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Mankind has never before witnessed a period with a greater proportion of older people. This will double in the next few decades to about a quarter of all people aged over 65 years.1 Absolute numbers of deaths will increase, and how people die will change significantly. Previously fatal illnesses have been largely tamed or even prevented. Medicine has virtually eliminated maternal mortality, and drastically reduced it from infections, accidents, cancer and cardiovascular disease. However, the frequent assertion that medicine has saved lives is wrong—all these advances have done is to defer death. It seems that society has limited the causes of death it tolerates to those from overwhelming accumulation of multiple ailments, dementia or (less frequently) organ failure or cancer.2
The structure of formal supportive and palliative care that has evolved—specialist palliative care—works best for people with cancer who only make up a fifth of those who die in old age.2 The trajectory of dying in progressive cancer is predictable and relatively short, so designing services for them is relatively straightforward. It is far more challenging to provide care for people with advanced diseases when the time frame is long and the course uncertain. The prevailing service model of specialist single-organ care can unintentionally create exhausting treatment burdens, potential for error and care duplication, especially in multimorbid patients.3 Non-physical dimensions can be, and often are, neglected in a disease systems-centred approach. Crucially, often no one coordinates care where multiple specialists are involved. The well-being of those who shoulder the greatest burden of care—close family—can often be entirely ignored. Critical evaluation of the entire health system and the philosophies that underpin it are required urgently as many people still die without any access to palliative care at all.
What are the essential elements of care as the …
Contributors GM initiated this commentary at the invitation of Professor Walsh. He wrote the initial draft, which was then extensively edited by both authors.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient consent for publication Not required.
Provenance and peer review Not commissioned; internally peer reviewed.
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