Challenges and Future Directions of Palliative Care

The unprecedented global development of palliative care over the past 50 years, originating in a counterculture and evolving through to an integral element of the health-care system, has enabled many more of the world’s population to have access to quality palliative care. More of the world’s population, particularly those living in high-income countries, such as Europe, North America, Australia, and parts of Asia, now die at an older age of, or with, noncommunicable diseases. The need for palliative care is also significant and largely unmet in low- and middle-income countries such as sub-Saharan Africa where communicable diseases such as HIV/AIDS, tuberculosis, and malaria continue to lead to expected deaths for many people.These new patterns of dying have implications for the configuration of international, national, and local palliative care policies, health-care service delivery models, palliative care delivery, engagement with primary and specialist clinical streams, workforce education, and the focus of future research.This chapter will describe the current and future challenges to palliative care development in low-, middle-, and high-income countries and the opportunities offered by adopting a public health approach, novel technologies, and remote monitoring and better engaging communities to increase palliative care access globally

The current and future landscape of dialysis

The development of dialysis by early pioneers such as Willem Kolff and Belding Scribner set in motion several dramatic changes in the epidemiology, economics and ethical frameworks for the treatment of kidney failure. However, despite a rapid expansion in the provision of dialysis - particularly haemodialysis and most notably in high-income countries (HICs) - the rate of true patient-centred innovation has slowed. Current trends are particularly concerning from a global perspective: current costs are not sustainable, even for HICs, and globally, most people who develop kidney failure forego treatment, resulting in millions of deaths every year. Thus, there is an urgent need to develop new approaches and dialysis modalities that are cost-effective, accessible and offer improved patient outcomes. Nephrology researchers are increasingly engaging with patients to determine their priorities for meaningful outcomes that should be used to measure progress. The overarching message from this engagement is that while patients value longevity, reducing symptom burden and achieving maximal functional and social rehabilitation are prioritized more highly. In response, patients, payors, regulators and health-care systems are increasingly demanding improved value, which can only come about through true patient-centred innovation that supports high-quality, high-value care. Substantial efforts are now underway to support requisite transformative changes. These efforts need to be catalysed, promoted and fostered through international collaboration and harmonization. Dialysis is a life-saving therapy; however, costs of dialysis are high, access is inequitable and outcomes are inadequate. This Review describes the current landscape of dialysis therapy from an epidemiological, economic, ethical and patient-centred framework, and describes initiatives that are aimed at stimulating innovations in the field to one that supports high-quality, high-value care