oncology services which have not either) thus, palliative care is thought of as something only for people who are dying very soon, and probably of cancer. Secondly, the situation is compounded by difficulties in definitions, with terms such as “terminal care”, “EOL care”, “palliative” and “hospice” meaning different things to different people in different healthcare settings around the world. In this ERS Monograph, the World Health Organization definition of palliative care is used, with its focus on optimising quality of life for people with progressive life-limiting illness through impeccable assessment of symptoms and other concerns throughout their illness, care of the dying and family support. This approach works in response to people’s needs rather than being limited either by diagnosis or prognosis, and can be initiated at the time it is recognised that the person has a life-limiting illness. In the first section, the issue of palliative care for people with respiratory diseases will be discussed in the context of the epidemiology of the diseases themselves, the palliative care needs resulting from the diseases and how palliative care services can be modelled and delivered. The second section focuses on the key symptom of breathlessness. Most clinicians only see people who have acute breathlessness, or see chronic breathlessness as an inevitable consequence of the underlying disease process, which, itself, is not worthy of clinical attention. Most people with chronic breathlessness only seek help for the symptom when it worsens acutely. The brief encounters that clinicians have with people who experience chronic breathlessness belies the overwhelming impact that such breathlessness has on millions of people every moment of the day around the world. Although their breathlessness may improve marginally after acute exacerbations, the lived reality for these people is that of severe breathlessness at rest or on minimal exertion, often for years at life’s end. The predominant cause of such breathlessness remains respiratory disease, with the contribution of tobacco, workplace exposures and domestic smoke from fires in ill-ventilated dwellings being key contributors to this burden of suffering. As this symptom burden continues to evolve and grow, so has the evidence base for defining and treating this pervasive and debilitating symptom. As is so often the case, the real challenge is not the development of new knowledge that can help to relieve the suffering caused by chronic breathlessness, but ensuring the widespread uptake of that new knowledge into clinical practice and policy. The pervasive nihilism that people with CRDs should silently tolerate chronic breathlessness should be defeated as a matter of urgency. People with chronic breathlessness should be demanding better symptom control and clinicians should be actively offering ways to minimise the impact of this life-changing, long-term disability. Finally, in the third section, the issue of caring for people with advanced disease and those who are dying is tackled head on. The response to the less clear trajectory of respiratory diseases has been to avoid the issue and, especially, to avoid conversations that discuss progression of disease or plans for future care. This is often for fear of upsetting the patient, exacerbated by lack of training in advanced communication and symptom management skills, and clinical service configurations that mitigate against exploring patients’ concerns, hopes or expectations. Sadly, the experience of patients and families is then one of poor knowledge and understanding of their disease, treatments and goals of care, poor involvement in their plans of care, and poor symptom control. When they come to die, they die by default in an acute care facility, still receiving invasive medical treatments, with poor access to the people they love at the time they need them most. xi
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