The ten barriers to appropriate management of patients at the end of their life

[Extract] It has been more than 60 years since the concept of intensive care was applied in Copenhagen, Denmark [1], and it was not until the 1970s that the concept became a recognised specialty with its own conferences, textbooks, journals, qualifications and societies. Intensivists have made great advances in how to effectively sustain life and are probably now at the stage where the effective implementation of these lessons is as important as the underlying knowledge.

However, while intensivists have been concentrating on these advances, a major challenge has emerged, almost imperceptibly. The majority of patients we are now treating do not have a single diagnosis; rather, they have multiple age-related co-morbidities that add up to a clinical condition which, as yet, has no universally accepted name or score. Yet, we are still using the same technology to treat these patients that we used previously to treat younger patients who had a single diagnosis and potentially reversible conditions. Many patients now spend their last few days of life on machines, and even the survivors often live a severely compromised existence during their remaining few months of life. How did this happen, and what can be considered the top ten potential barriers to managing patients at their end-of-life (EoL) transition in a more appropriate way?