Appropriate standardized care of medically complex terminally ill patients in a high-volume, specialized unit may significantly lower cost. These results should be confirmed in a randomized study but such studies are difficult to perform.

UDS on the 82 oncology patients at high risk for substance misuse were frequently positive (46%) for non-prescribed opioids, benzodiazepines or potent illicit drugs such as heroin or cocaine, and 39% had inappropriately negative UDS, raising concerns for diversion.

Although median pain scores improved at follow-up, less than half of patients were responders. Patients with AC had a significantly better response rate than NED patients and a lower pain score than NLLI patients at follow-up.

Delivering optimal and equitable palliative care is an international challenge. There are few cross-national comparisons examining challenges in expanding palliative care along public health lines. This paper presents a critical review of palliative care in the USA and England, which share similar challenges but have different contexts of healthcare.Beyond some obvious differences in the organisation of palliative care, a set of underlying common issues can be identified. A key tension in both is balancing attention 'downstream' in the dying phase, as well as 'upstream' earlier in the course of serious illness. In both, the dominant models of palliative care provision have resulted in excellent care towards the end of life for some patients, but there remain major deficiencies in care for the majority. England has a National Strategy for Endof-life care; the US has no equivalent, although a number of influential agencies have published statements.Achieving a public health approach in palliative care requires international consensus on the meaning and target population of palliative care, replacement of prognosis based understandings of entitlement to palliative care with a needs based approach, and development of an evidence base for cost effective partnerships between providers across the specialist-generalist divide.

The results of this review emphasize a lack of knowledge as a barrier to delivering palliative care. Nurses caring for individuals with heart failure need palliative care knowledge, skills and competencies to ensure that this vulnerable population receives patient centered care. To bring about practice change, education will need to be incorporated into all levels of nursing, including students and practicing nurses.