Draft 05.11.

2018

National Strategic Framework for Palliative Care Development

in Sri Lanka
2018 – 2022

Introduction to Palliative Care

Palliative care is an approach that improves the quality of life of patients (adults & children) and
their families who are facing the problems associated with life-threatening illness, through the
prevention and relief of suffering by means of early identification and impeccable assessment and
treatment of pain and other problems, physical, psychosocial and spiritual. (WHO)

Palliative care begins at the time of diagnosis of a life-threatening disease (eg. cancer) and continues
throughout the disease process until death and into the family's bereavement period according to
the current concept (better concept) as shown in Figure -1.

Fig. 1 Old concept & current concept of spectrum of palliative care

Ref. Murray, S. A et al. BMJ 2005;330:1007-1011

1
Draft 05.11.2018

It is a right of the every person with life-threatening illness to receive appropriate palliative care
wherever they are. It is also a responsibility of every health care professional to practice palliative
care according to the need, irrespective of the illness or its stage and any other characteristic of the
patient including age, sex, ethnicity, religion or the income status.

It is estimated that palliative care is needed for 40%-60% (WHO 2016) of all deaths annually. The
leading disease conditions which require palliative care for adults and children in global context are
listed in table 1.

Table 1: Disease conditions which need palliative care in global context.

Diseases among Adults Diseases among Children

Cardio vascular diseases (38.5%) Congenital anomalies (25.0%)
Cancer (34%) Neonatal conditions (14.6%)
Chronic respiratory diseases (10.3%) Protein energy malnutrition (14.1%0
AIDS (5.7%) Meningitis (12.6%)
Diabetes (4.6%) HIV/AIDS (10.2%)
Chronic kidney disease Cardio vascular diseases (6.1%)
Chronic liver disease Endocrine, blood & immune disorders (5.8%)
Dementia. Cancer (5.6%)
Chronic neurological diseases Neurological conditions (2.3%)
Congenital anomalies Kidney diseases (2.2%)
Drug resistant tuberculosis Cirrhosis of the liver (1.0%)
(WHO 2016)

With the demographic and epidemiological transition, deaths due to chronic non communicable
diseases are increasing and it has led to the increasing demand for palliative care services
worldwide.

The need for palliative care in Sri Lanka also continues to grow owing to the rising prevalence of
non communicable diseases and ageing of population. According to the cause of death data of year
2014 in Sri Lanka too it is shown that about 75% deaths are occurred due to the chronic non
communicable diseases as shown in figure 2.

Fig. 2 Cause of death data of Sri Lanka – Year 2014

2
Draft 05.11.2018

Palliative care in Sri Lankan context

Palliative care has been identified under the broad strategic direction of ‘Promotion of equitable
access to quality rehabilitation care’ at the ‘Sri Lanka National Health Policy 2016 – 2025’. It is
mentioned that ‘The mainstream health system should provide Palliative Care to all patients who
are in need of such care for them to live and die with dignity.’ In addition palliative care is identified
as continuum of care of several other policy documents in Sri Lanka including National Policy &
Strategic Framework for Prevention and Control of Chronic Non-communicable diseases (2010),
National Policy & Strategic Framework of Prevention & Control of Cancers (2015) and National
Elderly Health Policy (2017).

Palliative care has been identified at the Health Master Plan 2016 – 2025. Also palliative care is a
prioritized activity of National Multi Sectoral Action Plan for the Prevention & Control of Non
Communicable Diseases 2016 – 2020.

Overall Goal
To improve quality of life of patients with life-threatening illnesses and their families by offering
them a holistic support system for prevention and relief of suffering through evidence-based,
multi-disciplinary and cost effective approaches

The areas of support would include

 Pain and symptom management
 Psychological & emotional, social and spiritual support
 Support for families and caregivers to cope during the patient’s illness and bereavement
period

Guiding Principles
1. The delivery of palliative care should be respectful and responsive to the needs, preferences and
values of the persons receiving care and their families and carers
2. Care should be of high quality and evidence based
3. Should provide adequate integration across sectors and through various care settings
4. Services should ensure that care is accessible and equitable

Strategies
1. Ensure that palliative care is recognised and resourced as an integral component of the
health system by making palliative care as an essential component of comprehensive health
care

3
Draft 05.11.2018

2. Facilitate the effective integration of specialist palliative care and palliative care services
across all levels of service settings, namely at tertiary, secondary, primary and at community
level.

3. Develop and make available skilled multi disciplinary human resources and infrastructure for
delivery of palliative care services at institutional and at community levels.

4. Ensure that patients and their families receive palliative care services they need when and
where required & adherence to protocols & guidelines in palliative care

5. Ensure availability of essential drugs & technologies for provision of palliative care at all
levels: tertiary, secondary, primary and community level

6. Build partnerships with government and non-governmental organizations for delivery of

palliative care

7. Empower family members, care givers and general public for the provision of palliative care

8. Encourage research related to palliative care in assessing needs for palliative care and
suitable models for implementation of palliative care services.

9. Ensure adequate financing & resource allocation for cost effective delivery of palliative care

10. Strengthen legislative framework for delivery of palliative care

11. Ensure monitoring & evaluation framework for palliative care services

4
Draft 05.11.2018

Strategies & Major activities

1.Ensure that palliative care is recognised and resourced as an integral component of the health system by making palliative
care as an essential component of comprehensive health care

Major Activity Expected output Indicator Means of Time Responsibility

Verification Frame
1. Include policies related to Palliative care is Inclusion of National health policy 2018-2019 Secretary -Health
palliative care in the prioritized in delivery palliative care in document Director General of
national health policy of health care the national Health Services (DGHS)
health policy Director -Policy Analysis
& Development (PA& D)

2. Develop national palliative Comprehensive Availability of National palliative 2019-2022 DGHS

care policy linking approach to palliative national care policy document Director – PA & D
national health policy & care is facilitated. palliative care
other related health & non policy (Stand
health policies alone policy)

3. Identify palliative care as Palliative care is Inclusion of Other health related 2018-2020 Director – PA & D
a component of other included in continuum palliative care in policy documents Eg. Director –Non
related health policies & of care linking primary other health 1.NCD Policy Communicable Diseases
non health policies prevention, early related policies 2.Cancer control (NCD)
detection & treatment policy Director –National
programmes 3.Primary care policy Cancer Control
4.Elderly health care Programme (NCCP)
policy Director -Primary Care
5. HIV/AIDS policy Director - Elderly &
6. Medicinal Drug Disabilities
Policy Director - National STD
7.Mental Health and AIDS Control
Policy Programme
8.E-health policy Director - Information
9. Social Services Ministry of Social
Policy Services

5
Draft 05.11.2018

4. Strengthen National Availability of No. of meetings Reports & minutes of 2018-2022 DGHS
Steering Committee on functioning committee conducted per the steering
Palliative Care to coordinate and year committee meeting.
provide oversight for
the implementation
and monitoring of the
national strategy at all
levels.

5. Establish provincial & Availability of No. of meetings Reports & minutes of 2018- 2022 Provincial Director of
district steering functioning committee conducted per the steering Health Services (PDHS).
committees to coordinate to coordinate activities year committee meeting Regional Director of
palliative care at provincial & district Health Services (RDHS)
level.

6. Identify a separate focal Implementation of Availability of Circular of Ministry of 2018-2022 Secretary- Health
point for palliative care at strategic framework for separate focal Health DGHS
the Ministry of Health palliative care point with staff.
level development is
ensured.
7. Incorporate palliative care All stake-holders are Number of Reports 2018- 2022 DGHS
at the national, provincial actively involved in palliative care Provincial Director of
& district health delivery of palliative related activities Health Services (PDHS).
development agenda care successfully Regional Director of
implemented at Health Services (RDHS)
national,
provincial and
district levels
according to the
development
plan
8. Conduct advocacy All stake-holders are No. of advocacy Report of advocacy 2018- 2022 Director -NCCP
programmes to obtain actively involved in programmes programmes Director -Primary Care
support from all delivery of palliative Director -NCD
stakeholders care Director – Nursing

6
Draft 05.11.2018

Public Health &

Medical Services
Palliative Care & End of
Life Care Task Force of
SLMA
Palliative Care
Association
Professional Colleges

2.Facilitate the effective integration of specialist palliative care and palliative care services across all levels of service
settings, namely at tertiary, secondary, primary and at community level.

Major Activity Expected output Indicator Means of Time Responsibility

Verification Frame
1. Establish designated Team members of the No. of hospitals Reports 2018- 2022 DGHS
palliative care team within designated palliative with palliative Nat. Steering Comm. on
the hospital setting. team are aware about care teams Palliative Care
their clearly defined key DDG (MS 1), DDG (NCD)
tasks. Director /MS of the
hospital

2. Commence ‘Palliative care Palliative care consult No. of palliative Reports 2018- 2022 DGHS
consult services’ at the services are available care consult Nat. Steering Comm. on
tertiary & secondary care with the participation of services Palliative Care
level to deliver all aspects of Consultants, medical DDG (MS 1)
palliative care (Annex 1 & officers, nursing officers, DDG (NCD)
1.1) physiotherapists, PDHS, RDHS
‘ occupational therapists, Director /MS of the
pharmacists, social hospital
workers etc at tertiary & Director -NCCP
secondary care. Director -NCD

7
Draft 05.11.2018

Major Activity Expected output Indicator Means of Time Responsibility

Verification Frame

3. Link , clinically supervise The hospices are linked No. of hospices Reports 2018- 2022 DGHS
& monitor government, non with the closest palliative with direct links Nat. Steering Comm. on
government & private care consult service and with palliative Palliative Care
their activities are care consult PDHS
hospices by the closest
clinically supervised services out of RDHS
palliative care consult all the hospices
services

4. Integrate palliative care at Palliative care is No. of patients Survey report 2018- 2022 DDG (MS II)
primary care institutions & delivered for those who received Director -Primary Care
general practitioners need at the closest palliative care Director -NCCP
health setting at the primary Director -NCD
care settings Professional colleges

5.Conduct programmes on Experience is gained to No. of Programme 2018-2022 DDG (NCD), DDG (MS
home based palliative care scale up the home based Initiatives, No. evaluation reports II)
including involvement of palliative care of patients & Management DDG (PHS I & II)
primary care institutions & received home Information System PDHS; RDHS
general practitioners and based palliative Director - NCCP
scale up care Director -Primary care
SLMA
Palliative Care
AssociationOther NGOs

8
Draft 05.11.2018

Major Activity Expected output Indicator Means of Time Responsibility

Verification Frame
6. Ensure the role of Public PHNO is actively involved No. of PHNOs Management 2018-2022 DGHS
Health Nursing Officer in delivery of palliative involved in Information System DDG (PHS II), DDG (ET
(PHNO) in palliative care at care at family level palliative care for PHNOs & R)
home based setting. PDHS, RDHS
Director/Nursing (Public
Health )

3.Develop and make available skilled multi disciplinary human resources and infrastructure for delivery of palliative care services at
institutional and at community levels.

Major Activity Expected output Indicator Means of Time Frame Responsibility

Verification
1. Develop human resource Human resource Availability of Report 2018-2020 DDG (Planning)
deployment plan for requirement in different human resource Director (Planning)
palliative care (Annex 1 & categories and different deployment plan
2) levels of care is for palliative care
identified.

2. Conduct specialist Consultants in Palliative No. of trainees Reports of PGIM 2018- 2022 Secretary - Health;
training programme for medicine are available enrolled for MD DGHS, DDG (Planning)
palliative medicine (MD in in Sri Lanka palliative DDG (MS 1), DDG (ET &
Palliative Medicine) medicine R)
Director - PGIM
3. Include module on Palliative care services No. of specialist Reports of PGIM 2018-2022 Director -PGIM
palliative care in relevant are delivered at the training DDG (MS 1), DDG (ET &
specialist training different specialist programmes R)
programmes health settings. containing Boards of Studies at
palliative care PGIM
module Professional colleges

4. Commence and continue Medical officers are No of Medical Reports of PGIM 2018-2022 Director -PGIM

9
Draft 05.11.2018

Post Graduate Diploma in specially trained on Officers DDG (MS II),

Palliative Medicine for palliative medicine completed the DDG (ET & R)
medical officers Post Graduate
Diploma in
Palliative
Medicine

5. Commence and continue Nursing Officers are Availability of Report of Post 2018 -2022 DDG (ET & R)
a post basic diploma specially trained in post basic Basic School of Director (Nursing
programme in palliative palliative care diploma Nursing Education)
nursing for Nursing programme in Principal (Post basic
Officers palliative care for Nursing School)
nurses.
No of Nursing
Officers
completed the
Post Basic
Diploma in
Palliative Nursing

6. Include aspects of Health care workers are No. of study Reports of 2018 – 2022 DDG (ET & R)
palliative care in basic / trained in palliative care hours / length of teaching DDG (MS 1)
under graduate training at their basic trainings course in programmes & Director – Nursing
programmes of Medicine, to develop the required palliative care in audits (Training)
Nursing and other competencies. each training Dean / Faculty of
relevant health related programme Medicine, Nursing or
disciplines Allied Health Sciences
Professional
Associations

7. Develop and conduct in Health care workers are Number of Administrative 2018 – 2022 DDG (ET & R)
service training trained regularly in persons in each Reports DDG (NCD), DDG (MS
programmes in palliative palliative care category Audits II)
care for medical officers, undergone in- Director -NCCP,
nursing officers, service training in Director -Nursing

10
Draft 05.11.2018

pharmacists etc. palliative care (Medical Services)

delivery Professional
Associations
8. Establish a palliative care Health care workers Availability of Report of helpline 2019 – 2022 DGHS
help line (web site, e mail have access to essential palliative care National Steering
access & telephone hot information according to help line Committee on Palliative
line) to give necessary the need. Care
information for palliative
care teams including
general practitioners

4.Ensure that patients and their families receive palliative care services they need when and where required & adherence to
protocols & guidelines in palliative care

Major Activity Expected output Indicator Means of Time Frame Responsibility

Verification
1. Develop protocols & Palliative care protocols Availability of Reports on 2018 – 2022 DDG MS I & II
guidelines for delivery of & guidelines are protocols & protocols & Director -NCCP
palliative care developed for health guidelines guideline Director -NCD
care staff. Director - Primary care
SLMA,
Professional colleges
2. Facilitate availability of Palliative care protocols Number and Survey reports 2019 -2022 DDG MS I & II
protocols & guidelines in & guidelines are percentage of Director /MS of the
palliative care at the available for health care healthcare hospital
service delivery points staff (both hard copy units where PDHS/RDHS
and the soft copy). guidelines are Consultants
available
3. Review the adherence of Best possible care is Proportion of Audit reports 2018 -2022 Director /MS of the
guideline at palliative care offered with the use of patients hospital
setting through clinical existing resources received care PDHS/RDHS
audits according to Consultants
guideline

11
Draft 05.11.2018

Major Activity Expected output Indicator Means of Time Frame Responsibility

Verification
4.Include aspects of palliative Quality of palliative care Proportion of Quality assurance 2018 -2022 DDG MS I & II
care to the quality delivery is assured at palliative care reports Director- Health Care
assessment tools and quality every level of care at settings Audit reports Quality
improvement projects frequent intervals. quality Director /MS of the
assessment hospital
tools are PDHS/RDHS
introduced Consultants

5.Ensure availability of drugs & technologies for provision of palliative care at all levels of care: tertiary, secondary, primary
and community level

Major Activity Expected output Indicator Means of Time Frame Responsibility

Verification
1. Attend to the relevant Pain relieving medications Availability of Amendments to 2018 – 2020 Legal Draftsmen Dept.
amendments to the are adequately prescribed amendments Dangerous drug National Dangerous
existing legislation control act Drug Control Board;
regarding availability & Legal Officer, Ministry of
prescription practices of Health
controlled drugs
especially Morphine

2. Include WHO model list Essential medicines for Number of National list of 2018 – 2022 DGHS
of essential medicines palliative care are items of WHO essential NMRA
(adult & children) for available at health care model list of medicines DDG- MSD,
palliative care in settings essential Professional colleges
national list of essential medicines for
medicines palliative care
included in
the National
list of
essential
medicines
12
Draft 05.11.2018

Major Activity Expected output Indicator Means of Time Frame Responsibility

Verification
3. Prepare list of drugs Palliative care drugs are Availability of Survey Report 2018- 2022 DDG - MSD
need for palliative care available at each level. palliative care Director –Medical
for each level of health drugs in the Supplies Division
facility list in PDHS, RDHS
respective Professional colleges
level of care
4. Ensure continuous Adequate amounts of Proportion of Reports & returns 2018- 2022 Director –Medical
supply & availability of palliative care drugs are hospitals of Supplies Division
palliative care drugs at available throughout the each district Director/ MS of TH,
all levels of care year. where oral PGH, DGH, BH
morphine is PDHS, RDHS
available
5. Determine & obtain Necessary medical Proportion of Report 2018-2022 DDG (MSD)
medical technologies technologies (eg. Syringe hospitals in DDG (BME)
required for palliative drivers for pain each district D-MSD
care according to the management, infusion where specific Director/ MS of TH,
need at each level pumps, PEG tube) are medical PGH, DGH, BH
available technologies PDHS, RDHS
for palliative Professional colleges
care are
available

6. Build partnerships with government and non-governmental organizations for delivery of palliative care

Major Activity Expected output Indicator Means of Time Frame Responsibility

Verification
1. Identify government and Facilitate networking Availability of Reports 2018 – 2022 D NCCP
non-government among palliative care list of PDHS
organizations involved in providers & organizations RDHS
palliative care understanding of their at national & Director/ MS of TH,
roles and areas of work sub national PGH, DGH, BH
level

13
Draft 05.11.2018

Major Activity Expected output Indicator Means of Time Frame Responsibility

Verification
2. Develop networks Coordinated service No. of Reports 2018– 2022 Ministry of Health
nationally & regionally provision is ensured functional Ministry of Social
among organizations coordinated Services
coordinating or providing services. Director -NCD
palliative care Director -NCCP,
Director -Primary care
SLMA
Palliative Care
Association of Sri Lanka
NGOs

3. Advocate to obtain Aspects of palliative care Number of Survey Reports 2018 – 2022 DGHS
support of community are delivered at home community D NCCP
and religion based level by the community and religion Ministry of Social
organizations in the based organizations & based Services
delivery of palliative care volunteers. organizations PDHS
involved in RDHS
palliative care District Secretariat
4. Expand networking with International experience No. of Reports 2018 – 2022 D NCCP
international & support is received to international DDG NCD
organizations to strengthen palliative care organizations Professional Colleges
strengthen palliative care contributed in WHO Country office
palliative care

7. Empower family members, care givers & general public for the provision of palliative care

Major Activity Expected output Indicator Means of Time Frame Responsibility

Verification
1. Create awareness & their General public is aware No. of programmes Survey 2018 - 2022 Director- NCD
responsibility amongst about palliative care conducted Director -NCCP
general public on needs, services & their Director - Primary Care
palliative care and responsibility PDHS; RDHS
service availability Professional
14
Draft 05.11.2018

Major Activity Expected output Indicator Means of Time Frame Responsibility

Verification
Organizations
Professional Colleges

2. Empower family Family members & care No. of programmes Reports 2018- 2022 Ministry of Health
members & care givers givers are trained and are conducted. Ministry of Social
for delivery of palliative empowered. No. of educational Services
care materials developed. Ministry of Women &
Child welfare
Director- NCD
Director -NCCP
Director - Primary Care
Director –Elderly &
Disability
PDHS; RDHS
Hospices
NGOs
3. Facilitate establishment Community organizations No. of groups Reports 2018- 2020 Ministry of Health
of self-help / support are formed. Ministry of Social
groups for palliative Services PDHS; RDHS
patients NGO
Civil Society
organizations

8. Encourage research & clinical audit related to palliative care in assessing needs for palliative care and suitable models for
implementation of palliative care services.

Major Activity Expected output Indicator Means of Time Frame Responsibility

Verification
1.Incooperate palliative care Updated palliative care Availability of Reports of 2018 – 2022 DDG - ET & R
research into national research repository updated research Director - Research
health research agenda palliative care repository Director NCCP
research
repository
15
Draft 05.11.2018

Major Activity Expected output Indicator Means of Time Frame Responsibility

Verification
2. Identify research needs Priority research needs on Availability of Reports of 2018 – 2022 Nat. Steering Comm. on
on palliative care palliative care are list of prioritized palliative care Palliative Care
identified. research needs research needs DDG -ET & R
in palliative Director -Research
care
3.Facilitate research Palliative care research is No. of research Reports of 2018– 2022 DDG - ET & R
(financial and technical conducted at all levels related to research related Director - Research
grants )related to palliative palliative care to palliative care Universities
care
4. Disseminate & apply Delivery of palliative care No. of research Published 2018-2022 DDG- ET & R
findings of research related services are changed evidence used research reports Director - Research
to palliative care based on research for palliative Professional colleges
evidence. care practice Universities

5.Conduct clinical audits at Palliative care services are No. of clinical Report of clinical 2020-2022 Directors/ Medical
palliative care setting to compared with audits related audit Superintendents of the
compare with international international standard or to palliative hospitals
standard / adherence to locally developed care conducted. Professional colleges
guidelines guidelines.
Identify standards and
suitable models for
implementation

9. Ensure adequate financing & resource allocation for cost effective delivery of palliative care

Major Activity Expected output Indicator Means of Time Frame Responsibility

Verification
1. Ensure regular Financing mechanism is Financial Annual budget 2018-2022 Ministry of Finance
budgetary allocations for available for the cost allocation for allocation DGHS
the sustainable delivery of effective delivery of palliative care DDG (Planning)
palliative care at national & palliative care as a percentage DDG (MS I), DDG (MS
provincial level. of total budget II),
DDG (NCD)
16
Draft 05.11.2018

DDG (Finance)
Hospital Directors / MS
PDHS /RDHS

2. Encourage private sector Palliative care services are Number of Reports 2018-2022 Director – Private Health
to develop palliative care available at the private private health Sector Development
services in the private sector institutions Private Health Services
sector. with palliative Regulatory Council
care services Director NCCP
3. Encourage Public Private Public private partnership Number of PPP Reports 2018-2022 Director – Private Health
Partnership (PPP) to develop projects on palliative care projects on Sector Development
palliative care initiatives are commenenced palliative care Private Health Services
Regulatory Council
Hospital Directors
Director NCCP
PDHS, RDHS

10. Strengthen legislative framework for delivery of palliative care

Major Activity Expected output Indicator Means of Time Frame Responsibility

Verification
1.Identify existing legislative Patients with palliative Availability of Legislative 2018-2022 DGHS
provisions and utilize those care needs and palliative legislative Reports Legal officer -Ministry of
for delivery of palliative care care service providers are framework Health
protected legally. Director NCCP

2. Identify legislative needs Patients with palliative Availability of Legislative 2018-2022 Secretary -Health
for provision of palliative care needs and palliative new legislative Reports DGHS
care & develop new care service providers are framework Legal officer-Ministry of
legislative procedures protected legally. Health
Attorney General’s
Department
Director NCCP

17
Draft 05.11.2018

11. Ensure monitoring & evaluation framework for palliative care services

Major Activity Expected output Indicator Means of Time Frame Responsibility

Verification
1. Set up indicators to Monitoring & evaluation Availability of M Report 2018-2022 Director NCCP
develop monitoring & indicators for palliative & E Framework
evaluation framework for care service are developed
palliative care at all levels

2.Incorporate palliative care Palliative care indicators Availability of Management 2018-2020 DDG -Planning
monitoring & evaluation are included in the MIS with information Director - Information
indicators at the management information palliative care system (MIS) for PDHS /RDHS
management information system at each level of M&E palliative care Hospital Directors / MS
system (MIS) care. indicators Director NCCP
incorporated.

The Implementation of National Strategy will be guided by a detailed implementation plan. Accordingly the monitoring & evaluation
plan to measure how the national strategy is progressing will be developed in consultation of all stakeholders, once approval is
obtained for the strategic framework.

References
1. Asia Pacific Hospice Palliative Care Network (2017). Letter on ‘Development of Palliative care services in Sri Lanka’, send by Asia Pacific
Hospice Palliative Care Network 03.05.2017
2. Suresh Kumar (2012). ‘Palliative care in Sri Lanka’, Mission Report submitted to International Atomic Energy Agency (IAEA), October
2012.
3. Ministry of Health. (2015). National Policy & Strategic Framework on Prevention & Control of Cancers in Sri Lanka
4. Palliative care & End of Life care Task Force. (2017). Concept paper. Sri Lanka Medical Association
5. Sri Lanka College of Oncologists. (2017). Recommendations of on Palliative care of cancer patients in Sri Lanka 21.03.2017
6. WHO (2016).Planning & implementing palliative care services : A guide for Programme Managers
7. Palliative Care Association of Sri Lanka. (2016). Proposal on Palliative care submitted by Palliative Care Association of Sri Lanka to the
National Health Strategic Master Plan 2016 – 2025
8. Murray, S. A. et al. (2005). ‘ Illness trajectories & palliative care’, BMJ;330:1007-1011

18