End-of-life care needs a fundamental review, not just more funding | Hospices

Your editorial (October 29) highlights the urgent need for better funding for end-of-life care. As a physician and academic working in this field for 40 years, I would like to raise three underlying questions.

First, it implies that hospice is the only model for providing good end-of-life care. Arguably, in Britain we have relied too much on the charity sector. We now have NHS-funded hospital palliative care teams capable of providing excellent care when patients reach the end of life but still need specialist treatments – which very often hospices are unable or unwilling to provide.

In my evidence last week to the House of Lords Select Committee on the Terminally Ill Adults Bill, I highlighted that on average, patients are only referred to end-of-life services such as hospices in the final weeks of their lives. And about 80% of them suffer from cancer – other conditions leading to death and as much suffering are barely taken into account.

Second, increased funding for end-of-life care is likely to support the same unbalanced model, with its geographic and socioeconomic inequalities. It is easier to talk about more money than to fundamentally review service models.

Third, your editorial reiterates the fallacy that physician-assisted dying is competition for funding against the palliative care sector. There is ample evidence that, in countries where assisted dying is legalized, palliative care and assisted dying can coexist. Indeed, the introduction of medical assistance in dying has often led to increased funding and referrals to palliative care.

The truth is that end-of-life care has not evolved in the 60 years since the first modern hospice opened and in the 40 years since specialized palliative medicine existed. It may take forever for end-of-life care in hospices to get the funding it wants. And forever, that’s something the dying don’t have.
Teacher Sam H Ahmedzai
Professor Emeritus of palliative medicine, University of Sheffield

Your editorial is absolutely right to advocate greater commitment to palliative care services; my own specialty here in the Australian state of Victoria for 20 years. However, he forgets an essential point: medical assistance in dying is a complement to such care and not a competitor. (Subsequent letters (November 2) from industry leaders do not mention assisted dying at all; which is somewhat surprising given the high-profile debate in which the UK is currently engaged.)

In Victoria, where voluntary assisted dying (ADM) has been available since 2019, I have accompanied more than 70 patients through the process. Each of them received specialized palliative care. Most simply wanted to know that if their suffering became intolerable, they had another legal option. They did not reject palliative care; they appreciated him deeply. But for a small number, this could not completely meet their needs in the last days.

Experience has shown that the introduction of VAD has strengthened, not weakened, our culture of care. Around 80-85% of people who use VAD already receive palliative care, and governments have responded by investing more than A$1 billion (£500 million) in palliative care since 2017. My specialty, historically skeptical of assisted dying, has seen a significant shift in favor, finally recognizing what our patients have long been telling us: palliative care and choice go hand in hand.
Dr. Greg Mewett
Palliative Care Physician, Ballarat Central, Victoria, Australia