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This issue of our journal is concerned with initiating palliative care. The problem remains that we still lack the evidence that might convince policymakers and colleagues that systematically identify patients for assessment and palliative care planning will turn out well. The question of efficacy of such ambitious programmes has to be posed in relation to the whole population of patients to be screened for palliative care needs. Nikki McCaffrey and David Currow's editorial calls for palliative care researchers to engage with the discipline of health economics. They point out that, in order to justify the cost of palliative care services and provide better outcomes for patients and families, we must generate effective arguments and credible analyses of clinical- and cost-effectiveness.
My editor's choice is a feature by Irene Carey and colleagues, describing the AMBER care bundle; a strong candidate for rigorous evaluation by randomised controlled trial. The aim is laudable, to introduce the question of eligibility for palliative care into the routines of day-to-day medical management in acute hospital services. In the UK, the Neuberger report ‘More Care, Less Pathway: a review of the Liverpool Care Pathway’ emphasised the need for an individualised approach to patient care, while the Francis report into the Mid Staffordshire National Health Service Trust highlighted the need for effective teamwork and regular interaction among staff, patients and their families. The AMBER care bundle has the potential to attend to both imperatives.
The care bundle was developed for patients whose potential for recovery is uncertain in the acute hospital setting. Not designed to replace the Liverpool Care Pathway or an individualised end-of-life care plan, it is for use alongside acute medical care in a range of specialties. The authors remind us that the need for robust prospective evaluation of the impact of AMBER was recently emphasised by Currow and Higginson in this journal1 and a feasibility study examining the methodology to evaluate the care bundle is currently underway.
Simon Etkind and colleagues’ short report also describes an aspect of the first use of the AMBER care bundle that reinforces the emerging recognition that there is no simple way to industrialise palliative care. Within the hospital population, groups with multimorbidity and an unpredictable illness trajectory were less frequently allocated to the care bundle. The authors suggest that the care bundle is not yet being used as effectively as hoped in their hospital. However, might it also bring into question the utility of perceived risk of imminent death as the only trigger for palliative care?
Another interesting and as yet, untested idea about assessing the risk of dying is the subject of Magnolia Cardona-Morrell and Ken Hillman's review of clinical features predictive of death in 1–2 months. They have put together 29 variables, showing association with either inhospital, 30-day or 3-month mortality, from existing scales and published research findings. The proposed CriSTAL screening tool has already hit the UK national press under headlines about a ‘death-list’, although the articles are more measured. We await the results of a prospective evaluation of its predictive value.
Systems and processes dominate this issue's crop of studies and we have several papers on advance care planning, one on the Liverpool Care Pathway and two on a system of end-of-life care coordination, ‘Delivering Choice’. Sarah Purdy and others’ retrospective cohort study of the programme in South West England concluded that, after adjusting for potential confounders, those using Delivering Choice were at least 30% less likely to die in hospital or have an emergency hospital admission or an accident and emergency department visit in the last 30 or 7 days of life than those who did not. Jeff Round and colleagues’ paper reports another evaluation of the Delivering Choice programme, using a methodology that begins to anticipate the theme of Nikki McCaffrey and David Currow's editorial.
If the purpose of recognising a patient approaching death is to help to initiate the difficult conversation, clinicians might do well to see this issue's poem, Walt Whitman's ‘To One Shortly to Die’. John Birtwhistle explains that Whitman is dramatising what he might ideally wish to convey to any dying person in his care, exploring what it might be like to speak with integrity. He is encouraging and affectionate, and communicating with a rigour that respects the patient and his death. The poem is born of Whitman's personal experience of attending the dying as a nurse before the American Civil War, yet it resonates with clinicians who share that experience today.
Competing interests None.
Provenance and peer review Not commissioned; internally peer reviewed.
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