Intended for healthcare professionals

Analysis

Palliative care from diagnosis to death

BMJ 2017; 356 doi: https://doi.org/10.1136/bmj.j878 (Published 27 February 2017) Cite this as: BMJ 2017;356:j878

"Palliative" can be the wrong word

The approach outlined in the article by Murray et al has a wide relevance and not just for healthcare professionals but also encouraging such discussions with friends and family. There is no need to wait until disease onset. Such discussion is particularly applicable in the older population and can form the basis for an Advance Decision (AD). Essentially it is about the tipping point between quality and quantity, although these will interrelate in a variety of ways. “Palliative” with its origins in terminal care is the wrong word for the - often relatively fit - older population who may associate it with “giving up” and poor prognosis. “Anticipatory care” is not so threatening, apart from suggesting an aggressive proactive approach to screening and treatment which is just what many of us do not want. The old term of “taking stock” is less threatening, used widely and a way to start the conversation.

In the past few years, since reaching the age of 75, I have found the SWOT – Strengths, Weaknesses, Opportunities and Threats - framework a very useful tool and as a back-up for my AD. My emphasis now is on quality, not quantity. It is a framework which I can modify as new ailments emerge - as is happening - and gives me the chance to think through what it is about living that gives it quality. Updating anyway is a form of annual appraisal about life and opportunities as well as disease. The current majority view – and our health care is increasingly based on this – is likely to remain on the side of quantity rather than quality. Doctors, often only becoming involved after the onset of disease, tend to subscribe to this view. (Many do not: a well-known example is Dr Emmanuel – oncologist, ethicist and adviser on healthcare to Obama – who wrote an essay in 2014 on “Why I hope to die at 75” , a date he saw as flexible depending on progress.) For similar reasons doctors generally may not be the people best suited to have what can be a free-ranging and time consuming discussion. I have been even more involved with these since retirement than during my working life, which included the care of – and listening to - many patients towards the end of life.

Competing interests: No competing interests

06 March 2017
Simon Kenwright
Rtd Physician
Stowting, Ashford