Intended for healthcare professionals

Spotlight Spotlight: Palliative Care Beyond Cancer

Having the difficult conversations about the end of life

BMJ 2010; 341 doi: (Published 16 September 2010) Cite this as: BMJ 2010;341:c4862
  1. Stephen Barclay, general practitioner and Macmillan Postdoctoral Research Fellow1,
  2. Jane Maher, consultant clinical oncologist and chief medical officer, Macmillan Cancer Support2
  1. 1General Practice and Primary Care Research Unit, Institute of Public Health, Cambridge CB2 2SR
  2. 2Mount Vernon Cancer Centre, London
  1. Correspondence to: S Barclay sigb2{at}
  • Accepted 15 May 2010

Clinicians need to create repeated opportunities for patients to talk about their future and end of life care, guided by the patient as to timing, pace, and content of such talks, and respecting the wishes of those who do not want to discuss such matters

More than half a million people die each year in Britain—36% from cardiovascular disease, 27% from cancer, and 14% from respiratory disease; and 58% of all deaths occur in hospital,1 a proportion that has increased in recent years. While some deaths are sudden and unpredictable, many patients go through a period of illness when death becomes increasingly probable.

Recent General Medical Council guidance on good practice in decision making in treatment and care towards the end of life states that “patients whose death from their current condition is a foreseeable possibility are likely to want the opportunity to decide what arrangements should be made to manage their final illness” but also cautions that “you must approach all such discussions sensitively, as some patients may not be ready to think about their future care or may find the prospect of doing so too distressing.”

Some may not wish to talk with their clinicians or their family about the end of life, but others may greatly benefit from such conversations. The right conversations with the right people at the right time can enable patients and their loved ones to make the best use of the time that is left and prepare for what lies ahead.

In this article, some of our comments arise from our experience as clinicians in general practice and oncology, and others from the research evidence in this area, which is limited. We seek to stimulate discussion and debate: we focus mainly on issues that make these conversations difficult for patients and clinicians, …

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