There is certainly a risk of drawing an arbitrary distinction

between palliative care and what is simply good clinical practice in children. Nevertheless, those working in the field recognise a population of children within this wider group who are at high risk of death during childhood, and in whom complex symptom control is a frequent clinical challenge. It is that population that the Directory aims to help to identify. There are inevitable limitations to a study of this nature. The ACT/RCPCH archetypes Inhibitors,research,lifescience,medical provide a measure of objectivity but still rely on a certain degree of subjective judgment. It is not possible to list every possible LLC in a Directory: the pilot study enabled us to add some diagnostic labels that might otherwise have been missed, but if the Directory is to remain current there will need to be a mechanism for adding new diagnoses as they become apparent. Publically available data recorded Inhibitors,research,lifescience,medical on death certificates is limited to the principal causes of

death. It is possible that small numbers of children with LLC who died from incidental causes were not identified in our pilot study. In interpreting these results, it is important to make a distinction between diagnoses and patients. The Directory lists diagnoses. While it would not be valid to draw conclusions about number of children Inhibitors,research,lifescience,medical needing access to palliative care solely from observations of the number who actually do so, observations of service use do provide a valid source of diagnoses, since it is extremely likely (though not certain) that every important LLC would occur at least once. Similarly,

Inhibitors,research,lifescience,medical the Directory is designed simply to provide a tool for analysing epidemiological data. It would be impossible to draw conclusions about the numbers of children suffering from life-limiting conditions from the Directory alone. Effective use of the Directory relies on applying it to http://www.selleckchem.com/products/Adrucil(Fluorouracil).html databases that include Inhibitors,research,lifescience,medical accurate and detailed recording of ICD10 diagnostic labels to subheading level. On the other hand, the Directory was easy to use and enabled the authors to interrogate a robust existing database effectively and PAK6 immediately. We were able to make some important observations about LLC as causes of death in in Wales over a reasonable study period of five years. Most individual LLC caused only one death over that period and very few diagnoses (5 in neonates, 7 in older children) caused it 10 times or more (Tables 1 and ​and2).2). At the same time, nearly one third of deaths were accounted for by only ten different LLC, confirming clinicians’ impression that, while the range of possible LLC is wide, it is possible to identify a relatively small number of diagnoses whose symptom management should form the core of a specialist palliative care skillset. Of 420 deaths from LLC outside the neonatal period, 75% were from conditions other than cancer.