Most people believe their lives will be relatively healthy, punctuated by episodes of illness that last no more than a few weeks. On the rare occasions that we think about dying, we imagine short and overwhelming illness in old age. Healthcare systems are designed as if disability and ill health were aberrations, rather than a phase that lasts months or years near the end of our lives, despite the contrary evidence all around us. Because of improvements in sanitation, lifestyle, and medical care, only a small proportion of people in developed countries now die suddenly.1 Most serious chronic illnesses cannot be catered for adequately by traditional hospital and surgical services, and substantial restructuring is needed. The numbers of people living with serious chronic conditions in old age will double in the next two decades in the United States,2 and similar trends will be seen in many other countries.3 Finding sustainable ways to improve comfort and meaning in this last phase of life is therefore a priority.

Although hospice programmes have been an important and instructive initial response, they do not meet the needs of most patients who are sick enough to die. A minority of people who die with chronic conditions use …