We’re all going to die. Deal with itBMJ 2010; 341 doi: http://dx.doi.org/10.1136/bmj.c5028 (Published 16 September 2010) Cite this as: BMJ 2010;341:c5028
- Tony Delamothe, deputy editor 1,
- Mike Knapton, associate medical director 2,
- Eve Richardson, chief executive3
- 1BMJ, London WC1H 9JR, UK
- 2British Heart Foundation, London
- 3National Council for Palliative Care and Dying Matters coalition, London
In the years since Cicely Saunders opened St Christopher’s Hospice in 1967, palliative care has blossomed into one of the glories of British medicine. Although much has been learnt about caring for cancer patients at the end of their lives, these lessons have been inadequately appreciated by doctors treating patients dying from causes other than cancer. The series of specially commissioned reviews in this inaugural BMJ Spotlight is intended to help remedy that.
Eventually, everyone dies—many more of us after gradual physical and mental decline than cancer. Early recognition of those patients with advancing illness who would benefit from supportive and palliative care is the key to good management.1 A positive answer to the question: “Would I be surprised if this patient died within the next year?” is one trigger indicating that such care should begin.
After that decision come the difficult conversations. Not everyone will want to talk about the end of their life, but “the right conversations with the right people at the right time can enable a patient and their loved ones to make the best use of the time that is left and prepare for what lies ahead.”2
The obstacles to plain speaking, and clear thinking, about death are legion. We live in a culture in which people are uncomfortable with their own mortality.3 This needs to change, as the Dying Matters coalition argues, “so that dying, death and bereavement will be accepted as a natural part of everybody’s life cycle.” Doctors seem to find that message harder to accept than others, with some of them regarding any death as a failure. In a doomed attempt to stave off the inevitable, typically more money is spent on health care during a patient’s last year of life than in any other year.
But it must be an encouraging sign that “palliative care beyond cancer” topped a recent BMJ poll of topics respondents wanted to read more about. Similarly encouraging are initiatives of organisations such as the British Heart Foundation to start thinking about palliative as well as curative care.
Earlier this year, the UK’s General Medical Council published Treatment and Care Towards the End of Life, recommending that death should become an explicit discussion point when patients are likely to die within 12 months.4 5 Its guidance is in keeping with a raft of end of life reports and UK national strategies. For the time being at least, all parties seem to be on the same page.
Frank discussion of the topic throws up many challenges. We have room for only two of them here—the related issues of where patients want to die and who should provide their palliative care,6 and a recognition of the spiritual needs of patients facing death.7 But more is coming. The BMJ Group will launch BMJ Supportive and Palliative Care next April with Bill Noble as editor. This peer reviewed journal will publish original research as well as education, debate, commentary, and news with the aim of improving supportive and palliative care for patients with many kinds of illness.
We all have much work to do.
Cite this as: BMJ 2010;341:c5028
We are pleased to acknowledge the financial support of the British Heart Foundation in producing this Spotlight. The articles were commissioned and peer reviewed according to the BMJ’s usual process. We benefited from discussions with Jane Maher, Scott Murray, Ruth Sack, and Teresa Tate.