The continuing trend of medical subspecialisation and major advances in technology mean that new treatment frontiers are crossed every day. Whilst these advances clearly benefit many patients, the downside is that the quest to “do more” in a narrow technical sense is commonly associated with incidence of non-beneficial, inappropriate and burdensome care interventions. With the best of intentions, narrow medical specialists often cannot see that achievement of a short term apparent technical success can be burdensome and lead to an unsatisfactory end of life experience. In part this is driven by the mistaken view that a successful clinician is judged largely be the delivery of potentially life prolonging interventions (whether or not they do in fact prolong life in a meaningful way).

I have previously argued that the required clinical leadership to, for example, not offer dialysis to a bed bound elderly person with dementia, needs courage and an environment where the holistic quality of care, including the best end of life care, is of equal value to other therapeutic interventions. Even in the area of oncology, which has largely embraced the palliative care paradigm, medical heroics are still often seen.

At a practical level, this value shift can be difficult to achieve in most acute clinical environments. Whilst engagement of palliative care services is increasing, it is often too late to be of material benefit and after a period of burdensome treatment.

One way to restore an holistic mindset to acute care decision making is to embed expertise from palliative care in selected acute medical units, rather than use this expertise as a referral of ‘last resort’. I piloted such an initiative before I left clinical Nephrology nearly 20 years, in frustration at some of the decision making of my colleagues. I am aware of similar pilots in General Medical units at times. Even the presence of a palliative care medical or nursing specialist at unit and divisional meetings can be reset the discussion and clinical decision making. 

A strong message to acute clinicians from palliative care is that the palliative approach is far more than specific interventions at the very end of life but rather one of symptom control and quality of remaining life, which can be a surprisingly long and rewarding period of time. 

This audience knows all this but the challenge is getting the message to the other players in the health system. Whilst the major benefit is improved quality of end of life care, the impact on the sustainability of the health system from limiting non-beneficial treatment is also substantial.