End of Life Pathway – lessons learnt from the USA.

End of Life Care (EOLC) is one of the greatest challenges we face as a society and a health care system. Currently although well regarded internationally (the UK came top of the Quality of Death Audit) Thomas & Paynton 2013, we know there are serious problems and we are not yet getting it right. The majority of commissioners across the UK have some type of target around EOLC/Palliative Care for example to increase the number of patients on the supportive care/palliative register, increase the number of patients who die in their preferred place of choice, increase the number of patients on an appropriate care plan that allows for EOLC discussions and acknowledges the patient’s wishes.

Planning and purchasing of NHS services is referred to as commissioning. In England, general hospital services, urgent and emergency care, mental health and community services are commissioned at population level by 211 clinical commissioning groups (CCGs), who hold the majority of the NHS budget (65 billion in 2012/13). Each CCG is formed from the GP practices in that locality who come together to assess the needs of their population and commission services from NHS or other provider organisations that meet those needs (Kings Fund 2013).  Commissioning End of Life (EOL) Care passed to Clinical Commissioning Groups (CCGs) in April 2013. Patients who are approaching the end of their life need high-quality treatment and care that support them to live as well as possible until they die, and to die with dignity. In light of recent publicity of the Liverpool Care Pathway, Do not resuscitate orders, and lack of dignity in hospitals (NHS Confederation 2012) the author felt that a scholarship to understand observe and add knowledge to our current understanding of EOL could benefit the NHS system. End of life care involves a large number of third sector providers, notably hospices, and some are small organisations that could be unintentionally destabilised by changes in commissioning arrangements, including the impact of potentially having to work with multiple commissioning organisations. In addition it is now widely agreed (General Medical Council 2010) that high-quality treatment and care towards the end of life includes palliative care that focuses on managing pain and other distressing symptoms; providing psychological, social and spiritual support to patients; and supporting those close to the patient. However, it is not always recognised that palliative care can be provided at any stage in the progression of a patient’s illness, not only in the last few days of their life. Whilst there is a considerable amount we can learn from the USA the author also found that many of the UK practices are heralded as best practice by the USA and they look to us for many ideas, inspirations and knowledge to improve their current practices.