Please,Let Us In

She stares at you with a sticky gaze while moving around unsteadily in the room, stating that she knows what you are thinking about and what kind of medicine you are planning to give her. You notice that she sweats profusely, and since it is one of these rare summer days in Sweden when the temperature rises above 25 degrees Celsius, it is not hard to guess that she is dehydrated. This old lady with advanced cancer is obviously not feeling well. The young nurses at the hospital ward are frustrated; repeated doses of diazepam have no sedative effect; they rather make her more agitated. You are the palliative care consultant at the hospital and this is yet another routine case for you. Stop the diazepam, give her some fluid, and prescribe haloperidol. Is there an underlying infection? You talk with the worried daughter, explain how the advanced disease, her mother's small reserves, and poor fluid intake interact to make things worse. On your way out from the ward you start to plan your next scheduled noon conference on this department, something around diagnosing and managing delirium versus anxiety in palliative care patients. …

Is this a rare scenario? No, we know that delirium is common in end of life, and in this issue Okamoto and colleagues look at risk factors for agitated delirium in terminal cancer patients. ¹ Is this a rare scenario in Sweden? Yes, definitely! Why? Are there no patients with delirium in the cold Nordic countries? Indeed there are, but there are no palliative care consultants or teams at the acute hospitals in Sweden, assisting in the management of seriously ill patients. The presence of palliative care professionals at hospitals is an important facilitator of timely referral to palliative care, as Kirby and colleagues point out in this issue. ² In my country we obviously lack one of the keystones to overcoming the difficulties in allocating limited resources wisely for this patient group.

In Sweden we can sing our own praises around how we in 2012 succeeded in making palliative medicine a new medical specialty and during the same year agreed upon and published national guidelines in palliative care. We can brag about our unique national quality register in end-of-life care which today covers more than 60% of all deaths in the country and presents detailed data online. ³ But what if all this competence, knowledge, and new findings do not reach the seriously ill patient at the hospital ward, where approximately 35% of all people in Sweden spend their last days in life? Then we have failed.…No, make it a challenge instead! While palliative care consultants at hospitals in the United Kingdom are increasingly an integrated part of hospital care, the economy and the possibility to save money has supported the rapid growth of palliative teams in U.S. acute hospitals. One of the challenges for palliative care professionals in Sweden is to convince politicians and decision makers that the presence of palliative care competence in acute hospitals will both save money and (more importantly) help regular staff at the wards in providing good palliative care to those who need it. I am convinced that if team members act as teachers and encourage the growth of general palliative knowledge among regular staff, other patient groups also will benefit from this. You will see better symptom control and quality of life in patients, and slowly, something positive will happen with the general atmosphere at the ward. Palliative care starting to transform health care. …

But is it possible to teach these attitudes and skills and does it make a difference? Yes! In this issue von Gunten and his colleagues show the impact and sustained effects of palliative care education for third-year medical students. ⁴ I know that Sweden is not the only country where palliative care has problems finding ways into hospitals. Integrating palliative care and specialist knowledge with general medicine at hospitals is a great challenge for all of us. Do the seriously ill and dying patients benefit from us being an exclusive part of medicine? Let us be inclusive instead, and teach all the goodies we have discovered to those who stand at the bedside. Just let us in. …