Conclusion

Good home care is vital. We now have the new situation of a population growing old and unwell more slowly than in previous generations—this is a new "epidemic" that we have not previously met or dealt with. With the demographic changes of ageing populations, better treatments and chronicity of end stage illnesses, fewer inpatient beds, and rising costs, there is a growing imperative to provide good home care for all seriously ill patients. Key issues include enablement of generalists, advanced care planning to determine need and preference, application of successful developments to patients with diseases other than cancer and in other settings, enhanced carer support and self care, high quality 24 hour clinical management and service provision, and good communication across boundaries.

As we rethink our palliative and supportive care services in response to this burgeoning need, the holistic approach of primary care is well placed to meet the challenge, if it is enabled to do so. Primary care teams in the community can deliver excellent palliative care for their dying patients and enable patients to die well where they choose when complemented by good access to specialist services, support, and expertise. As demand for community care increases in future, it is important to maximise the potential of primary palliative care and the use of frameworks or protocols with good collaboration with specialists.

A death dominated by fear, crises, inappropriate admissions, overmedicalisation, and poor communication can be a tragedy and a failure of our medical system; enabling a peaceful death at home can be a great accomplishment for all concerned

Further reading

• Gomas J-M. Palliative care at home: A reality or mission impossible? Pall Med 1993;7:45-59.

• Piercy J. The plight of the informal carer. In: Charlton R, ed. Primary palliative care. Oxford: Radcliffe Medical Press, 2002.

• Simon C. Informal carers and the primary care team. Br J Gen Pract 2001;51:920-3.

• Thomas K. Out of hours palliative care—bridging the gap. Eur J Pall Care 2000;7:22-5.

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