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Spotlight Spotlight: Palliative Care Beyond Cancer

Achieving a good death for all

BMJ 2010; 341 doi: (Published 16 September 2010) Cite this as: BMJ 2010;341:c4861

Rapid Response:

Re:A good death for all?

Ellershaw and colleagues point out the importance of structured
approaches to end of life care improvement as part of the 'core business'
of hospitals (1) They highlight the benefits that flow from the adoption
of the Liverpool care pathway for the dying patient and point to the audit
of care of the dying in 155 English hospitals, among 3893 patients,
showing that patients were symptom free in 70% of assessments undertaken
in the last 24 hours of life. As Clearkin points out however, pathways
are not without problems and reports of misuse are 'disturbingly
frequent'(2). Pathways are of course embedded in a complex mesh of
clinical and organisational practice that both contains and limits their
impact. The focus should perhaps be less on their technical properties
and more on the context in which they are used.

An audit of end of life care in Irish hospitals has been conducted as
part of the Hospice Friendly Hospitals programme(3)and covers 999 deaths
in 24 acute and 19 community hospitals. It found significant differences
in the assessment of quality of care outcomes by nurses, doctors and
relatives, with the former giving the highest ratings and the latter the
lowest. Multi-systems modelling was used to identify eight sets of
influences on hospital care at the end of life. These were: cause of
death; route of admission to hospital; team meetings; quality of staff
discussion with patients and relatives; support for families to be with
the patient; staff preparedness for the death of a patient; aspects of
hospital governance. Doctor assessment of symptom management was 4.89%
higher in hospitals with end of life care objectives in their service
plan. Eighteen ways to improve hospital care at the end of life were

Hospice Friendly Hospitals, begun in 2007, is a five year initiative
designed to change hospital cultures of care and organisation relating to
dying, death and bereavement in Ireland. It works across four thematic
areas: competence and compassion; planning and coordination; the
physical environment; ethical issues. It has built up a network of
'champions for change' in the participating hospitals, produced a wide
range of information, educational and training materials and a set of
quality standards for end of life care in Irish hospitals (4). Published
in June 2010, and adopting a not dissimilar approach, the 'route to
success' document for achieving quality end of life care in acute
hospitals in England identifies six levers that will improve care for
individuals and families while making the best use of available resources.
Pathways are but one element in this(5).

In the Hospice Friendly Hospitals programme in Ireland, effort is
concentrated on an 'all systems' approach designed to achieve measurable
and sustainable improvement. It is a sophisticated model that uses public
engagement, advocacy and targeted resources to achieve change in all the
dimensions of end of life care across the hospital: for persons 'brought
in dead', to patients with progressive disease; from the mortuary
environment to the mode of returning a deceased relative's belongings;
from the use of symbols to denote a death on the ward, to the quality of
staff support and confidence in recognising and acknowledging the dying
process. This more holistic orientation, though challenging, has much
to commend it and deserves wider recognition beyond Irish shores.

1. Ellershaw J, Dewar S , Murphy D, Achieving a good death for all.
BMJ 2010; 341: 656-58.
2. Clearkin RJ, A good death for all?, accessed 4 October 2010.
care-in-hospitals?layout=item, accessed 4 October 2010.
life-care-in-hospitals?layout=item, accessed 4 October 2010.
accessed 4 October 2010.

Competing interests: The authors are undertaking a study of Hospice Friendly Hospitals commissioned by the Irish Hospice Foundation.

05 October 2010
David Clark
Fiona Graham
University of Glasgow