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Health Care Systems for Critically Ill Patients Need Restructuring

The health needs of people in the last phase of life are not sufficiently met and need to be upgraded 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 m ight create a reliable care system for this fragmented and inefficient part of the health care picture.


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