Articles: palliative-care.
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Palliative care is generally agreed to be the standard of care for the dying, but there remain some patients for whom intolerable suffering persists. In the face of ethical and legal controversy about the acceptability of physician-assisted suicide and voluntary active euthanasia, voluntarily stopping eating and drinking and terminal sedation have been proposed as ethically superior responses of last resort that do not require changes in professional standards or the law. ⋯ Safeguards are presented for any medical action that may hasten death, including determining that palliative care is ineffective, obtaining informed consent, ensuring diagnostic and prognostic clarity, obtaining an independent second opinion, and implementing reporting and monitoring processes. Explicit public policy about which of these practices are permissible would reassure the many patients who fear a bad death in their future and allow for a predictable response for the few whose suffering becomes intolerable in spite of optimal palliative care.
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A key element within the programme of reform introduced into the UK National Health Service in the 1990s has been the concept of health needs assessment, which must be undertaken by health care purchasers as a guide to the planning process. As part of a wide-ranging study of the impact of the NHS reforms on hospices and specialist palliative care services, providers' perceptions of needs assessment for palliative care were examined, including the extent to which needs assessments had been carried out in local districts, together with the implications. ⋯ Palliative care needs assessment has considerable potential to influence future purchasing and service provision, yet not all health commissions are undertaking it. There is a high level of provider enthusiasm for palliative care needs assessment, albeit coupled to low levels of technical knowledge and a lack of involvement in the process at local level. Purchaser-provider dialogue on needs assessment should focus on both raising awareness of appropriate techniques and debating 'ethical neutrality' about the outcome.