• Supportive care

I read with particular interest the recent letter from Dr Fenning1 about the importance of identifying the ‘end-of-life’ (EOL) period in everyday medical practice. Working with geriatric patients in an acute geriatric clinic on the Italian territory, I directly experience the unpredictable impact of multimorbidity and chronic progressive conditions on life expectancy. Compared to other European countries, Italy is lagging behind in the approval of coded laws aimed at regulating EOL care. The unique cultural and religious background, often amplified by the mass-media, strongly influences public opinion on palliative care and EOL issues.

A recent bill (2009), prompted by the publicised case of Mrs Eluana Englaro,2 received great criticism mainly because of the attempt to regulate such a complex argument with a rushed and reductionist approach.3 Mrs Englaro was a young Italian woman in persistent vegetative state since a dramatic car accident occurred in 1992, who died in February 2009 after discontinuation of artificial nutrition and hydration. The last years of her life were characterised by intense debate between her father, who repeatedly asked for discontinuation of the support (in line with young Eluana’s verbal advance directives), and a consistent part of Italian politicians, sustained by the Catholic Church. The discontinuation request was finally granted by the Supreme Court at the end of 2008, but the majority coalition firmly opposed by presenting emergency legislative decrees, albeit unsuccessfully. In that occasion, the controversies spread through mass-media and divided the Italian population’s opinion.

I strongly agree with Dr Fenning about the main points of his letter, which describes the contribution of UK media in distorting EOL identification ‘from a marker of care needs to a financial forecaster of future savings’. Having a dialogue with patients and their families about their wishes, fears and expectations about EOL is the most reasonable approach in order to accept that death is not a defeat, neither for physicians nor for assisted people. It is probably not a coincidence if the UK and Italy, despite an increase in palliative care services during recent years, both experience a reduction in the number of patients who die at home.4 If legislation is late, great work is currently ongoing in Italy to promote EOL best practices, the importance of patient–physician–caregiver communication and shared decision-making. Of note, years ago the Italian Society of Anaesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI) published comprehensive guidelines about EOL decision-making in its multiple aspects.5 First produced as a guidance for intensivists, this consensus document has been progressively updated and expanded. It is a fact that the media and cultural background still tend to idealise a vision of ‘life’ as ‘physical survival’, instead of discussing and pursuing ‘quality of life’ as the main goal. In line with the quote from Antoine de Saint-Exupéry reported by Dr Fenning, it is not just the identification of EOL that will help to establish a different culture and encourage dialogue about dying, but also early education of medical and nursing students about EOL issues—still not uniformed in Italy—could make a big contribution to shift the vision towards ‘the endless immensity of the sea’.