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Introduction
Delivering better care for the increasing numbers of people with two or more chronic illnesses poses substantial challenges for health and social care systems which have previously focused on single diagnoses with multimorbidity largely ignored. 1-4 The need to develop more effective, person-centred care for people living with multiple long-term conditions has been recognised but interventions have shown mixed results. 5 6 As multimorbidity becomes the norm in the last year of life, patient and carer experiences must inform improvements in palliative and end-of-life care. 7 8 These patients spend most of their last year of life at home being cared for by family, general practitioners, community nurses and voluntary sector services; many receive outpatient care. 9 10 Hospitals remain the most common place of death. 10 Caring for someone with multimorbidity at home places a considerable burden on family carers. 11 While patients with a single, dominant illness often have a keyworker or named specialist, family carers of people with several conditions frequently face the additional challenge of coordinating care from multiple services. 12 13
While conducting a multicentre study on experiences of coordination of care for people considered by professionals to be in their last year of life, we found significant differences in the care experiences of people with two or more advanced illnesses compared with those who had one readily identifiable diagnosis. 12 14 We carried out a more detailed analysis of the interviews with this large subgroup (37 of 56 patients and their carers). We classified this group as having 'advanced multimorbidity' which we defined as multiple, life-limiting illnesses or progressively deteriorating health due to several long-term conditions.
Methods
Serial, multiperspective interviews were conducted with patients and their family carers recruited in one of three settings: a large, general practice serving multiethnic urban and rural locations in England, an acute admissions unit in a Scottish teaching hospital, and a respiratory outpatients department in a central London teaching hospital. 14 Interviews with patients with advanced multimorbidity and their family carers were selected for additional analysis.
Recruitment
Staff in the three settings identified patients they considered to be in the last year of life using the question 'Would you be surprised if this patient died within the next 12 months?' 15...