Identify and treat people with any and all life-threatening illnesses, taking palliative care beyond cancer from which only 25% of people now die.
Palliative care for all
In economically developed countries most people die after a longish period of disability at an average age of 78 with the top three categories of death now being cancer, organ failure and frailty/dementia.(1) Despite having equally pressing and more prolonged symptoms and psycho-social needs than cancer survivors, people with non-oncological diagnoses tend to be offered less care, which is inequitable.
Palliative care can help all patients with progressive illnesses
As illustrated here, a general practitioner in the UK, who has on average about 2000 patients on his or her registered list, has 20 deaths on average per year. Five of these deaths are from cancer, six from organ failure, (such as chronic obstructive pulmonary disease, heart failure, liver failure, renal failure, and seven from frailty (either physical frailty or dementia). Only about two of the 20 are likely to die totally unexpectedly.
So as around 80 to 90% of deaths are not totally unexpected, primary care staff have the opportunity to adopt a palliative care approach with most patients approaching death.
Different illnesses, different care?
For these three main categories of dying, the implications for palliative care provision are quite different as the patients' needs are generally different.
The acute, typically cancer, trajectory normally follows a generally predicable course with a short decline towards the end. Hospice care fits well with people dying with cancer and meets their needs.(2)
Conversely, patients with organ failure may have a gradual decline over 2-5 years physically, but during that period there are acute declines, and frequently hospital admissions. Patients with organ failure may die suddenly at any time, but are not expected to die in the next few months. Due largely to this prognostic uncertainty and various funding reasons such patients rarely benefit from specialist palliative care.
The frailty trajectory is variable and may last for many years with the onset of deficiencies in activities of daily living. The needs of this group are for integrated clinical care and long term support at home, carer support and nursing care. In many countries support for this group is unreliable.
Therefore, to reliably meet the end-of-life needs of all patients we must provide multi-dimensional support to patients with all illnesses, and primary care is uniquely placed to identify most patients with one or more advanced progressive illnesses.
- Lunney JR, Lynn J, Foley DS, Lipson S, Guralnik JM. Patterns of functional decline at the end-of-life. JAMA 2003;289:2387-92.
- Murray SA, Kendall M, Boyd K, Sheikh A. Illness trajectories and palliative care. Clinical Review. BMJ 2005; 330:1007-11.