care has been established recently to review and consider palliative care provision within community and primary care structures. This review will be based on a selection of ten existing primary care teams and will also consider the views of specialist palliative care practitioners, out-of-hours GP services and community pharmacies. On the issue of assisted suicide and euthanasia, there are no plans to develop policy and I assure Senator Walsh that there are no working or other groups formulating policy in the area.
I acknowledge the great work done by the voluntary sector in this area. Many of our hospices are run by this sector, together with an army of volunteers who tirelessly give of their time and of themselves to those who need them at this challenging time, including patients, families and friends. We also have an active voluntary sector which raises awareness and funds to support the parties involved, including the Irish Hospice Foundation. We owe a significant debt of gratitude to all concerned and I can give an assurance that the work is valued and appreciated.
It is clear from what I have outlined to the House that the Government's commitment to end-of-life policies is obvious. I assure the House that we will continue to work with the HSE and all other relevant stakeholders to develop further palliative care throughout Ireland.
Let me quote the following lines from James Shirley's "Death the Leveller" to emphasise that death is something which comes to us all and that the experience of seeing loved ones die is one we will all share:
The glories of our blood and state
Are shadows, not substantial things;
There is no armour against Fate;
Death lays his icy hand on kings.
Sceptre and Crown
Must tumble down,
And in the dust be equal made
With the poor crooked scythe and spade.
There is a need to level at a high standard the quality of end of life care available in Ireland.
There is unity in the points of view being expressed on different sides tonight, although there is no unity of approach. I acknowledge the bona fides of the Government side and would have been willing to accept the Government's amendment with all that it contains, as credit should be given where it is due. However, what has been offered is an alternative rather than an addition to what is being proposed from the Independent benches. We are calling on the Government to develop measures to allow people to die at home rather than in hospital where that is their choice, with resources allocated in order that more can access comprehensive hospice services in the community. It should also ensure national guidelines are operational in all acute and community hospitals to address all key end of life care issues, etc.
The problem with old politics is that we must rub out what opposing factions propose and substitute our own version. There should be no problem in the Oireachtas with Members on all sides urging the Government to provide for the taking of action that we all recognise is required. In that context, I give credit where it is due. Other Senators have pointed out that there are good things happening. Notwithstanding what I said, it is the case that in many care settings efforts are made to assist, for example, to provide a single room for a person and so on. Much is done in many places, but this is about trying to ensure a high standard across the board. In that regard, we must admire the missionary spirit of the Irish Hospice Foundation, as the hospice movement is central to what is required in end of life care. What we see, particularly with the hospice friendly initiative, is a recognition that the spirit and practices that characterise hospice care must be replicated in other settings such as hospitals and in the home. A great tribute must be paid for the work being done to spread the vision and replicate the practices and spirit of the hospice movement and the work being done in conjunction with hospitals. In many places there is great receptivity to what is being proposed.
The Government is to be commended for supporting the hospice friendly programme and the Design and Dignity Fund. The making available of resources is such that improvements can be made in particular settings to end of life care facilities, which is to be welcomed. In the event that there is money to spare, unlikely as it might sound, it would be useful if we could look at the state of mortuaries, particularly at a time when there is emphasis on providing care for greater numbers in larger centres. It is clear that in some places such as Sligo mortuary facilities are very small and inadequate. Considering what people must experience when visiting mortuaries, it is important that there be a preferential option for end of life care. That explains my reluctance to pull back from the motion. The Seanad should state clearly what is required.
Dúirt mé níos luaithe go bhfuil sé tábhachtach a rá nach bhfuil sé toil gach éinne bás a fháil sa bhaile. Is í an méid atá á rá againn ná ba chóir go mbeadh sé indéanta bás a fháil sa bhaile, má tá sé sin á iarraidh ag daoine. Ba cheart dúinn a chinntiú go bhfuil cúram deireadh saoil ar fáil mar chroí-sheirbhís sna seirbhísí sláinte ar fud na tíre. Ní mar sin atá an córas faoi láthair, áfach. Ba bhreá le go leor daoine bheith sa bhaile agus cúram deireadh saoil á fháil acu. Ní mar sin a bhíonn sé dóibh, áfach. Ní bhfaigheann ach idir 20% agus 30% de dhaoine cúram maolaitheach speisialtóra san ospidéal. Is féidir go bhfaigheann 25% de dhaoine bás leo fhéin. We have much to do to develop consistency across the board in the provision of end of life care facilities.
At this point I mention the excellent audit of end of life care services and the excellent standards achieved. One can consider about 18 recommendations made by the Irish Hospice Foundation and see the importance of providing for more planned admissions to hospitals. It should not be the case that 84% of those who die in hospital are admitted through the accident and emergency department when one considers how predictable cases are. That is one of the reasons cancer care services are so good relative to others: there is dialogue and planned admission, as well as single bed wards and programmes or procedures for end of life care in such cases.
"A lot done, more to do" is a discredited phrase but it summarises our position in the area of end-of-life care and on that basis I will press the motion. Even if I do not get Government support for it I hope the Government will study closely what was put forward in the motion from the Independent benches.
Amendment put.
The Seanad divided: Tá, 29; Níl, 21.
Tá
- Boyle, Dan.
- Brady, Martin.
- Butler, Larry.
- Carroll, James.
- Carty, John.
- Cassidy, Donie.
- Corrigan, Maria.
- Daly, Mark.
- Dearey, Mark.
- Ellis, John.
- Feeney, Geraldine.
- Glynn, Camillus.
- Hanafin, John.
- Harris, Eoghan.
- Keaveney, Cecilia.
- Leyden, Terry.
- MacSharry, Marc.
- McDonald, Lisa.
- Mooney, Paschal.
- Ó Brolcháin, Niall.
- Ó Domhnaill, Brian.
- Ó Murchú, Labhrás.
- O’Brien, Francis.
- O’Donovan, Denis.
- O’Malley, Fiona.
- O’Sullivan, Ned.
- Ormonde, Ann.
- Walsh, Jim.
- Wilson, Diarmuid.
Níl
- Bradford, Paul.
- Burke, Paddy.
- Buttimer, Jerry.
- Cannon, Ciaran.
- Coffey, Paudie.
- Coghlan, Paul.
- Cummins, Maurice.
- Doherty, Pearse.
- Donohoe, Paschal.
- Fitzgerald, Frances.
- Hannigan, Dominic.
- Healy Eames, Fidelma.
- McCarthy, Michael.
- McFadden, Nicky.
- Mullen, Rónán.
- Norris, David.
- O’Toole, Joe.
- Ross, Shane.
- Ryan, Brendan.
- Twomey, Liam.
- White, Alex.
Tellers: Tá, Senators Niall Ó Brolcháin and Diarmuid Wilson; Níl, Senators Paudie Coffey and Rónán Mullen.
Amendment declared carried.
Question put: "That the motion, as amended, be agreed to."
The Seanad divided: Tá, 29; Níl, 21.
Tá
- Boyle, Dan.
- Brady, Martin.
- Butler, Larry.
- Carroll, James.
- Carty, John.
- Cassidy, Donie.
- Corrigan, Maria.
- Daly, Mark.
- Dearey, Mark.
- Ellis, John.
- Feeney, Geraldine.
- Glynn, Camillus.
- Hanafin, John.
- Harris, Eoghan.
- Keaveney, Cecilia.
- Leyden, Terry.
- MacSharry, Marc.
- McDonald, Lisa.
- Mooney, Paschal.
- Ó Brolcháin, Niall.
- Ó Domhnaill, Brian.
- Ó Murchú, Labhrás.
- O'Brien, Francis.
- O'Donovan, Denis.
- O'Malley, Fiona.
- O'Sullivan, Ned.
- Ormonde, Ann.
- Walsh, Jim.
- Wilson, Diarmuid.
Níl
- Bradford, Paul.
- Burke, Paddy.
- Buttimer, Jerry.
- Cannon, Ciaran.
- Coffey, Paudie.
- Coghlan, Paul.
- Cummins, Maurice.
- Doherty, Pearse.
- Donohoe, Paschal.
- Fitzgerald, Frances.
- Hannigan, Dominic.
- Healy Eames, Fidelma.
- McCarthy, Michael.
- McFadden, Nicky.
- Mullen, Rónán.
- Norris, David.
- O’Toole, Joe.
- Ross, Shane.
- Ryan, Brendan.
- Twomey, Liam.
- White, Alex.
Tellers: Tá, Senators Niall Ó Brolcháin and Diarmuid Wilson; Níl, Senators Paudie Coffey and Rónán Mullen.
Question declared carried.