John Ellershaw on end of life care

The General Medical Council’s guidance to doctors on end of life care, which came into force on 1 July, is obviously a welcome and much-needed initiative. It is interesting to see that Dominic Bell in his BMJ editorial emphasised that the GMC acted in response to concerns from doctors themselves, particularly about issues around patients allegedly being “denied informed choice regarding the remainder of their life and the manner in which they die” and the Mental Capacity Act (2005).

Obviously doctors will be studying the GMC guidance carefully and will be relieved that the council has set out the practices and procedures they should follow to avoid allegations of professional misconduct. The very need for such guidance, however, emphasises the importance of clear communication with the individual nearing the end of life and their family from an early stage and careful individual assessment and co-ordinated care.

The National End of Life Care Programme (the NHS programme supporting the implementation of the Department of Health’s 2008 End of Life Care Strategy) has published a practical guide for hospital doctors, nurses, managers and board members that highlights the key factors in high quality end of life care.

The route to success in end of life care – achieving quality in acute hospitals identifies six key levers that will improve care for the individual and their family while making the best use of available resources.
These are:

• Co-ordinated care and discharge planning based on assessed need and working with patients and families – as well as partners in the community and social care
• Senior clinicians should make treatment decisions close to the patient, intervening early and managing uncertain prognosis
• Use recognised tools already developed, such as advance care planning or the Liverpool Care Pathway for the Dying Patient (LCP), and train staff in their use
• There should be strong organisational governance, including trust board oversight and senior management engagement
• There should be training and education as appropriate to each team member’s role, with full use of e-learning and more traditional learning methods while addressing staff attitudes towards death and dying
• There should be access to a hospital specialist palliative care team seven days a week in line with NICE’s Improving outcomes guidance (2004).

Advance care planning is a central element to both high quality care and reducing the risk around “best interest” and informed choice issues that arise from the 2005 legislation.

By initiating discussions about death, dying and future care with individuals and their families at a relatively early stage, doctors (working in partnership with colleagues in health and social care) can ensure that the person’s wishes and preferences for care and where they receive that care and die are taken into account even if they lose capacity at a later stage.

It is important that such information, with the patient’s consent, is shared with partners across acute care, the community and social care.

More than half of the deaths that occur in England each year take place in hospital. The End of Life Care Strategy provides a blueprint to reduce that figure but it is clearly vital that care in acute settings is of the highest possible quality. Both those aims can only be achieved through health professionals talking to individuals nearing the end of their life and ensuring their wishes and preferences for what care they receive and in what setting are respected.

The route to success in end of life care – achieving quality in acute hospitals is available at this link  or by emailing

John Ellershaw is professor of palliative medicine at the University of Liverpool and director of Marie Curie Palliative Care Institute. He is also national deputy clinical director for end of life care.