Spiritual issues were significant for many patients in their last year of life and their carers. Many health professionals lack the necessary time and skills to uncover and address such issues. Creating the opportunity for patients and carers to discuss spiritual issues, if they wish, requires highly developed communication skills and adequate time.

Objective To compare the illness trajectories, needs, and service use of patients with cancer and those with advanced non-malignant disease. Design Qualitative interviews every three months for up to one year with patients, their carers, and key professional carers. Two multidisciplinary focus groups. Setting Community based. Participants 20 patients with inoperable lung cancer and 20 patients with advanced cardiac failure and their main informal and professional carers. Main outcome measures Perspectives of patients and carers about their needs and available services. Results 219 qualitative interviews were carried out. Patients with cardiac failure had a different illness trajectory from the more linear and predictable course of patients with lung cancer. Patients with cardiac failure also had less information about and poorer understanding of their condition and prognosis and were less involved in decision making. The prime concern of patients with lung cancer and their carers was facing death. Frustration, progressive losses, social isolation, and the stress of balancing and monitoring a complex medication regimen dominated the lives of patients with cardiac failure. More health and social services including financial benefits were available to those with lung cancer, although they were not always used effectively. Cardiac patients received less health, social, and palliative care services, and care was often poorly coordinated. Conclusions Care for people with advanced progressive illnesses is currently prioritised by diagnosis rather than need. End of life care for patients with advanced cardiac failure and other non-malignant diseases should be proactive and designed to meet their specific needs.

Objectives To examine the care experiences of South Asian Sikh and Muslim patients in Scotland with life limiting illness and their families and to understand the reasons for any difficulties with access to services and how these might be overcome. Design Prospective, longitudinal, qualitative design using in-depth interviews. Setting Central Scotland. Participants 25 purposively selected South Asian Sikh and Muslim patients, 18 family carers, and 20 key health professionals. Results 92 interviews took place. Most services struggled to deliver responsive, culturally appropriate care. Barriers to accessing effective end of life care included resource constrained services; institutional and, occasionally, personal racial and religious discrimination; limited awareness and understanding among South Asian people of the role of hospices; and difficulty discussing death. The most vulnerable patients, including recent migrants and those with poor English language skills, with no family advocate, and dying of non-malignant diseases were at particularly high risk of inadequate care. Conclusions Despite a robust Scottish diversity policy, services for South Asian Sikh and Muslim patients with life limiting illness were wanting in many key areas. Active case management of the most vulnerable patients and carers, and "real time" support, from where professionals can obtain advice specific to an individual patient and family, are the approaches most likely to instigate noticeable improvements in access to high quality end of life care. Improving access to palliative care for all, particularly those with non-malignant illnesses, as well as focusing on the specific needs of ethnic minority groups, is required.

Advance care planning is being promoted as a central component of end-of-life policies in many developed countries, but there is concern that professionals find its implementation challenging. AimTo assess the feasibility of implementing advance care planning in UK primary care. Design of studyMixed methods evaluation of a pilot educational intervention. SettingFour general practices in south-east Scotland. MethodInterviews with 20 GPs and eight community nurses before and after a practice-based workshop; this was followed by telephone interviews with nine other GPs with a special interest in palliative care from across the UK. ResultsEnd-of-life care planning for patients typically starts as an urgent response to clear evidence of a short prognosis, and aims to achieve a 'good death'. Findings suggest that there were multiple barriers to earlier planning: prognostic uncertainty; limited collaboration with secondary care; a desire to maintain hope; and resistance to any kind of 'tick-box' approach. Following the workshop, participants' knowledge and skills were enhanced but there was little evidence of more proactive planning. GPs from other parts of the UK described confusion over terminology and were concerned about the difficulties of implementing inflexible, policy-driven care. ConclusionA clear divide was found between UK policy directives and delivery of end-of-life care in the community that educational interventions targeting primary care professionals are unlikely to address. Advance care planning has the potential to promote autonomy and shared decision making about end-of-life care, but this will require a significant shift in attitudes. Keywordsadvance care planning; cancer; palliative care; primary health care. INTRODUCTIONAdvance care planning is viewed as an intrinsic component of end-of-life care programmes in many developed countries. In the US, advance directives were originally intended to allow people to record an advance refusal of invasive, life-prolonging interventions.1 The limitations of this approach resulted in a progressive move internationally towards a broader process of advance care planning that also includes discussion of personal goals, wishes, and preferences about future care. [2][3][4] Programmes in the US and Australia that have adopted a regional strategy towards educating professionals, patients, and the general public about advance care planning have had some success. 5,6 Proactive care planning is central to recent UK policies, and the expectation is that it will now be offered to all patients approaching the end of life.

What constitutes a good death in sub-Saharan Africa? In Meru District in Eastern Kenya, we listened to 32 patients with ongoing cancer or AIDS, and to their carers as they talked about end-of-life experiences and care needs. Patients described how the support of close family relationships, and the care shown by their community and religious fellowships helped meet many of their emotional, social, and spiritual needs. But physical needs often went unmet. Patients died in pain. Some suffered in poverty, others were troubled by the guilt of using all available family resources to pay for treatment and care. Accessible pain relief, affordable clinic or inpatient care when required, and help to cope with the burden of care we~e among the key needs of patients. Until these are available, many will not die well. Resume I Qu'est-ce qui constitue une « bonne mort » en Afrique sous-saharienne? Dans Ie district de Meru, situe dans I'est du Kenya, nous avons interviewe 32 patients atteints du sida ou du cancer ainsi que leurs soignants afin qu'ils nous parlent de leurs experiences de fin de vie et des soins dont lis avaient besoin. Les patients nous ont dit a quel point Ie support de .Ieurs proches et "aide de leur eornmunaute et de leur Eglise leur avaient ete d'un grand secours en repondant a leurs besoins d'ordre emotionnel, social, et spirituel. Par ailleurs, leurs besoins d'ordre physique sont souvent derneures sans reponse. Les patients meurent dans la douleur. D'autres souffrent dans une grande pauvrete, ou encore eprouvent des sentiments de culpabllite parce qu'ils utilisent toutes les :essources flnancieres de leur famille pour payer les tralternents et les soins dont i1s ont besoin. Parmi les besoins primerdiaux qui ont ete souleves mentionnons I' acc.e~a des medicaments pour soulager la douleur, les cliniques a prix abordables, les soins dispenses en etablissements hospitaliers, et I'aide d'autres personnes pour partager et soulager Ie fardeau des soignants. Tant qu'on ne pourra repondre aces besoins, beaucoup de patients n'auront pas une « bonne mort ».