Palliative care in non-malignant diseases.

Historically, palliative care services have focused on patients with incurable cancer. In its 2004 guidance document Improving Supportive and Palliative Care for Adults with Cancer the National Institute for Clinical Excellence (NICE) emphasizes the importance not only of optimal symptom control but also of psychological, social and spiritual support for patients and their families.1 However, the current view is that access to palliative care should be based on need rather than diagnosis,2,3 and on that criterion many patients with non-malignant diseases qualify as well. The potential requirement for palliative care in other life-limiting illnesses is reflected in the National Service Frameworks (NSFs). The NSF for Coronary Heart Disease identifies the need for patients with heart failure to have access to palliative care services for ongoing support and advice;4 and the NSF for Renal Services goes further, listing as a quality requirement for patients near the end of life to have ‘a jointly agreed palliative care plan, built around their individual needs and preferences’.5 The NSF for Long-term Conditions, soon to be published, identifies palliative care as one of eleven quality requirements; people with long-term neurological conditions, for example, should have access to a range of palliative care services when near the end of life.6 However, despite the general acknowledgment that palliative care services must be extended beyond cancer care, this is not yet common practice.3 Part of the reason is a lack of the sort of research that, in advanced cancer, has led to substantial improvement of services.7 A consensus statement from the US National Institutes of Health highlights the challenges posed by such conditions as congestive heart failure, end-stage renal disease, chronic obstructive pulmonary disease, liver failure and dementia.8 The strongest body of research is on pain management; each condition presents its own special difficulties in end-of-life care.