What to do if your patient is going to die

Health, social, and palliative care services are continuing to fail many people with progressive chronic illnesses in whom death may be approaching, reflecting a failure to think proactively and holistically about their care.1 Such people could, however, readily be identified by clinicians asking themselves, ‘Would I be surprised if my patient were to die in the next 12 months?’ For patients in whom the answer is no, delivery of patient centred active treatment and supportive care are needed.

Prognostic paralysis has been described, whereby clinicians of patients with uncertain illness trajectories prevaricate when considering end of life issues.2 For example, one general practitioner graphically summarised the feelings many experience in caring for people with terminal heart failure: ‘You're paddling downstream to Niagara.’ Another felt reduced to clinical tasks: ‘I feel impotent, merely a blood leech and monitor.’3 End stage chronic obstructive pulmonary disease is another example where patients seldom receive holistic care appropriate to their needs.4 Decision analysis in end stage renal failure should include the option of palliative care.5 Similarly, management of diabetes at the end of life may …