The Last Aid Course as Measure for Public Palliative Care Education: Lessons Learned from the Implementation Process in Four Different Countries

Abstract

This chapter provides an overview over the Last Aid Course (LAC) as measure for Public Palliative Care Education (PPCE) and the experiences from different countries on the implementation of Last Aid Courses. The concept of Last Aid and the public knowledge approach to teach Palliative Care for the public were first described by Bollig in 2008. Last Aid Courses can be seen as educational basis of compassionate communities and have now been spread to 21 countries worldwide. Experiences show differences and similarities in the national implementation process of LAC in four different countries.

1. Introduction

Today most people want to die at home, but the majority actually die in institutions as hospitals, long-term care facilities and hospices. As the numbers of people who need palliative care at home will rise in the future [1] the healthcare system will not be able to meet the needs of those requiring palliative care without the support and contribution from members of the public. This includes relatives, friends, neighbors, colleagues and others in the community. Everybody, all parts of communities and societies have a responsibility to provide end-of-life care for others [2, 3]. Thus, it makes sense to prepare the public to participate in palliative care provision in the community. One measure that can assist with this is delivery of Last Aid Courses to the public in order to raise awareness on topics like palliative care, death, dying, grief and bereavement. Last Aid Courses have been introduced in different countries since 2014 and have been shown to help inform people, and to encourage and empower them to participate, in palliative care and end-of-life care [4, 5, 6]. Learning both First Aid and Last Aid should be part of the normal school education and be a part of ongoing life-long learning for everyone [4]. A six-step approach to education in Palliative Care for ALL including both the public and health care professionals has been described by Bollig [4, 7]. An overview over the Last Aid Movement and the experiences from the implementation of LAC in different countries will be described in more detail in the following parts of this chapter.

2. Last Aid International and the Last Aid Movement

The first description of the Last Aid Course and its curriculum and contents was presented by Bollig in a Masterthesis in 2008 and published as a book in 2010 [4]. The International Last Aid working group with representatives from Norway, Germany and Denmark established the first consensus about the Last Aid Course curriculum and slide set in 2014. Last Aid International was founded as a private organization to promote and implement Last Aid with the aim to enhance the public discussion about death, dying, grief and to improve Palliative Care in different countries in 2014 by its founder Georg Bollig. Mills et al. have in 2020 proposed to introduce a World Last Aid Day to raise awareness about the topics death, dying and Palliative Care [8]. During the course of the years from 2015 until today a variety of organizations from different countries and different backgrounds joined Last Aid International and Last Aid developed to become an international Last Aid Movement with many participating organizations, supporters and volunteers. The Last Aid Course concept is protected by an international trademark. Between 2017 and 2019 the implementation of Last Aid in different countries was promoted as part of Bolligs project in a European Palliative Care Academy (EUPCA) leadership course [9]. Today partner organizations from 21 countries from Europe, Brazil, Canada and Australia are part of Last Aid International and work together on the implementation of Last Aid Courses in different countries. Interestingly the national organizations that implement LAC in the different countries are not always the national Palliative Care organizations but can also be universities, hospices or the church. This will be addressed in the descriptions of different implementation models from different countries in part 3 of this chapter. In 2019 a Last Aid Research Group was established during the 1. International Last Aid Conference in Sønderborg, Denmark. The Last Aid Research Group International (LARGI) is led by Erika Zelko and Georg Bollig and is today a group of researchers from around the world working together to investigate the effects of Last Aid Courses and Public Palliative Care Education. The Last Aid Course project and its founder Georg Bollig have been nominated for and received a number of prizes. A summary of the timeline of the development of Last Aid International and the Last Aid Movement is shown in Table 1.

2008	First presentation of the Last Aid Course in the Master Thesis of Georg Bollig
2009	Poster presentation 11th Congress of the European Association for Palliative Care, Vienna
2010	Masterthesis published as a book
2009–2011	Development of a Last Aid Course with 16 teaching hours in cooperation with the Austrian Red Cross and the IFF Vienna, University Klagenfurt/Graz
2012	Honorable mention for the lecture” The public knowledge approach as educational concept for bringing Palliative Care to the public” International Palliative Care Network conference
2013–2014	Development of a Last Aid Course with 4 teaching hours in cooperation of the Norwegian and Danish Associations for Palliative Care with Letzte Hilfe Deutschland
2014–2015	First pilot courses in Norway, Germany and Denmark
2015	Participation in the project startsocial - Invitation to Chancellor Angela Merkel
2015	Honorable mention for the poster presentation” Teaching Palliative Care to the Public: The Last Aid Course – An International Multicentre project from Norway, Denmark and Germany” International Palliative Care Network conference
2015	Reception of an award for Palliative Care from the German Association for Palliative Medicine and the pharmaceutical company Grünenthal
2016	Symposium of the Paula-Kubitschek-Vogel Stiftung München on Last Aid
2016	Publication of a German handbook for Last Aid Course participants
2016	Lecture on Last Aid on the International Palliative Care congress in Montreal, Canada
2017	1st German Symposium on Last Aid in Hamburg
2017	Lecture on Last Aid on the Scottish Palliative Care congress in Edinburgh, Scotland
2017–2019	Last Aid International as EUPCA project
2018	Last Aid courses recognized and recommended by German Hospice Association (DHPV) and the German Association for Palliative Medicine (DGP)
2018	Meeting of the International Last Aid working group in May in Frankfurt
2018	Relaunch of the German and English homepage www.lastaid.info
2018	Lecture on Last Aid on the 1. Baltic Palliative Care Conference in Liepaja, Latvia
2018	2nd German Symposium on Last Aid in Kassel
2018	Publication of a Danish handbook for Last Aid Course participants
2019	EAPC taskforce Last Aid and Public Palliative Care Education
2019	1stInternational Last Aid Conference Sønderborg, Dänemark
2019	3rd Letzte Hilfe Symposium München
2020	2nd International Last Aid Conference online
2020	Heinrich Pera prize for Georg Bollig
2021	4th Letzte Hilfe Symposium Frankfurt
2021	Order of merit of Schleswig-Holstein für Georg Bollig
2022	3rd International Last Aid Conference Maribor, Slovenia
2022	Workshop on Last Aid and Public Palliative Care Education 23rd Int. Palliative Care Congress Montreal, Canada
2023	Participation in the project startsocial - Invitation to chancellor Olav Scholz
2023	4th Letzte Hilfe Symposium Magdeburg
2023	Nomination for Schleswig Holsteinischer Bürgerpreis

Table 1.

The timeline of the development of last aid international and the last aid movement.

3. Implementation of Last Aid Courses in different countries

To implement and promote Last Aid Courses in different countries Last Aid International usually cooperates with one partner organization in each participating country. During the EUPCA-project to promote the international distribution of LAC, the first idea was to cooperate with the national Palliative Care organization. Interestingly the project has shown that not all Palliative Care organizations were interested or motivated to implement LAC and that different national organizations can be the best option to promote LAC in different countries [9]. For implementation and sustainability of the LAC, it is paramount that the participating national organization makes a commitment to keep to the agreed course rules, presentation and delivery guidelines provided by the International Last Aid working group. This can ensure that the Last Aid Course has the same content and learning outcomes in every country round the world. The only differences required are the national organizations of Palliative Care services, and explanation of national legislation and laws that concern Palliative Care provision and end of-life care for example rules for advance care planning and surrogate decision-making/power of attorney. Although physician assisted suicide or medical assistance in dying is legal in some countries, this is not a part of the curriculum. This decision was made as it was felt adequate Palliative Care does not usually include these options.

The LAC is in all participating countries based on the same standardized curriculum and slide set that is based on a consensus of the experts of the International Last Aid working group. This group consists of 1–2 experts from the field of Palliative Care from each of the participating countries. The group regularly meets every other year in connection with the International Last Aid Conference. The last meeting was held in Maribor, Slovenia in 2022 and the next meeting is planned to be held in Cologne, Germany in September 2024. Additional meetings or subgroups may be established when needed and meet online when needed. The contents of the current LAC curriculum are shown in Table 2.

Module No.	Main topic and duration (minutes)	Course Content
Module 1	Dying as a normal part of life; 45 minutes	Welcome and introductions First Aid and Last Aid What you can do to care The process of dying
Module 2	Planning ahead; 45 minutes	Networks of Support Making decisions Medical and ethical aspects Advance care planning Advance Directive Medical Power of Attorney
Module 3	Relieving suffering; 45 minutes	Typical problems and symptoms Caring/relieving suffering Nutrition at the end of life How to comfort
Module 4	Final goodbyes; 45 minutes	Saying goodbye/final farewell rituals Funeral and various forms of burials Grieving is normal Grief and ways of grieving Questions, Comments

Table 2.

The last aid course contents.

The implementation and distribution in the different countries is done by a national partner organization. The cooperation and work within the International Last Aid Movement is based on the following ethos and principles.

Ethos and Principles of Last Aid:

• Not for profit public awareness course: Last Aid should be delivered to members of the public with charges only being made to cover the cost of delivery (maximum 20 EUR per each course participant).

• The Last Aid course is a method of encouraging open discussions about the principles of death, dying and grief in order to improve the public’s ability to cope with these aspects of life.

• The Last Aid Course provides a holistic overview of the human experience of death, dying and grief.

• The Last Aid Course aims to normalize the process of death, dying, bereavement and the aspects of care required.

• The Last Aid Course can be seen as educational basis of Compassionate Communities and aims to motivate and empower everyone to participate in Palliative Care and end-of-life care for everybody in need.

The national Last Aid partner organizations, also called national Last Aid hubs are responsible for the implementation and promotion of Last Aid Courses in the respective countries. The national Last Aid hubs can be supported by regional or local Last Aid hubs in the country if needed. The national Last Aid organizations have some general roles in their organization assigned. These include Last Aid Course instructor/facilitator; Last Aid Course Director and Last Aid Course Trainer in some regions supported by a local coordinator who works with the organization of the LAC and LAC instructor courses.

Last Aid Course Instructors/Facilitators

All Last Aid Course instructors/facilitators will deliver the Last Aid Course at least once per year (as per Last Aid International rules). They will attend facilitator training, by an approved Last Aid Trainer. Last Aid Course Instructors/Facilitators are required to have the following qualities:

1. Understanding of palliative/end of life care

2. Ability to commit to delivering the course with another Facilitator

3. Personal or professional experience with death, dying and bereavement concepts

4. A full understanding of the Last Aid course rules.

In addition understanding of online video conferencing uses, and being prepared to learn how to facilitate Last Aid online is helpful. They must demonstrate fidelity to the Last Aid Course, and the course rules. The approach to fidelity within the Last aid Movement is shown in Figure 1.

Figure 1.

Approach to Fidelity to the last aid concept.

The Local Last Aid Hub has the responsibility to recruit the appropriate facilitators to deliver Last Aid.

Last Aid Trainers

Last Aid Trainers have a dual role as Instructors/Facilitators of the Last Aid course and train the future Last Aid Course instructors/facilitators. They will deliver the one day Last Aid Instructor/Facilitator course together with a Last Aid Course Director.

The national Last Aid organization recruits Facilitator Trainers based on the points below:

1. Background in facilitation/teaching

2. Relevant clinical/educational experience in Palliative and End of Life Care services.

3. Awareness of local palliative care strategic development

4. Ability to attend train the trainers course

The national Last Aid organization will approve those recruited to be Facilitator Trainers, to ensure quality assurance and fidelity to the Last Aid Course.

Last Aid Course Directors

Last Aid Course directors are experienced trainers who lead the Last Aid Instructor/Facilitator course together with another trainer. They have the responsibility for the training. The Course Director must ensure the fidelity of the Last Aid Course, its ethos and principles.

The processes outlined below provide further guidance on preparing for the delivery of the Last Aid Courses. Figure 2 illustrates the steps in the process of implementation of Last Aid Courses. Ongoing support and guidance will be provided by the National Last Aid Hub.

Figure 2.

Steps in the process of implementation of last aid courses.

In the following parts 3.1 to 3.4 the experiences from the implementation of LAC in four different countries will be described. In Germany LAC were started in 2015, in Scotland, Switzerland in 2017 and Slovenia in 2018.

3.1 Experiences from Germany

The first delivery of LAC in Germany was held in Schleswig in January 2015. It was the second LAC worldwide after the first course in Norway in November 2014. Led by Georg Bollig, the first LAC slide set was created by a group of Palliative Care experts, with a variety of professional backgrounds, from Germany, Norway and Denmark, as part of the International Last Aid working group in 2014. Courses in Germany were being delivered parallel with the work to establish a national organization that could take care of the further development of Last Aid in Germany. The process to start an organization proved to be complicated due to the complex rules for establishing a new non-governmental organization (NGO) in Germany. Bollig decided to deliver the LAC with some volunteers and co-workers to ensure the German public benefitted from the LAC. A first Last Aid instructor course was designed by Bollig and held in October 2015 in Schleswig. The concept of a one-day Last Aid instructor Course for people with experience from the field of Palliative Care proved feasible and was thereafter organized and managed by Bollig and co-workers. In 2018 Letzte Hilfe Deutschland gUG was founded as a non-governmental organization by Marina Schmidt, Ingmar Hornke and Georg Bollig. Today Letzte Hilfe Deutschland gGmbH is a self-sustaining non-profit NGO that works with the implementation of LAC in Germany and has contributed to the further development of the Last Aid Movement by developing new course formats for LAC for kids and teens; LAC online that was developed during the COVID-19 pandemic; LAC in easy language for people with learning disabilities and mental handicaps; LAC professional for health care professionals; and LAC Diversity for people with diverse backgrounds and the time to discuss cultural and other differences in more depth. Furthermore Letzte Hilfe Deutschland gGmbH engages in advocacy and promotion of Last Aid Courses and Public Palliative Care Education (PPCE) for the whole society and supports research projects on Last Aid and PPCE. The Last Aid Course for kids and teens (LAC-KT) has already been introduced in Switzerland and Austria. With these activities and a number of active working groups driven by volunteers Letzte Hilfe Deutschland gGmbH is a major contributor for the further development and testing of new LAC formats for special groups. Along with the countrywide implementation and delivery of the course, a need for fulltime employees became obvious. Today Letzte Hilfe Deutschland gGmbH has 1,5 fulltime employees (one of them being the CEO Marina Schmidt), a number of paid free-lancers for special tasks and many volunteers. There are several Last Aid working groups on different topics like course formats, advocacy, etc. that are working on a voluntary basis. The work of Letzte Hilfe Deutschland is financed via grants and income from fees of Last Aid Instructor Courses and LAC for the public that are in part paid by health-insurance companies. So far there have been educated more than 5000 Last Aid Course instructors and over 70,000 citizens. Germany is a major contributor in the nationwide implementation of LAC in Germany and the future development and improvement of the Last Aid Movement and new course formats.

3.2 Experiences from Scotland

The Highland Hospice, based in Inverness in the North of Scotland, is the main partner for the implementation of LAC in Scotland after a short period of cooperation with the Scottish partnership for Palliative Care Highland Hospice and Highland Hospice since 2017. The Highlands of Scotland has a geographical area similar to the country of Belgium, and a population of approx. 240,000 people. It has the lowest population density in Scotland, with around 8 people per sq. km. The Highland Hospice provides Pallaitive Care and outreach to this population. After an informational presentation from Georg Bollig, Highland Hospice CEO, Kenny Steele, felt that the public of the Highlands would benefit greatly from the Last Aid Course. In March 2019, the Facilitator course training was delivered by Georg Bollig to a group of 12 facilitators, many paid employees and volunteers with Highland Hospice, with a member of a charitable local agency also taking part in the training.

Led by Siobhan Neylon and Dr. Jeremy Keen, Consultant in Palliative Care from Highland Hospice, plans were made to connect with community groups to offer the LAC as part of a pilot delivery of the course. These groups were: Police Scotland, Church Groups and Community Centres. Each course had 3 members of the Facilitator group to ensure exposure to delivery as early as possible. The 4 pilot sessions received positive feedback, and the Hospice agreed to embed Last Aid Course delivery as part of their commitment to empowering and supporting the population of the Highlands. The engagement and delivery strategy for Last Aid required adjustment due to COVID-19, with online courses being well attended, not just with a Highland audience, but with a wider reach to all of Scotland, England, Wales, Northern and Republic of Ireland and even as far reaching as Poland and Canada. The courses were advertised online via Social Media platforms, and on the Highland Hospice website. However, the most influential advertising method was word of mouth and verbal dialog. A research study conducted with University of Highlands and Islands (UHI) and Highland Hospice using the Death Literacy Index as a guide, compared attendees’ experiences before and after attending the Last Aid Course. Researchers also interviewed facilitators and examinded their experiences on delivering the course in person and online. The findings showed increased confidence in communicating about topics regarding death and dying, and planning ahead [10]. Facilitators expressed feelings of reduced confidence on delivering the course online and missing the in-person interaction with attendees. This study began a strong academic and research relationship with UHI and Highland Hospice for Last Aid and Public education initiatives. The Hospice adapted the Last Aid Course Handbook from German, and translated it to the English language, to ensure our new facilitators had more foundational knowledge behind the course and guidance on delivering the course online. An education website was also established, using the Moodle Platform. This allowed faciltiators to have links to further learning around each Module and topics within the Module, such as podcasts, YouTube videos, articles and website links. An adapted Facilitator Course was developed to enhance the confidence of the facilitator to deliver the course. This became a 2 day course, with an emphasis on the topics from expert speakers, such as Child bereavement officers, Occupational Therapists, MacMillan Citizen’s Advice Bureau, Consultant Physicians and previous LAC Facilitators. This facilitator course was then delivered to members of the Fire Service, Scottish Ambulance Service (who would deliver to Tri-Services including Police Scotland) and Macmillan Cancer nursing team, along with Hospice Volunteers, who would become part of the Scottish Last Aid Course delivery to improve public knowledge and awareness of death, dying and bereavement. The course was being delivered in a hybrid method, with some attendees attending on Zoom platform, and others in person. This allowed for careers who were looking after their dying relatives to attend from their homes, people who lived further away in the Highlands to attend, and those who were hard of hearing to attend using the Closed Caption section of Zoom platform. This was oftentimes challenging for facilitators, and IT support was provided by the Hospice to ensure online attendees had positive experiences. Today, Highland Hospice has a dedicated Last Aid Development Officer who works with engagement of new hub development and outreach to rural communities in the Highlands. This role has become vital in the ongoing progress being made to ensure Last Aid is a widely recognized public education course. The Highland Hospice also provides leadership and support to the facilitators currently delivering the course and is committed to increasing public awareness and knowledge across the population.

3.3 Experiences from Switzerland

Since 2017, the Evangelical- Reformed Church of the Canton of Zurich has been a licensee for Last Aid Courses in Switzerland. Although this Church is the licencee, there are many other organizations that are involved in this project. These include: other Churches, sections of the Swiss professional association of Palliative Care, hospitals, nursing homes and foundations from 17 cantons of Switzerland. Through these organizations, Last Aid in Switzerland is being delivered in German, French and Italian languages. When developing the organizational structure, attention was paid to low-threshold, resource-saving processes. At the same time, emphasis was placed on the fact that there is a clear feedback relationship with the course leaders and the quality of the delivery of their courses. Up to time of writing, 360 course instructors are involved and more than 7000 people have attended the course. The national Last Aid structure has strong foundations that allows capacity for expansion or development as needed.

From the beginning, the Church Council of the Evangelical- Reformed Church of the Canton of Zurich was open to Last Aid Course and provided the necessary resources for nationwide development, management, and coordination. Funding was provided for 20% of the rolefor the project management/coordination of Last Aid Switzerland has been approved until further notice.

Accompanying people in dying, death and mourning is one of the church’s core pastoral and diaconal tasks. In its actions, it actively participates in a discourse on good communal living and dying. In doing so, it also encourages dialog. After all, palliative and hospice care for chronically ill and dying people cannot succeed through professional services alone, but only with the commitment and participation of volunteers. The Evangelical- Reformed Church of the Canton of Zurich sees itself as jointly responsible for ensuring knowledge about dying, death and mourning is accessible to all people and encouraging them to seek support. It contributes to networking with other organizations around dying, death and bereavement. It thus shows itself to be a contributor to a caring community.

Switzerland will be known to some people for its liberal regulations in dealing with medically assisted suicide. One of the better-known euthanasia organizations is, for example, the association Exit. Although the number has increased, this is a rather small group, accounting for 1.8% of all deaths.

The title of the Last Aid Course is appealing and was correctly understood in Switzerland from the outset in accordance with the content of the course. There are no misunderstandings about assisted suicide.

In 2018, representatives from the French-speaking part of Switzerland, from Palliative Vaud, a section of the Swiss professional association of Palliative Care, contact project management in Zurich. They have translated all course materials, texts for the website and much more into French. They thus launched the version of “Derniers Secours”. Palliative Vaud cooperates in the French-speaking part of Switzerland, among others with the Reformed and Catholic Churches and mediates other organizations to Last Aid Course Switzerland. They are not only involved in networking for the Last Aid Course in the French-speaking regions of Switzerland, but also played a key role in enabling France to join the project in 2022.

In 2022, the Italian version “Ultimo Soccorso” was created. On behalf of the Evangelical- Reformed Church of the Canton of Graubünden, two Italian speaking course instructors translated all course materials into Italian. The first courses in Italian took place.

In 2023, 25 people were trained for the Kids & Teens Last Aid Course. The first courses are mainly run by parishes. It is expected that this offer will also become more widespread. Palliative Vaud has again agreed to translate and adapt the material into French.

3.4 Experiences from Slovenia

The Last Aid course, first organized in 2019 by the Institute for Palliative Medicine and Hospice Care at the University of Maribor’s Faculty of Medicine Maribor, has undergone significant growth and adaptation over the past five years. In collaboration with the Slovenian Lions clubs and the Slovenian Hospice Association, this course has been delivered forty-five times, with eight of those deliveries transitioning to an online format during (six) and two after the COVID-19 pandemic. The organizers also developed a specialized online course (webinar) to cater to the deaf and hard of hearing community by utilizing sign language. To ensure effective interaction and active participation, each delivery of the Last Aid course accommodated a maximum of 15 participants. The participants’ professional backgrounds span a wide spectrum, encompassing medical and healthcare students, nurses, physicians, teachers, social workers, business professionals, lawyers, engineers, priests, nuns, homemakers, and individuals without current employment. The course’s content and materials were made possible through the Slovenian government-financed Assistance for a Better Quality of Life in the Last Phase of Life (PO-LAST) project, a collaborative effort involving Slovenian medical and healthcare professionals, hospice representatives, university teachers and students. The Slovenian Hospice Association and the University of Maribor’s Medical Faculty and the Faculty of Arts were key contributors to the project, along with Alma Mater Europaea, an independent higher learning institution. The primary aim of the project was to provide comprehensive information and access to resources for individuals facing life-threatening illnesses and their caregivers. The project members, totalling thirteen, undertook various tasks to support this objective. They produced the Slovenian Atlas of Palliative Care, offering insights into support options and information sources for the terminally ill and their caregivers. Additionally, they translated the Last Aid instructor manual from German to Slovene and adapted its content to suit the Slovenian context. The team also created a brochure containing essential information about palliative care in Slovenia and organized and conducted dissemination workshops. All the materials generated during this project have been invaluable in facilitating the implementation of Last Aid courses in Slovenia. The courses have garnered high praise from participants. In 2022 the Medical Faculty Maribor organized also the third LAST AID Conference in presence, after the online Conference in 2020, which was also organized from the Slovenian LAST AID hub. The next challenge of the Slovenian hub is establishing a coordination and administration support for the LAST AID course providers and intensification of the research in this field. Some publications regarding the acceptance of the model were already done [11].

4. Lessons learned from the implementation process in different countries

In the starting phase of the international implementation a cooperation with national Palliative Care associations was sought but proved not to be a successful approach to promote LAC. Many national Palliative Care associations showed little or no interest to implement LAC in their countries. Many could not envisage the potential that the LAC has to raise awareness and to enhance the public dialog about death, dying, grief and Palliative Care. In contrast an approach that proved to be very successful was a cooperation with different national organizations that showed a great interest and commitment in bringing LAC to their countries. As the above four examples show this can be the formation of an own NGO as in Germany, the church as in Switzerland, a Hospice as in Scotland or a University as in Slovenia. That shows that an important factor for successful cooperation and implementation is to find people and organizations that support the ideas and aims of the Last Aid Movement and are willing to agree on common rules for implementation, further development and research to improve and adapt the LAC to the needs of the participants. In the countries that have successfully started LAC, there are always people who are willing to be the pioneers and the driving force for the implementation of LAC. Sometimes it seems most important to have a dedicated pioneer or small group of pioneers who show commitment to the idea of teaching the public by the use of LAC.

Experiences from all presented countries show that the promotion of the courses by word of mouth is a usual way of promoting and distributing the LAC. Media interest has been great in the participating countries. In Germany many reports have been published in newspapers, magazines, radio, podcasts and television. The media attention has in Germany led to the fact that many LAC are fully booked in advance after they are advertised on the homepage www.letztehilfe.info.

As described above the most important steps for the implementation of Last Aid in a country are:

1. An organization and dedicated people to start LAC

2. To establish a first Last Aid instructor/facilitator course

3. To run LAC and to gain experience

4. Establish a core group of trainers

5. Establish an organizational structure for the national Last Aid program and LAC and instructor/facilitator courses

6. Engage in media work and advocacy if possible

The international cooperation and collaboration has led to important improvements and the further development of the course contents as well as the development of new course formats. For example, delivering LAC for police officers, first carried out in Scotland, has gone on to inspire German colleagues to start such courses in Hessen, Germany where the courses were appreciated and will now be implemented more widely in other parts of Germany. In Germany a number of different course formats have been established. A LAC for deaf people has been tried out in Slovenia and the further work on that course format is still ongoing. The LARGI research group and the International Last Aid Conferences are important meeting places for the exchange of experiences with LAC and the discussion of new ideas and new projects with international cooperation and participation. Many researchers and members of LARGI have contributed with a number of scientific articles about the experiences with and the effects of LAC at a national level and across different countries, ethnic and cultural backgrounds. A review of the research was published by Bollig and Bauer [12].

In summary, the collected experiences so far show that one of the most important learning points was that international cooperation and consensus on the LAC curriculum, as well as research, are important parts of the further development and sustainability of the Last Aid Movement.

5. Last Aid as learning system

As already pointed out above international cooperation and collaboration in the International Last Aid working group and the Last Aid Research Group International are the major factors for the worldwide success and implementation of LAC. Last Aid is viewed and perceived as a learning system where everyone can contribute to enhance knowledge and improve to better Palliative Care provision for everybody in need. Evaluation of the courses and research are an integral part of the implementation process of Last Aid. Evaluation and research results can be used in the communication with policymakers, media and the public to ensure public interest and support. Figure 3 illustrates the different groups that interact and cooperate in order to make Last Aid a successful learning system and thereby ensure that the educational needs of the public are reflected and adapted in regular intervals with input from citizens, Last Aid Course instructors, experts from the field of Palliative Care and researchers.

Figure 3.

Last Aid is a learning system.

6. Implications for the future development of Last Aid and the international distribution of PPCE and LAC

In the future the need for palliative care in the community will increase. According to the World Health organization lack of awareness of Palliative Care is a major barrier for Palliative Care provision [12]. Education about palliative care by Last Aid courses or other initiatives of Public Palliative Care Education in combination with a compassionate community approach may serve to improve both the awareness and the public discussion about death and dying as well as palliative care provision in the community [6, 13]. There is a need for more research about Last Aid courses and other measures to empower the public to engage in palliative care provision in the community.

Possible conflict of interest

GB receives financial compensation for teaching Last Aid Instructor courses. GB owns the trademarks “Last Aid” and “Letzte Hilfe”. EN is working for the church in Switzerland and is responsible for the implementation of Last aid Courses in Switzerland. SN has no conflicts of interest.