The authors and sites of the articles in this issue of the journal span a broad geographical range, from Washington, Florida, Pennsylvania, and Massachusetts to far across the globe in South Korea. The populations of interest in these studies also are widely varied. However, the articles have a very common theme: Palliative care and hospice are implemented far too late in the course of disease. Despite the very widespread implementation of hospice and palliative care, these studies speak to the common theme of excellent, patient-centered care that comes too late. This observation is of course not a surprise to any nurse reading this journal.

Although the issue of late referral of palliative care is not new, perhaps we are finally at a point in time to moral outrage. Yes, moral outrage. Strong words but well justified. The systematic avoidance of hospice and palliative care and silence surrounding advance directives clearly results in outcomes that are not just "bad" but also wrong. Over the past 30 years, we have accumulated abundant clinical and empirical data supporting the reality that palliative care provides symptom management, support of families, attention to suffering, and care that respects patients' values and preferences. Delaying or denial of that care is wrong.

Moral voices have emerged in recent years. From my own clinical area of oncology, there have been voices that have acknowledged unacceptable realities, such as the number of patients who receive chemotherapy in the last 2 weeks of life. Three of the articles in this issue address populations of liver failure and heart failure. We know the trajectories of these diseases, their high symptom burden, and the kinds of deaths that happen if unsupported by palliative care. But we also know how complex the barriers are, even to providing care known to be superior. Even when well integrated, early palliative care is available, patients and families themselves may avoid any discussion of such care because of many cultural and personal beliefs.

What can be done? Nurses are vital witnesses and have an obligation to speak up for change. Perhaps it is time for nurses to be more militant in advocating for earlier referral to palliative care. Dying with unrelieved symptoms, being admitted to hospice days before death or not at all, and continuing to design and support health systems that avoid palliative care in diagnosis where death is predictable are no more justified than any other area of unethical care.

Use the articles in this issue as a springboard for conversation in your settings. Gather data to compare your care with the findings reported here. The articles in this issue report on family caregivers who clearly state that palliative care came much too late, in fact after they had already taught themselves how to care for their loved ones.

And the good news is that now is the time. We live with a health system that is unsustainable in its current form and one that must be fixed. Earlier referral to palliative care would be a major step forward. Nurses have a history of speaking up against the intolerable in health care. It is urgent that we collectively champion earlier palliative care and advance care planning.

Betty Ferrell, PhD, MA, FAAN, FPCN, CHPN

Editor-in-Chief

[email protected]

The author has no conflict of interest to disclose.