Care for all at the end of life
BMJ 2008; 336 doi: https://doi.org/10.1136/bmj.39535.491238.94 (Published 24 April 2008) Cite this as: BMJ 2008;336:958
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
Palliative Care for non-malignant diseases is also a great need in developing countries. In Kyrgyzstan the Hospice movement is very new and small. It is based in the national Oncology centres, from the initiative of local Oncologists, but from the beginning, they have said clearly that their hospice services are desperately needed for cardiac, neurological, respiratory and other patients too.
Sadly I believe this need is all the more urgent in developing countries, where more expensive disease-specific treatments are far out of reach. A reasonable standard of basic Palliative Care is achievable now, in most places, with a relatively small amount of training and resources, and can go a long way to improve the situation for the poorest populations.
Competing interests: None declared
Competing interests: No competing interests
For an area of care that is over 30 years old and has been a medical speciality for nearly 20 years, it is disappointing to find it is still misunderstood and misrepresented today.
Murray and Sheikh (1) rightly demand that palliative care must move beyond cancer. However, palliative care has long recognised the needs of non-cancer patients(2) and it is now an integral part of many non-cancer frameworks.(3) Their inclusion of three ‘typical’ dying trajectories is a concept that has been replaced by the realisation that many different trajectories exist.(4) Even cancer is increasingly needing palliative care for months or years. Their claim that hospices ‘are not configured’ for non-cancer would surprise the non-cancer patients who make up to 30% of our adult inpatient unit, 40% of our day unit and 100% of our children’s unit. We would take a higher proportion if they were referred.
References
1) Murray S, Sheikh A. Care at the end of life. BMJ; 2008; 336: 958- 9.
2) Addington-Hall J, Fakhoury W, McCarthy M. Palliative Medicine, 1998; 12: 417 - 427.
3) Department of Health Longterm Conditions NSF Team. The National Service Framework for Long-term Conditions. London: DH Publications, 2005.
4) Gott M, Barnes S, Parker C, Payne, Seamark, Gariballa S, Small N. Dying trajectories in heart failure. Palliative Medicine, 2007; 21: 95-99.
Competing interests: None declared
Competing interests: No competing interests
Sir,
I personally feel that policies should be made by the government of all countries especially that in developing and underdeveloped countries, where resources are limited even for children universal immunisation programme.
Following would be the policies that can be considered
1. Palliative care training at the level of clinical internship of every medical students
2. Incorporation of palliative care at the level of Primary Health care or community/District hospital level by training of man-power from these places
3. Promotion of Health Insurance to all the citizens of the countries
4. Severe penal and legal action against the institute who has provided treatment at earlier date but refuse for palliative care of these patients
5. Ensuring the prognosis sheet of patient be read, understood and signed by patients and next of kin, explained of the cost, benefits and the principles of palliative care i.e. no intubation, no regular blood investigation or other intervention unless proved necessary otherwise.
6. Following principles and practices of palliative care, Severe penal and legal action against the institute/individual who breech these principles.
7. No costly intervention/interventions without any survival benefit in any case of palliative care settings
8. Providing or renewal of License of the institute/health care facility only if adequate or optimal out-patient attendence :in-patients beds; palliative care beds ratio is established or maintained respectively.
Dr.Ramaiah Vinay Kumar, Junior Resident of Radiotherapy/Radiation oncology at All India Institute of Medical Sciences, New Delhi-110029. India. Email I.D; Vinaykumar33223@yahoo.ca or vinaykumar.irch@gmail.com.
Competing interests: None declared
Competing interests: No competing interests
The author highlights a pertinent issue identifying the need to include facilitating dying as a core clinical competency. The Foundation Curriculum merely touches upon discussing DNAR orders whereas subsequent management seems to be left to our imagination in the form of uncertainty amongst team members on the true meaning of 'TLC' or 'conservative management'.
Recognising the dying patient is a skill that few of us possess, or perhaps we remain in a state of subconscious denial; especially as junior doctors, out of fear of litigation in a post-Shipman era. My personal experience of the Liverpool Care Pathway; a protocol for use in the management of terminally ill patients, seems to be a blessing for staff, relatives and patients alike. Patients are eventually allowed to die in comfort without the need drown them in IV fluids or with intractable chronic pain, poorly treated due to reluctance of juniors to prescribe more than 10mg of morphine IV 4 hourly, or even for nurses to administer it. In some cases blood tests are regularly requested and observations are monitored unnecessarily.
Palliative care for patients with chronic disease should be an iniative spearheaded by Primary Care Trusts and be available to all in the event where patients present to hospital to ensure they receive appropriate individualised patient care.
Competing interests: None declared
Competing interests: No competing interests
Palliative Care- opportunities in Scotland
Now that the votes have been cast, and Palliative Care beyond Cancer has taken the lead I welcome the opportunity that the BMJ will now take as laid out in Fiona Godlees editorial "We need to choose one or two of these topics to focus on over the next year, on which we will create and compile content across the BMJ Group’s portfolio of products: the BMJ, BMJ Journals, Clinical Evidence, Best Treatments, and BMJ Learning."
In NHS Scotland we have the strategic commitment to improve access to palliative care based on need ( Better Health Better Care- Action Plan) and the frameworks to use quality improvement methodology, as discussed by Don Berwick and Joanne Lynn, to implement it. To have this supported by the content of the BMJ Group's portfolis of products enables those of us charged with the responsibility of making it happen with unexpected opportunities. I hope that the BMJ will also support the spread and share of knowledge gained from international research that will continue to facilitate the improvement of Palliative Care beyond Cancer.
Competing interests: None declared
Competing interests: No competing interests