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Reforms needed to improve the care in the last
phase of life
Reforms are urgently needed to improve the health
needs of people in the last phase of life, say doctors in this
week's BMJ.
Our health care systems do not reliably meet the
needs of people living with serious illness in the last phase of
life, write Sydney Dy and Joanne Lynn, two palliative care doctors
based in the United States.
Even though contrary evidence is all around us,
we use language – and build health care systems – as
if disability and ill health were aberrations,
rather than an expected phase that lasts months or
years nearer the end of most of our lives, they say.
Yet only a few per cent of people in developed
countries now die suddenly. Traditional hospital and surgical
services no longer match most patients' serious chronic illnesses, a
fact that calls for substantial restructuring.
And since the numbers of people living with
serious chronic conditions in old age will double within the next
two decades in the United States and many other countries, finding
sustainable ways to improve comfort and meaningfulness in this last
phase of life has become a priority.
Patients coming to the end of life tend to follow
one of three trajectories, with different priorities and needs, they
explain. For example, patients with a short period of decline most
need continuity of care and aggressive symptom management. Those
with chronic organ system failure most need disease management and
advance planning, while those with long-term dementia or frailty
most need support services rather than intensive treatment.
Customising and reengineering care to match the
needs, rhythms, and situations of these three trajectories offers a
promising way to improve outcomes for patients sick enough to die,
they say. If a community can build a care system that reliably
serves patients in each trajectory in their area, then almost
everyone there could count on good care in the last phase of life.
This might create a reliable care system for this fragmented and
inefficient part of the health care picture.
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